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									Health at a Glance
Europe 2010
Health at a Glance:
  Europe 2010
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.


  Please cite this publication as:
  OECD (2010), Health at a Glance: Europe 2010, OECD Publishing.
  http://dx.doi.org/10.1787/health_glance-2010-en



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ISBN 978-92-64-09031-6 (PDF)




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                                                                                                                  FOREWORD




                                                     Foreword
         T  his first edition of Health at a Glance: Europe presents a set of key indicators on health and
         health systems across 31 countries – the 27 European Union member states, three European Free
         Trade Association countries (Iceland, Norway and Switzerland), and Turkey. The selection of
         indicators is based on the European Community Health Indicators (ECHI) shortlist – a set of
         indicators used by the European Commission to guide the development of health information
         systems in Europe. In addition, the publication provides detailed information on health expenditure
         trends across countries, building on the OECD’s established expertise in this area.
               This publication is a concrete example of the long and fruitful collaboration between the OECD
         and the European Commission in the development and reporting of health statistics. This collaboration
         also involves the World Health Organization (WHO).
               The preparation of this report has been greatly facilitated by the increased co-operation in the
         collection of health statistics at the international level in recent years. A joint data collection between
         the OECD, Eurostat (the European statistical agency) and WHO was launched at the end of 2005 to
         improve the availability and comparability of data on health expenditure and financing, based on the
         System of Health Accounts. Building on the success of the joint Health Accounts collection, a new
         joint data collection between the three organisations was launched in 2010 to gather data on
         non-monetary health care statistics. These joint data collections are improving the comparability of
         data across countries, while reducing the data collection burden on national administrations.
               Health at a Glance: Europe 2010 would not have been possible without the effort of national
         data correspondents from the 31 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 publication 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 and Valerie Moran, with a contribution from Carol Jagger and Jean-Marie Robine
         (Network on Health Expectancy, REVES) for the indicators related to life expectancy and healthy life
         years. Chapter 3 was prepared by Gaétan Lafortune and Gaëlle Balestat, with a contribution from
         Vladimir Stevanovic and Rie Fujisawa for the two indicators related to cancer care. Chapter 4 was
         written by David Morgan and Rebecca Bennetts. It is important to recognise the contribution of
         colleagues from Eurostat (in particular Elodie Cayotte and Albane Gourdol) and WHO-European
         Office (in particular Ivo Rakovac), who have shared some of the data presented in this publication.
         This publication benefited from comments from Mark Pearson (Head of OECD Health Division) and
         Nick Fahy, Fabienne Lefebvre and Federico Paoli (European Commission – DG Sanco).




                            Aart De Geus                                     Paola Testori Coggi
                     Deputy Secretary-General                                 Director-General
               Organisation for Economic Co-operation           Directorate-General for Health and Consumers
                          and Development                                   European Commission


HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                             3
                                                                                                                                                 TABLE OF CONTENTS




                                                             Table of Contents
         Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        7

         Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                9

         Résumé . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     15

         Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       21

         Chapter 1. Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               25
                1.1.      Life expectancy and healthy life expectancy at birth . . . . . . . . . . . . . . . . . . . . .                                    26
                1.2.      Life expectancy and healthy life expectancy at age 65 . . . . . . . . . . . . . . . . . . .                                       28
                1.3.      Mortality from all causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                 30
                1.4.      Mortality from heart disease and stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                             32
                1.5.      Mortality from cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               34
                1.6.      Mortality from transport accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                        36
                1.7.      Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   38
                1.8.      Infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          40
                1.9.      Infant health: Low birth weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                     42
                1.10.     Self-reported health and disability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                       44
                1.11.     Incidence of selected communicable diseases . . . . . . . . . . . . . . . . . . . . . . . . . .                                   46
                1.12.     HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      48
                1.13.     Cancer incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .            50
                1.14.     Diabetes prevalence and incidence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          52
                1.15.     Dementia prevalence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                54

         Chapter 2. Determinants of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                        57
                2.1.      Smoking and alcohol consumption among children . . . . . . . . . . . . . . . . . . . . .                                          58
                2.2.      Nutrition among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  60
                2.3.      Physical activity among children. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                       62
                2.4.      Overweight and obesity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                               64
                2.5.      Supply of fruit and vegetables for consumption . . . . . . . . . . . . . . . . . . . . . . . . .                                  66
                2.6.      Tobacco consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                              68
                2.7.      Alcohol consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            70
                2.8.      Overweight and obesity among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                             72

         Chapter 3. Health Care Resources, Services and Outcomes . . . . . . . . . . . . . . . . . . . . . . . .                                            75
                3.1.      Practising physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             76
                3.2.      Practising nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           78
                3.3.      Childhood vaccination programmes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                             80
                3.4.      Influenza vaccination for older people. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                           82
                3.5.      Medical technologies: CT scanners and MRI units . . . . . . . . . . . . . . . . . . . . . . .                                     84


HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                      5
TABLE OF CONTENTS



              3.6.     Hospital beds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
              3.7.     Hospital discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
              3.8.     Average length of stay in hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
              3.9.     Cardiac procedures (coronary angioplasty) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
              3.10.    Cataract surgeries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
              3.11.    Hip and knee replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
              3.12.    Screening, survival and mortality for cervical cancer . . . . . . . . . . . . . . . . . . . . 98
              3.13.    Screening, survival and mortality for breast cancer. . . . . . . . . . . . . . . . . . . . . . 100

       Chapter 4. Health Expenditure and Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
              4.1.     Health expenditure per capita . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             104
              4.2.     Health expenditure in relation to GDP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   106
              4.3.     Health expenditure by function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               108
              4.4.     Pharmaceutical expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .              110
              4.5.     Financing of health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        112
              4.6.     Trade in health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        114

       Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

       Annex A. Additional Information on Demographic and Economic Context . . . . . . . . . 122




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6                                                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                ACRONYMS




                                               Acronyms


         AIDS                Acquired immunodeficiency syndrome
         ALOS                Average length of stay
         AMI                 Acute myocardial infraction
         BMI                 Body mass index
         CAT (or CT)         Computed axial tomography (scanner)
         EFTA                European Free Trade Association
         EU                  European Union
         EU-SILC             European Union Statistics on Income and Living Conditions survey
         GALI                Global activity limitation indicator
         GDP                 Gross domestic product
         GP                  General practitioner
         HBSC                Health Behavior in School-aged Children survey
         HIV                 Human immunodeficiency virus
         HLY                 Healthy life years
         IHD                 Ischemic heart disease
         ISIC                International Standard Industrial Classification
         MRI                 Medical resonance imaging
         PPP                 Purchasing power parities
         SHA                 System of Health Accounts
         SIDS                Sudden infant death syndrome




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                           7
Health at a Glance: Europe 2010
© OECD 2010




                                  Executive Summary

E  uropean countries have achieved major gains in population health over recent decades.
Life expectancy at birth in European Union (EU) countries has increased by six years
since 1980, while premature mortality has reduced dramatically. Improvements in living
and working conditions and in some health-related behaviours have contributed greatly to
these longevity gains, but progress in medical care also deserves much credit. Health
systems are of growing size and complexity in European countries, and spending on health
care has never been higher, consuming an ever-increasing share of national income.
This first edition of Health at a Glance: Europe, the result of a long-standing collaboration
between the OECD and the European Commission, presents a set of key indicators of health
and health systems in 31 European countries – the 27 member states of the European Union,
and Iceland, Norway, Switzerland and Turkey. 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 (European Commission, 2010a). However, a number of indicators in this report
differ from ECHI definitions because of data availability or constraints, or in some instances
because ECHI indicators are not yet ready for implementation. The publication also provides
detailed information on health expenditure and its financing, building on the OECD’s
established data collection and expertise in this area. The data presented in the publication
come mainly from official national statistics, as gathered in OECD Health Data, the Eurostat
Statistics Database and WHO-Europe’s Health for All Database.
Health at a Glance: Europe 2010 presents evidence of wide variations across European
countries in population health status, risk factors for health, the inputs, outputs and
outcomes of health care systems, and levels of health expenditure and financing sources.
It offers some explanation for these variations, providing a background to understand
more fully the causes underlying such variations and to develop policy options to reduce
gaps across countries. It should also be noted that while basic population breakdowns by
sex and age are presented, this publication does not generally provide detail by
sub-national regions, by socio-economic groups or by ethnic/racial groups. For many
indicators, readers should keep in mind that there may be as much variation within a
country as there is across countries.




                                                                                                 9
EXECUTIVE SUMMARY




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

        ●   Life expectancy at birth in EU countries has increased by six years since 1980, reaching
            78 years in 2007. On average across the 27 EU countries, life expectancy at birth for the
            three-year period 2005-07 stood at 74.3 years for men and 80.8 years for women. France had
            the highest life expectancy at birth for women (84.4 years), while Sweden had the highest
            life expectancy for men (78.8 years). Life expectancy at birth in the European Union was
            lowest in Romania for women (76.2 years) and Lithuania for men (65.1 years). The gap
            between countries with the highest and lowest life expectancies at birth is around
            eight years for women and 14 years for men.
        ●   Whether the gains in life expectancy involve additional years of life lived in good health
            has important implications for health and long-term care systems in Europe. Healthy life
            years at birth is defined as the number of years of life in which a person’s day-to-day
            activities are not limited by a condition or health problem. In 2005-07, healthy life years
            stood at 61.3 years for women and 60.1 years for men, on average, in the European Union.
            The gender gap is much smaller than for life expectancy, reflecting the fact that a higher
            proportion of women’s lives are spent with activity limitations. Healthy life years at birth
            in 2005-07 was greatest in Malta for both men and women, and shortest in Latvia for
            women and Estonia for men.
        ●   Life expectancy at age 65 has also increased substantially over the past decades in
            European countries. The average in 2005-07 for the 27 EU countries was 15.9 years for
            men and 19.5 years for women. As for life expectancy at birth, France had the highest life
            expectancy at age 65 for women (22.6 years) but also for men (18.1 years). Life expectancy
            at age 65 was lowest in Eastern Europe – in Latvia for men (12.7 years) and in Bulgaria for
            women (16.3 years).
        ●   As is the case at birth, the gender gap for healthy life years at age 65 is much narrower
            than for life expectancy. In 2005-07, men were slightly favoured, at 8.4 years versus
            8.1 years for women.
        ●   It is difficult to estimate the relative contribution of the numerous medical and
            non-medical factors that might affect variations in (healthy) life expectancy. Higher
            national income is generally associated with higher life expectancy across European
            countries, although the relationship is less pronounced at higher levels of national
            income, suggesting a “diminishing return” after a certain level. Other determinants of
            health also play an important role.


Risk factors to health are changing

        ●   Many EU countries have achieved remarkable progress in reducing tobacco consumption,
            although it is still a leading cause of early death. Much of this decline can be attributed to
            policies at national and EU level promoting public awareness campaigns, advertising bans
            and increased taxation. Less than 18% of adults in Sweden and Iceland now smoke daily,
            down from over 30% in 1980. However, almost 40% of adults in Greece continue to smoke
            on a daily basis. Smoking rates are also relatively high in Bulgaria, Ireland and the
            Netherlands.




10                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                               EXECUTIVE SUMMARY



         ●   Alcohol consumption has also fallen in many European countries over the past three
             decades. Curbs on advertising, sales restrictions and taxation have proven to be effective
             measures to reduce alcohol consumption. Traditional wine-producing countries such
             as Italy, France and Spain have seen their alcohol consumption per capita drop
             substantially since 1980. On the other hand, consumption rose significantly in a number
             of countries including Ireland, the United Kingdom and some Nordic countries.
         ●   More than half of the total adult population across the European Union are now
             overweight or obese. This is also true in 15 of the 27 EU countries. The prevalence of
             obesity – which presents greater health risks than overweight – varies from less than
             10% in Romania, Switzerland and Italy to over 20% in the United Kingdom, Ireland, Malta
             and Iceland. On average across EU countries, 15.5% of the adult population is obese.
         ●   The rate of obesity has more than doubled over the past 20 years in most EU countries
             for which data are available. The rapid increase occurred regardless of what the levels of
             obesity were two decades ago. Obesity more than doubled in both the Netherlands and
             the United Kingdom between 1988 and 2008, even though the rate in the Netherlands is
             currently less than half that of the United Kingdom.
         ●   Because obesity is associated with higher risks of chronic illnesses, it is linked to
             significant additional health care costs. A recent study in England estimated that total
             costs linked to overweight and obesity could increase by as much as 70% between 2007
             and 2015, and be 2.4 times higher by 2025 (Foresight, 2007).


Shortages of health workers is a concern
in many countries

         ●   There are concerns in many European countries about shortages of doctors. The number
             of doctors per capita varies greatly, and is lowest in Turkey, followed by Poland and
             Romania. Doctor numbers are also relatively low in the United Kingdom and Finland.
         ●   Since 2000, the number of physicians per capita has however increased in all European
             countries, except the Slovak Republic. On average, the number grew from 3.0 doctors per
             1 000 population in 2000 to 3.3 in 2008. It increased particularly rapidly in Ireland, rising
             by nearly 50%. A large part of this increase was due to the recruitment of foreign-trained
             physicians, with the share of foreign-trained doctors tripling during that period.
             Similarly, the number of doctors per capita in the United Kingdom increased by 30%
             between 2000 and 2008, rising from 2.0 per 1 000 population to 2.6.
         ●   In contrast, there has been virtually no growth in the number of doctors per capita in
             France and Italy since 2000. Following a reduction in the number of new entrants in
             medical schools during the 1980s and 1990s, the number of doctors per capita in Italy
             peaked in 2002, and has declined since then. In France, the number peaked in 2005, and
             the decline is expected to continue over the next ten years.
         ●   In nearly all countries, the balance between general practitioners and specialists has
             changed over past decades, with the number of specialists increasing much more
             rapidly. As a result, there are more specialists than generalists in most countries, except
             Romania and Portugal. This may be explained by a reduced attractiveness in the
             traditional mode of practice of general/family practitioner, as well as a growing
             remuneration gap. The slow growth or reduction in the number of generalists per capita



HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                  11
EXECUTIVE SUMMARY



            raises concerns about access to primary care. Many countries are considering ways to
            improve the attractiveness of general practice as well as developing new roles for other
            health care providers, such as nurses.
        ●   There are also concerns about shortages of nurses in many European countries. Nurses
            play an important 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 patients’ homes. In 2008, there were about
            15 nurses per 1 000 population in Finland, Iceland, Ireland and Switzerland, and slightly
            fewer in Denmark and Norway. Turkey had the fewest nurses, followed by Greece,
            Bulgaria and Cyprus, at less than five per 1 000 population.
        ●   Since 2000, the number of nurses per capita has increased in all European countries,
            except Lithuania and the Slovak Republic. The increase was particularly large in
            Portugal, Spain, France and Switzerland.


Growing health expenditure puts pressure
on government budgets

        ●   Health expenditure has risen in all European countries, often increasing at a faster rate
            than economic growth, resulting in a rising share of GDP allocated to health. In 2008,
            EU countries spent, on average, 8.3% of their GDP on health, up from 7.3% in 1998.
            However, the share of GDP allocated to health spending varies considerably across
            countries, ranging from less than 6% in Cyprus and Romania to more than 10% in France,
            Switzerland, Germany and Austria.
        ●   In some countries, the recent economic downturn resulted in a marked increase in the
            ratio of health spending to GDP. In Ireland, the percentage of GDP devoted to health
            increased from 7.5% in 2007 to 8.7% in 2008. In Spain, it rose from 8.4% to 9.0%.
        ●   In 2008, Norway spent the most on health per capita among European countries, with
            spending of about EUR 4 300. Switzerland, Luxembourg and Austria were the next
            highest spending countries. Most northern and western European countries spend
            between EUR PPP 2 500 and 3 500 per person, that is, 10% to 60% more than the EU
            average. Those countries spending below the EU average are eastern and southern
            European countries such as Turkey, Romania, Bulgaria, Poland and Hungary.
        ●   Health expenditure per capita tends to be positively correlated with GDP per capita,
            although the association is stronger among European countries with low GDP per capita.
            Even for countries with similar levels of GDP per capita, there can be substantial
            differences in health expenditure. For example, Spain and France have similar GDP per
            capita, but Spain spends less than 80% of the level of France on health.
        ●   Health systems are sometimes criticised for being overly focused on “sick care”: for
            treating the ill, but not doing enough to prevent illness. Only around 3% of current health
            expenditure is spent on prevention and public health programmes on average in
            EU countries.
        ●   The public sector is the main source of health financing in all European countries, except
            Cyprus. On average, nearly three-quarter of all health spending was publicly financed
            in 2008, through general taxation or social security contributions. In Luxembourg, the
            Czech Republic, the Nordic countries (except Finland), the United Kingdom and
            Romania, public financing accounted for more than 80% of all health expenditure.


12                                                                          HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                            EXECUTIVE SUMMARY



         ●   The size and composition of private financing differs across countries. In most
             countries, it is in the form of out-of-pocket payments by patients. Private health
             insurance accounts for only around 3-4% of total health expenditure on average across
             EU countries. However, in some countries, it plays a significant role. In Germany, it
             provides primary coverage for certain population groups. In France, private health
             insurance finances 13% of overall spending, but provides complementary and
             supplementary coverage in a universal public system.
         ●   Given the current need to reduce budget deficits in many countries, governments may be
             faced with difficult policy choices in the short-term. They may either have to curb the
             growth of public spending on health, cut spending in other areas, or raise taxes or social
             security contributions to reduce their deficits. Improving productivity within the health
             sector may help to reconcile these pressures, for example through more rigorous
             assessment of health technologies or increased used of information and communication
             technologies (“eHealth”). These initiatives may also have the added benefit of improving
             the quality of care, which is another area of collaboration between the OECD and the
             European Commission.




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                               13
Health at a Glance: Europe 2010
© OECD 2010




                                      Résumé

L  es pays européens ont accompli d’importants progrès en matière de santé au cours des
dernières décennies. Dans les pays de l’Union européenne, l’espérance de vie à la naissance a
augmenté de six ans depuis 1980, tandis que la mortalité précoce a fortement reculé. Si
l’amélioration des conditions de vie et de travail, ainsi que de certains comportements
vis-à-vis de la santé, a joué un rôle majeur dans l’augmentation de la longévité, les progrès de
la médecine doivent également être salués. Les systèmes de santé dans les pays européens
occupent une place de plus en plus importante et les dépenses consacrées aux soins de santé
n’ont jamais été aussi élevées, représentant une part croissante du revenu national.
Cette première édition de Panorama de la santé : Europe, fruit d’une collaboration de longue
date entre l’OCDE et la Commission européenne, propose un ensemble d’indicateurs clés de
la santé et des systèmes de santé dans 31 pays européens, à savoir les 27 États membres de
l’Union européenne, l’Islande, la Norvège, la Suisse et la Turquie. La sélection d’indicateurs
s’appuie sur la liste des indicateurs de santé de la Communauté européenne (European
Community Health Indicators – ECHI), élaborée par la Commission européenne pour étayer la
production et la publication de statistiques sur la santé (Commission européenne, 2010a).
Certains des indicateurs diffèrent parfois des définitions retenues pour la liste ECHI pour des
questions de disponibilité des données. Dans d’autres cas, les indicateurs ECHI ne sont pas
encore prêts à être mis en œuvre. Par ailleurs, la publication fournit également des
informations détaillées sur les dépenses de santé et leur financement, en s’appuyant sur
l’expérience de l’OCDE en matière de collecte de données dans ce domaine. Les informations
présentées dans Panorama de la santé : Europe sont essentiellement issues de sources
statistiques nationales officielles, notamment d’Éco-Santé OCDE, de la base de données
statistique Eurostat et de la base de données Santé pour tous de l’OMS-Europe.
Panorama de la santé : Europe 2010 montre qu’il existe d’importants écarts entre les pays
européens en termes d’état de santé de la population, de facteurs de risques pour la santé,
d’intrants, d’extrants et de résultats des systèmes de santé, et de niveaux des dépenses de
santé et des sources de financement. L’étude propose des explications à ces écarts, en
fournissant le contexte nécessaire pour mieux comprendre leurs causes sous-jacentes. Il
convient aussi de noter que si des disparités par sexe et par âge sont présentées, cette
publication ne fournit généralement pas d’informations sur les disparités par région, par
groupe socioéconomique ou par groupe ethnique. Pour de nombreux indicateurs, le lecteur
doit garder à l’esprit que les variations peuvent être aussi importantes au sein d’un même
pays qu’entre les pays.




                                                                                                   15
RÉSUMÉ




L’état de santé s’est amélioré de manière
remarquable dans les pays européens,
même si des écarts importants persistent

         ●   Dans les pays de l’UE, l’espérance de vie à la naissance s’est allongée de six ans depuis 1980,
             pour atteindre 78 ans en 2007. En moyenne dans les 27 pays de l’UE, l’espérance de vie à la
             naissance pour la période 2005-07 s’élevait à 74.3 ans pour les hommes et à 80.8 ans pour les
             femmes. La France affiche l’espérance de vie à la naissance la plus longue pour les femmes
             (84.4 ans), tandis que l’espérance de vie la plus longue pour les hommes est observée en
             Suède (78.8 ans). Au sein de l’Union européenne, c’est en Roumanie que l’espérance de vie à
             la naissance est la plus courte pour les femmes (76.2 ans) et en Lituanie pour les hommes
             (65.1 ans). L’écart entre les pays à l’espérance de vie la plus longue et ceux où l’espérance de
             vie est la plus courte s’établit à 8 ans environ pour les femmes et à 14 ans pour les hommes.
         ●   Il importe de savoir si l’allongement de l’espérance de vie implique des années de vie
             supplémentaires en bonne santé, parce que cela a des répercussions majeures sur les
             systèmes de santé et de soins de longue durée en Europe. L’espérance de vie en bonne
             santé à la naissance est définie ici comme le nombre d’années de vie au cours desquelles
             les activités quotidiennes de l’individu ne sont pas limitées par une maladie ou un
             problème de santé. En 2005-07, l’espérance de vie en bonne santé s’établissait à 61.3 ans
             pour les femmes et 60.1 ans pour les hommes en moyenne dans l’Union européenne.
             L’écart hommes-femmes est donc bien moindre qu’en ce qui concerne l’espérance de
             vie, ce qui tient au fait qu’une plus forte proportion de la vie des femmes est marquée
             par des limitations de leur activité. En 2005-07, c’est à Malte que l’espérance de vie en
             bonne santé était la plus longue à la fois pour les hommes et pour les femmes, tandis
             que la Lettonie affichait l’espérance de vie en bonne santé la plus courte pour les
             femmes et l’Estonie pour les hommes.
         ●   L’espérance de vie à l’âge de 65 ans s’est aussi considérablement accrue en Europe au
             cours des dernières décennies. En 2005-07, elle s’élevait en moyenne dans les 27 pays de
             l’UE à 15.9 ans pour les hommes et 19.5 ans pour les femmes. Comme pour l’espérance
             de vie à la naissance, la France se distingue par l’espérance de vie à 65 ans la plus longue
             pour les femmes (22.6 ans) mais aussi pour les hommes (18.1 ans). Au contraire, c’est en
             Europe de l’Est que l’espérance de vie à 65 ans est la plus courte : en Lettonie pour les
             hommes (12.7 ans) et en Bulgarie pour les femmes (16.3 ans).
         ●   Comme pour l’espérance de vie à la naissance, l’écart hommes-femmes s’agissant de
             l’espérance de vie en bonne santé à 65 ans est bien plus restreint que pour l’espérance de
             vie : en 2005-07, les hommes étaient légèrement avantagés, avec 8.4 ans contre 8.1 ans
             pour les femmes.
         ●   Il est difficile d’estimer la contribution relative des multiples facteurs médicaux et non
             médicaux susceptibles d’influencer les écarts dans l’espérance de vie (en bonne santé).
             Un revenu national élevé est généralement associé à une meilleure espérance de vie
             dans les pays européens, quoique cette corrélation soit moins prononcée pour les
             niveaux de revenu élevés, ce qui suggère un « rendement décroissant » à partir d’un
             certain seuil. D’autres déterminants de la santé jouent également un rôle clé.




16                                                                              HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                           RÉSUMÉ




Les facteurs de risques évoluent

         ●   De nombreux pays de l’UE ont accompli des progrès remarquables dans la lutte contre le
             tabagisme, même s’il demeure l’une des principales causes de mortalité précoce. Cette
             réussite peut en grande partie être attribuée aux mesures mises en œuvre à l’échelle
             nationale et européenne pour promouvoir les campagnes de sensibilisation publique,
             les interdictions de publicité et la hausse des taxes. En Suède et en Islande, moins de
             18 % des adultes fument désormais quotidiennement, contre plus de 30 % en 1980. En
             revanche, près de 40 % des adultes continuent de fumer quotidiennement en Grèce. Le
             taux de tabagisme demeure également élevé en Bulgarie, en Irlande et aux Pays-Bas.
         ●   La consommation d’alcool a également diminué dans nombre de pays européens ces
             30 dernières années. Les restrictions sur la publicité et les ventes et la hausse des taxes
             se sont avérées des outils efficaces pour réduire la consommation d’alcool. Les pays
             traditionnellement producteurs de vin, comme l’Italie, la France et l’Espagne, ont vu la
             consommation d’alcool par habitant chuter fortement depuis 1980. À l’inverse, la
             consommation a sensiblement augmenté dans plusieurs pays comme l’Irlande, le
             Royaume-Uni et certains pays nordiques.
         ●   Plus de la moitié de la population adulte totale de l’Union européenne est désormais en
             situation de surpoids ou d’obésité. C’est également le cas dans 15 des 27 pays de l’UE. La
             prévalence de l’obésité – qui présente des risques pour la santé supérieurs à ceux du
             surpoids – est comprise entre moins de 10 % en Roumanie, en Suisse et en Italie à plus
             de 20 % au Royaume-Uni, en Irlande, à Malte et en Islande. En moyenne dans les pays de
             l’UE, 15.5 % de la population adulte est obèse.
         ●   Le taux d’obésité a plus que doublé ces 20 dernières années dans la plupart des pays de
             l’UE pour lesquels des données sont disponibles. Cette progression rapide est intervenue
             indépendamment des taux d’obésité observés il y a 20 ans. L’obésité a plus que doublé
             aux Pays-Bas et au Royaume-Uni entre 1988 et 2008, même si le taux observé aux
             Pays-Bas est actuellement inférieur de plus de moitié à celui du Royaume-Uni.
         ●   L’obésité étant associée à une augmentation des risques de maladie chronique, elle
             entraîne un coût supplémentaire important au niveau des soins de santé. Selon une
             étude récente réalisée en Angleterre, la hausse du coût représenté par le surpoids et
             l’obésité pourrait aller jusqu’à 70 % entre 2007 et 2015 et il pourrait être 2.4 fois plus
             élevé d’ici à 2025 (Foresight, 2007).


La pénurie de professionnels de santé est un sujet
d’inquiétude dans de nombreux pays

         ●   De nombreux pays européens s’inquiètent d’une pénurie de médecins. Le nombre de
             médecins par habitant varie fortement entre les pays; il atteint son niveau le plus bas en
             Turquie, suivie par la Pologne et la Roumanie. Il est également relativement bas au
             Royaume-Uni et en Finlande.
         ●   Depuis 2000, le nombre de médecins par habitant a néanmoins augmenté dans tous les
             pays européens, à l’exception de la Slovaquie. En moyenne, il est passé de 3.0 médecins
             pour 1 000 habitants en 2000 à 3.3 en 2008. Cette progression a été particulièrement
             rapide en Irlande, avec une hausse de près de 50 %. Ceci s’explique en grande partie par
             le recrutement de médecins formés à l’étrangers : le nombre de médecins formés à


HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                   17
RÉSUMÉ



             l’étranger a en effet triplé sur la période. De la même façon, le nombre de médecins par
             habitant au Royaume-Uni a progressé de 30 % entre 2000 et 2008, passant de 2.0 pour
             1 000 habitants à 2.6.
         ●   À l’inverse, le nombre de médecins par habitant est resté pratiquement inchangé en
             France et en Italie depuis 2000. Après une baisse du nombre de nouveaux inscrits en
             école de médecine dans les années 80 et 90, le nombre de médecins par habitant a
             atteint son point le plus haut en 2002 en Italie, pour s’orienter ensuite à la baisse. En
             France, il a touché son plus haut niveau en 2005 et la baisse devrait se poursuivre au
             cours des dix prochaines années.
         ●   Dans la quasi-totalité des pays, le rapport entre médecins généralistes et spécialistes a
             évolué au cours des dernières décennies, le nombre de spécialistes ayant progressé bien
             plus rapidement. Par conséquent, les spécialistes sont aujourd’hui plus nombreux que les
             généralistes dans la plupart des pays, à l’exception de la Roumanie et du Portugal. Ce
             phénomène peut s’expliquer par une diminution de l’attrait offert par le mode traditionnel
             de la pratique du médecin généraliste/de famille, ainsi que par un écart de rémunération
             croissant. La hausse limitée, voire la baisse, du nombre de généralistes par habitant
             suscite des inquiétudes quant à l’accès aux soins primaires. De nombreux pays étudient
             des moyens pour renforcer l’attractivité de la médecine générale et pour concevoir de
             nouveaux rôles pour d’autres professionnels de santé, comme le personnel infirmier.
         ●   Par ailleurs, de nombreux pays européens sont touchés par une pénurie de personnel
             infirmier. Les infirmiers jouent un rôle important dans la prestation des soins de santé non
             seulement dans le cadre traditionnel de l’hôpital ou des établissements de soins de longue
             durée mais aussi, de plus en plus, dans les soins primaires, notamment auprès des malades
             chroniques et dans les traitements à domicile. En 2008, on comptait environ 15 infirmières
             pour 1 000 habitants en Finlande, en Islande, en Irlande et en Suisse, et un peu moins au
             Danemark et en Norvège. La Turquie est le pays où l’on compte le moins d’infirmiers, suivie
             par la Grèce, la Bulgarie et Chypre, avec moins de 5 pour 1 000 habitants.
         ●   Depuis 2000, le nombre de personnel infirmier par habitant a progressé dans tous les
             pays européens, à l’exception de la Lituanie et de la Slovaquie. Cette progression est
             particulièrement importante au Portugal, en Espagne, en France et en Suisse.


L’augmentation des dépenses de santé pèse
sur les budgets nationaux

         ●   Les dépenses de santé ont augmenté dans tous les pays européens, la plupart du temps
             à un rythme supérieur à celui de la croissance économique, ce qui se traduit par une
             augmentation de la part du PIB allouée à la santé. En 2008, les pays de l’UE ont consacré
             en moyenne 8.3 % de leur PIB aux dépenses de santé, contre 7.3 % en 1998. Néanmoins,
             la part du PIB allouée aux dépenses de santé varie considérablement entre les pays, de
             moins de 6 % à Chypre et en Roumanie à plus de 10 % en France, en Suisse, en Allemagne
             et en Autriche.
         ●   Dans certains pays, la récession récente a provoqué une hausse notable de la part des
             dépenses de santé dans le PIB. Ainsi, en Irlande, la part du PIB consacrée à la santé a
             progressé de 7.5 % en 2007 à 8.7 % en 2008. En Espagne, elle est passée de 8.4 % à 9.0 %.




18                                                                           HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                            RÉSUMÉ



         ●   En 2008, la Norvège est le pays qui affiche les dépenses de santé par habitant les
             plus élevées parmi les pays européens, à 4 300 EUR environ, suivie par la Suisse, le
             Luxembourg et l’Autriche. La plupart des pays d’Europe du Nord et de l’Ouest ont
             dépensé entre 2 500 et 3 500 EUR par habitant, ce qui est supérieur de 10 à 60 % à la
             moyenne de l’UE. Les pays où les dépenses de santé sont inférieures à la moyenne de
             l’UE sont les pays d’Europe de l’Est et du Sud comme la Turquie, la Roumanie, la Bulgarie,
             la Pologne et la Hongrie.
         ●   Les dépenses de santé par habitant présentent généralement une corrélation positive
             avec le PIB par habitant, même si celle-ci est plus étroite dans les pays européens
             caractérisés par un PIB par habitant relativement bas. Cependant, même dans les pays
             au PIB par habitant équivalent, on peut observer des écarts importants en matière de
             dépenses de santé. Par exemple, l’Espagne et la France affichent un PIB par habitant
             assez proche, mais les dépenses de santé de l’Espagne représentent moins de 80 % de
             celles de la France.
         ●   On déplore parfois que les systèmes de santé soient trop tournés sur les soins aux malades,
             c’est-à-dire qu’ils sont davantage axés sur le traitement des maladies plutôt que sur leur
             prévention. En moyenne dans les pays de l’UE, seulement 3 % environ des dépenses de santé
             sont consacrées à la prévention et aux programmes de santé publique.
         ●   Le secteur public représente la principale source de financement de la santé dans tous les
             pays européens, à l’exception de Chypre. En moyenne, près de 75 % des dépenses de santé
             totales étaient financées par les fonds publics en 2008, au moyen des recettes fiscales ou
             des cotisations de sécurité sociale. Au Luxembourg, en République tchèque, dans les pays
             nordiques (hors Finlande), au Royaume-Uni et en Roumanie, le financement public couvre
             les dépenses de santé à hauteur de plus de 80 %.
         ●   L’ampleur et la composition du financement privé varient selon les pays. Généralement, il
             prend la forme d’une participation financière par les patients. L’assurance maladie privée
             ne représente que 3-4 % seulement des dépenses de santé totales en moyenne dans les
             pays de l’UE. Toutefois, dans certains pays, elle a un rôle de financement important. Ainsi,
             elle assure une couverture primaire à certaines catégories de population en Allemagne. En
             France, l’assurance maladie privée finance 13 % des dépenses totales mais elle fournit une
             couverture complémentaire et supplémentaire dans le cadre d’un régime public universel.
         ●   De nombreux pays étant actuellement soucieux de réduire leurs déficits budgétaires, les
             pouvoirs publics seront confrontés à des choix difficiles à court terme. Ils pourraient en
             effet être contraints soit de freiner la croissance des dépenses publiques de santé, soit de
             réduire les dépenses dans d’autres secteurs, ou soit d’augmenter les impôts ou les
             cotisations de sécurité sociale, pour réduire leurs déficits. Des gains de productivité et
             d’efficience dans le secteur de la santé pourraient contribuer à alléger les pressions, par
             exemple au moyen d’une évaluation plus rigoureuse des technologies de santé ou d’un
             recours accru aux technologies de l’information et de la communication. Ces initiatives
             pourraient en outre permettre d’améliorer la qualité des soins, ce qui constitue un autre
             axe important de collaboration entre l’OCDE et la Commission européenne.




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                    19
      Health at a Glance: Europe 2010
      © OECD 2010




                                           Introduction
      H   ealth at a Glance: Europe 2010 presents key indicators of health and health systems in
      31 European countries, including the 27 European Union member states, three EFTA
      countries (Iceland, Norway and Switzerland), and Turkey. It builds on the format used in
      the OECD’s previous editions of Health at a Glance to provide comparable information on
      important public health issues in Europe. The indicators have been selected on the basis of
      the European Community Health Indicators (ECHI) shortlist (European Commission, 2010a;
      ECHIM, 2010). However, in some instances, this report deviates from the formal ECHI
      definitions because of issues related to data availability and comparability. Detailed
      information is also provided in this publication on health expenditure and financing
      trends, based on the OECD’s long-standing data collection in this area. All indicators are
      presented in the form of easy-to-read figures and explanatory text.

Structure of the publication
          The structure of Health at a Glance: Europe 2010 generally reflects the structure of the
      European Community Health Indicators. It is divided into four 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 habits, physical activity, and overweight and obesity.
      ●   Chapter 3 on Health Care Resources, Services and Outcomes reviews some of the inputs,
          outputs and outcomes 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. It concludes with a review of care related to cancer, focusing on the
          coverage of screening programmes and survival rates for two types of cancer: breast and
          cervical cancer.
      ●   Chapter 4 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.




                                                                                                      21
INTRODUCTION



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 discloses 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) countries, and is calculated as the unweighted
       average of those EU countries presented (up to 27, if there is full data coverage).

Data limitations
           Limitations in data comparability are indicated both in the text (in the box related to
       “Definition and deviations”) 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 2010 for all OECD member countries. This
       information is available at www.oecd.org/health/healthdata.
            For the six non-OECD member countries (Bulgaria, Cyprus, Latvia, Lithuania, Malta and
       Romania), readers should consult the Eurostat Database at 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 SANCO health indicators tool at www.ec.europa.eu/health/indicators/indicators/index_en.htm.

Population figures
            The population figures presented in the annex and used to calculate rates per capita
       in this publication come from the OECD Labour Force Statistics Database (as of May 2010) for
       OECD member countries, and refer to mid-year estimates. For the six non-OECD member
       countries, the data come from the Eurostat Demographics Database (as of July 2010), and refer
       to estimates at the beginning of the year. Population estimates are subject to revision, so
       they may differ from the latest population figures released by national statistical offices.
            Note that some countries such as France and the United Kingdom have overseas
       colonies, protectorates and territories. These populations are generally excluded. The
       calculation of GDP per capita and other economic measures may, however, be based on a
       different population in these countries, depending on the data coverage.




22                                                                        HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                      INTRODUCTION



Country codes (ISO codes)
          Austria                                 AUT              Lithuania                                LTU
          Belgium                                 BEL              Luxembourg                               LUX
          Bulgaria                                BGR              Malta                                    MLT
          Cyprus1                                 CYP              Netherlands                              NLD
          Czech Republic                          CZE              Norway                                   NOR
          Denmark                                 DNK              Poland                                   POL
          Estonia                                 EST              Portugal                                 PRT
          Finland                                  FIN             Romania                                  ROM
          France                                  FRA              Slovak Republic                          SVK
          Germany                                 DEU              Slovenia                                 SVN
          Greece                                  GRC              Spain                                    ESP
          Hungary                                 HUN              Sweden                                   SWE
          Iceland                                  ISL             Switzerland                              CHE
          Ireland                                  IRL             Turkey                                   TUR
          Italy                                    ITA             United Kingdom                           GBR
          Latvia                                  LVA

         1. Note by Turkey: The information in this document with reference to “Cyprus” relates to the Southern part of the
            Island. There is no single authority representing both Turkish and Greek Cypriot people on the Island. Turkey
            recognises the Turkish Republic of Northern Cyprus (TRNC). Until a lasting and equitable solution is found within
            the context of United Nations, Turkey shall preserve its position concerning the “Cyprus” issue.
            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 2010 © OECD 2010                                                                                     23
Health at a Glance: Europe 2010
© OECD 2010




                                                           Chapter 1




                                               Health Status


         1.1.     Life expectancy and healthy life expectancy at birth . . . . . . . . . . . . .                                    26
         1.2.     Life expectancy and healthy life expectancy at age 65. . . . . . . . . . . .                                      28
         1.3.     Mortality from all causes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                30
         1.4.     Mortality from heart disease and stroke. . . . . . . . . . . . . . . . . . . . . . . .                            32
         1.5.     Mortality from cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               34
         1.6.     Mortality from transport accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . .                        36
         1.7.     Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   38
         1.8.     Infant mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          40
         1.9.     Infant health: Low birth weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                     42
         1.10. Self-reported health and disability . . . . . . . . . . . . . . . . . . . . . . . . . . . .                          44
         1.11. Incidence of selected communicable diseases . . . . . . . . . . . . . . . . . .                                      46
         1.12. HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         48
         1.13. Cancer incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               50
         1.14. Diabetes prevalence and incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . .                            52
         1.15. Dementia prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  54




                                                                                                                                         25
1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH


     Life expectancy at birth continues to increase                     1.9 years more HLY for men at birth than women in
remarkably in EU countries, reflecting reductions in                    the Netherlands. Of the remaining countries, Poland
mortality rates at all ages. These gains in longevity                   had the largest gender gap in HLY at birth favouring
can be attributed to a number of factors, including                     women.
rising living standards, improved lifestyle and better                       Higher national income (as measured by GDP per
education, as well as greater access to quality health                  capita) is generally associated with higher life expec-
services. Other factors, such as better nutrition,                      tancy at birth, although the relationship between GDP
sanitation and housing also play a role, particularly in                and HLY is less obvious (Figure 1.1.2). There is a
countries with developing economies (OECD, 2004).                       modest positive relationship, with increasing GDP per
      Ave ra g e l i f e e x p e c t a n cy a t b i r t h f o r t h e   capita associated with increasing HLY, although it is
years 2005-07 across the 27 countries of the European                   less pronounced at higher levels of national income.
Union reached 74.3 years for men and 80.8 years for                     There are also notable differences in HLY between EU
women (Figure 1.1.1), a rise of approximately three                     countries with similar income per capita. Sweden and
years for men and two years for women over the                          the United Kingdom have higher, and Finland and
decade from 1995-97. In around 70% of EU countries,                     Estonia lower HLY than would be predicted by their
life expectancy at birth in 2005-07 exceeded 80 years                   GDP alone. Similarly, Figure 1.1.3 shows the relation-
for women and 77 years for men. France had the high-                    ship between HLY at birth and health spending per
est life expectancy at birth for women (84.4 years),                    capita. Higher health spending per capita is generally
while Sweden had the highest life expectancy at birth                   associated with higher HLY.
for men (78.8 years). At the other end of the scale, life
expectancy at birth in the European Union was lowest
in Romania for women (76.2 years) and Lithuania for
                                                                                    Definition and deviations
men (65.1 years). The gap between EU countries with
the highest and lowest life expectancies at birth is                        Life expectancy measures how long, on
around eight years for women and 14 years for men.                        average, people would live based on a given set
      The gender gap in life expectancy at birth                          of age-specific death rates. However, the actual
in 2005-07 stood at 6.5 years, almost one year less                       age-specific death rates of any particular birth
than a decade earlier. However, this average hides a                      cohort cannot be known in advance. If age-
huge range among countries with the smallest gender                       specific death rates are falling (as has been the
gap in life expectancy at birth in the United Kingdom                     case over the past decades in EU countries),
and Cyprus (4.1 years) and the largest in Lithuania                       actual life spans will be higher than life expec-
(12.1 years). The recent narrowing of the gender gap in                   tancy calculated with current death rates.
life expectancy can be attributed at least partly to the                    Healthy life years (HLY) at a particular age are
narrowing of differences in risk-increasing behaviours                    the number of years spent free of activity limita-
between men and women, such as smoking, accom-                            tion. They are calculated by Eurostat for each EU
panied by sharp reductions in mortality rates from                        country using the Sullivan method (Sullivan,
cardio-vascular diseases among men.                                       1971). The underlying health measure is the
      On average for EU countries healthy life years                      Global Activity Limitation Indicator (GALI) which
(HLY) at birth in 2005-07 was 61.3 years for women                        comes from the European Union Statistics on
and 60.1 years for men. HLY at birth in 2005-07 was                       Income and Living Conditions (EU-SILC) survey.
greatest in Malta for both men and women, and                             The GALI measures limitation in usual activities.
shortest in Latvia for women and Estonia for men                          The questionnaire responses used in Denmark
(Figure 1.1.1). The spread of values for HLY at birth                     differ slightly, resulting in an under-estimation
among EU countries were much greater than for                             of activity limitation. Data are not available for
life expectancy, being 17.0 years for women and                           Bulgaria, Switzerland and Turkey.
19.5 years for men, but there was a much smaller                            Comparing trends in HLY and life expectancy
absolute difference between men and women                                 can show whether extra years of life are healthy
(2.5 years). Since the HLY indicator has only recently                    years. However, valid comparisons depend on
been developed, there is as yet no long time series.                      the underlying health measure being truly
     In contrast to the 6.5 year gap in life expectancy                   comparable. While HLY is the most comparable
at birth for EU countries on average, the gender gap in                   indicator to date, there are still problems with
HLY at birth was 1.2 years in 2005-07. For life expec-                    translation of the GALI question, although it
tancy at birth the gender gap is always in favour of                      does appear to satisfactorily reflect other health
women. However, eight countries had a gender gap in                       and disability measures (Jagger et al., 2010).
HLY at birth which favoured men, the greatest being



26                                                                                        HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                          1.1. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT BIRTH



                                  1.1.1. Life expectancy and healthy life years (HLY) at birth, by gender, 2005-07
                                                                       HLY                                                 LE with activity limitation

                                             Females                                                                                                            Males
  84.4                                                                                                   France                                                                                       77.2
  84.2                                                                                                Switzerland                                                                                        79.1
  84.1                                                                                                    Spain                                                                                        77.5
  84.0                                                                                                     Italy                                                                                        78.4
   83.3                                                                                                 Iceland                                                                                           79.5
   83.0                                                                                                 Sweden                                                                                          78.8
   82.9                                                                                                 Finland                                                                                   75.8
   82.8                                                                                                 Norway                                                                                          78.1
    82.7                                                                                                Austria                                                                                       77.1
    82.3                                                                                               Germany                                                                                        77.1
    82.2                                                                                                Belgium                                                                                       76.6
     82.1                                                                                             Netherlands                                                                                      77.7
     82.1                                                                                            Luxembourg                                                                                       76.7
     82.0                                                                                                Ireland                                                                                       77.4
     82.0                                                                                              Portugal                                                                                  75.5
     81.9                                                                                               Cyprus                                                                                         77.8
     81.8                                                                                                Greece                                                                                       77.0
     81.7                                                                                                 Malta                                                                                       77.2
     81.6                                                                                               Slovenia                                                                                74.3
        81.4                                                                                        United Kingdom                                                                                     77.3
         80.8                                                                                               EU                                                                                  74.3
         80.6                                                                                          Denmark                                                                                    76.1
          79.8                                                                                      Czech Republic                                                                             73.4
           79.6                                                                                          Poland                                                                          70.9
              78.5                                                                                      Estonia                                                                   67.3
               78.3                                                                                 Slovak Republic                                                                      70.4
                77.6                                                                                    Hungary                                                                     69.1
                77.2                                                                                   Lithuania                                                             65.1
                  76.4                                                                                    Latvia                                                             65.5
                  76.4                                                                                  Bulgaria                                                                    69.2
                  76.2                                                                                 Romania                                                                      69.2
                     75.3                                                                                Turkey                                                                          71.0

90              80                70               60              50             40          30                      30            40             50            60               70                   80              90
Years                                                                                                                                                                                                               Years

Source: European Health and Life Expectancy Information System (EHLEIS); OECD Health Data 2010; Eurostat Statistics Database.
                                                                              1 2 http://dx.doi.org/10.1787/888932335400


   1.1.2. Healthy life years (HLY) at birth, 2005-07                                                              1.1.3. Healthy life years (HLY) at birth, 2005-07
              and GDP per capita, 2007                                                                                 and health spending per capita, 2007
HLY (years)                                                                                                   HLY (years)
   70                                                                                                            70
                                                                 ISL
                  R 2 = 0.31                                                                                                R 2 = 0.33                                ISL
                                                                       DNK                                                                                                        DNK
                                                         GRC                                                                                                      GRC
                                                                       SWE                                                                                        GBR        SWE
                                                          GBR
   65                                               ITA
                                                                         NLD            NOR                      65                                        ITA                           NLD
                                                                                                                                                                                                              NOR
                                                                FRA             IRL                                                                                   IRL
                                                    ESP                                                                                                   ESP
                                                                                                                                                                                  FRA
                            ROU                           BEL                                 LUX                             ROU                                                                LUX
                                              CYP                                                                                                  CYP                      BEL
                                       POL                                                                                                POL
   60                                   CZE                                                                      60                       CZE
                                                        SVN            AUT                                                                               SVN                             AUT
                                              PRT                                                                                                         PRT
                                                                  DEU                                                                                                               DEU

                                             SVK                                                                                         HUN
   55                          HUN                                                                               55                               SVK
                              LTU                                  FIN                                                                                                FIN
                                                                                                                                      LTU
                             LVA                                                                                                            LVA
                                             EST                                                                                EST
   50                                                                                                            50
          0              10 000         20 000            30 000             40 000    50 000 60 000                  0             1000                2000            3000         4000       5000
                                                                             GDP per capita (EUR PPP)                                                           Health spending per capita (EUR PPP)

Source: European Health and Life Expectancy Information System                                                Source: European Health and Life Expectancy Information System
(EHLEIS); OECD Health Data 2010; Eurostat Statistics Database; WHO.                                           (EHLEIS); OECD Health Data 2010; Eurostat Statistics Database; WHO.
           1 2 http://dx.doi.org/10.1787/888932335419                                                                    1 2 http://dx.doi.org/10.1787/888932335438




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                           27
1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65


     Life expectancy at age 65 has increased signifi-        women than for men. Longer life expectancy at age
cantly among both women and men over the past                65 does not necessarily imply more HLY.
several decades in all EU countries. Some of the                  Contrary to life expectancy where the rankings
factors explaining the gains in life expectancy at age       for men and women are different, there is a close
65 include advances in medical care combined with            association between HLY at age 65 for men and
greater access to health care, healthier lifestyles and      women. At the overall EU level, this consistency
improved living conditions before and after people           between the number of years spent free of activity
reach age 65.                                                limitation (HLY) between men and women at birth
     The average life expectancy at age 65 years             and at age 65 is true also for intermediate ages.
in 2005-07 for the 27 countries of the European Union        Women’s longer life expectancy at all ages are more
was 15.9 years for men and 19.5 years for women              often years spent with activity limitation. Lower HLY
(Figure 1.2.1). As for life expectancy at birth, France      at age 50 across EU countries has been shown to be
had the highest life expectancy at age 65 for women          associated with lower GDP and with higher long-term
(22.6 years) but also for men (18.1 years). Life expec-      unemployment and lower life-long learning for men
tancy at age 65 in the European Union was lowest in          (Jagger et al., 2008).
Eastern Europe – in Latvia for men (12.7 years) and in
Bulgaria for women (16.3 years).
     The average gender gap in life expectancy at age 65
in 2005-07 stood at 3.6 years, down from the previous                   Definition and deviations
decade by 0.4 years. Greece had the smallest gender gap          Life expectancy measures how long, on
of two years and Estonia the largest at 5.1 years.             average, people would live based on a given set
      Gains in longevity at older ages in recent decades       of age-specific death rates. However, the actual
in EU countries, combined with the trend reduction in          age-specific death rates of any particular birth
fertility rates are contributing to a steady rise in the       cohort cannot be known in advance. If age-
proportion of older persons in EU countries (see               specific death rates are falling (as has been the
Annex Tables A.2 and A.4). Whether longer life expec-          case over the past decades in EU countries),
tancy is accompanied by good health and functional             actual life spans will be higher than life expec-
status among ageing populations has important                  tancy calculated with current death rates.
implications for health and long-term care systems.              Healthy life years (HLY) at a particular age are
     As is the case for HLY at birth, HLY at age 65            the number of years spent free of activity limita-
in 2005-07 for EU countries was similar for men and            tion. They are calculated by Eurostat for each
women, being 8.4 years for men and 8.1 years for               EU country using the Sullivan method (Sullivan,
women. HLY at age 65 in 2005-07 was greatest in                1971). The underlying health measure is the
Denmark and shortest in Estonia for both men and               Global Activity Limitation Indicator (GALI) which
women (Figure 1.2.1). It should be noted though, that          comes from the European Union Statistics on
the question used to measure activity limitation in            Income and Living Conditions (EU-SILC) survey.
Denmark differs slightly from that used in other               The GALI measures limitation in usual activities.
countries, resulting in an over-estimation of HLY. HLY         The questionnaire responses used in Denmark
is based on the Global Activity Limitation (GALI)              differ slightly, resulting in an under-estimation
question, which is one of three indicators included in         of activity limitation. Data are not available for
the Minimum European Health Module along with                  Bulgaria, Switzerland and Turkey.
global items on self-perceived health and chronic                Comparing trends in HLY and life expectancy
morbidity. Health expectancies based on these alter-           can show whether extra years of life are healthy
native questions would rank the countries differently.         years. However, valid comparisons depend on
In addition, since the HLY indicator has only been             the underlying health measure being truly
developed relatively recently, there is as yet no long         comparable. While HLY is the most comparable
time series.                                                   indicator to date, there are still problems with
    The relationship between life expectancy and               translation of the GALI question, although it
HLY at age 65 is not clear-cut (Figure 1.2.2). Higher life     does appear to satisfactorily reflect other health
expectancy at age 65 is generally associated with              and disability measures (Jagger et al., 2010).
higher HLY, but the relationship is less pronounced for




28                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                  1.2. LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY AT AGE 65



                                          1.2.1. Life expectancy and healthy life years (HLY) at 65, by gender, 2005-07
                                                                          HLY                                                      LE with activity limitation

                                                    Females                                                                                                              Males
  22.6                                                                                                            France                                                                                  18.1
   22.0                                                                                                        Switzerland                                                                                  18.4
    21.7                                                                                                           Spain                                                                                 17.6
     21.6                                                                                                           Italy                                                                                17.8
         21.1                                                                                                    Finland                                                                             16.9
         20.9                                                                                                    Iceland                                                                                     18.4
         20.9                                                                                                    Norway                                                                                 17.4
         20.8                                                                                                    Sweden                                                                                  17.7
          20.7                                                                                                   Austria                                                                              17.3
          20.6                                                                                                   Belgium                                                                             17.0
           20.4                                                                                                 Germany                                                                              17.1
           20.4                                                                                                Netherlands                                                                         16.8
              20.3                                                                                            Luxembourg                                                                           16.7
              20.1                                                                                                Ireland                                                                            16.9
               19.9                                                                                             Portugal                                                                          16.5
                19.8                                                                                             Slovenia                                                                     15.6
                19.8                                                                                         United Kingdom                                                                           17.2
                19.5                                                                                                 EU                                                                          15.9
                19.5                                                                                               Malta                                                                          16.3
                 19.5                                                                                            Cyprus                                                                                 17.3
                 19.4                                                                                             Greece                                                                                17.3
                  19.2                                                                                          Denmark                                                                           16.3
                     18.8                                                                                         Poland                                                                  14.5
                       18.3                                                                                      Estonia                                                           13.1
                        18.2                                                                                 Czech Republic                                                                14.8
                          17.7                                                                                  Lithuania                                                       13.0
                            17.6                                                                                 Hungary                                                            13.5
                            17.3                                                                             Slovak Republic                                                       13.4
                             17.2                                                                                  Latvia                                                       12.7
                                 16.5                                                                           Romania                                                             13.6
                                   16.3                                                                          Bulgaria                                                          13.2
                                    15.7                                                                          Turkey                                                               13.9

25                   20                     15                     10                 5                0                       0                5             10                       15                       20            25
Years                                                                                                                                                                                                                      Years

Source: European Health and Life Expectancy Information System (EHLEIS); Eurostat Statistics Database; OECD Health Data 2010.
                                                                               1 2 http://dx.doi.org/10.1787/888932335457


                          1.2.2. Relationship between life expectancy and healthy life years (HLY) at 65, 2005-07
                                                       Females                                                                                                 Males
Life expectancy (years)                                                                                                Life expectancy (years)
    24                                                                                                                     20
                     R 2 = 0.36                                                                                                    R 2 = 0.55
                                                                        FRA                                                                                                                                          ISL
   22                                                                                                                     18                                           ITA          FRA
                                                             ITA               ESP                                                                                                 ESP GBR                     SWE
                                                                                                                                                             AUT
                                                                                                                                                    CYP                              GRC                    NOR
                                                      FIN                                  NOR                                                                               BEL
                                                                                     SWE               ISL                                             DEU         FIN                           NLD
                                                AUT     DEU LUX BEL                                                                                                                       IRL
                                                                                                                                                     PRT                           LUX
                                                          SVN            NLD                                                                                                                 MLT                       DNK
   20                                       PRT                   IRL  GBR
                                                                                                                          16                                             EU
                                                        EU                                                                                                                         SVN
                                                              CYP     MLT
                                                                                                 DNK
                                                                         GRC
                                                            POL                                                                                                    CZE
                                                                                                                                                                          POL
                             EST                       CZE
   18                                                                                                                     14
                                 HUN        LTU                                                                                              SVK                   ROU
                                                                                                                                                     HUN
                        SVK               LVA                                                                                      EST           LTU
                                                             ROU                                                                                LVA

   16                                                                                                                     12
          2                  4                  6            8                10       12          14      16                  2         4             6           8               10              12          14      16
                                                                                     Healthy life years (HLY)                                                                                    Healthy life years (HLY)

Source: European Health and Life Expectancy Information System (EHLEIS); Eurostat Statistics Database; OECD Health Data 2010.
                                                                               1 2 http://dx.doi.org/10.1787/888932335476




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                  29
1.3. MORTALITY FROM ALL CAUSES


     Mortality rates are one of the most common             are in the order of eight years for females and 12 years
measures of population health. Statistics on deaths         for males. Some important causes of mortality below
remain one of the most widely available and compa-          the age of 65 years that may be avoided through effec-
rable sources of information on health. Registering         tive evidence-based public health measures include
deaths is compulsory in all European Union countries,       ischemic heart disease, lung cancer, alcohol-related
and the data collected through the process of registra-     mortality, suicide, transport accidents, cervical cancer
tion can be used by statistical and health authorities      and AIDS (Cayotte and Buchow, 2009).
to monitor diseases and health status, and to plan               Although mortality rates in Central and Eastern
health services. In order to compare levels of mortal-      Europe are still comparatively high, significant declines
ity across countries and over time, the data need to be     have occurred in a number of these countries since 1994
aggregated in suitable ways and standardised for            (Figures 1.3.2 and 1.3.3). Mortality rates in Estonia,
differences in age-structure.                               Slovenia, the Czech Republic, Hungary and Poland have
     In 2008 there were large variations in age-            fallen by more than 30%, a decline that is greater than
standardised total mortality rates for all causes of        the EU average. Ireland has also seen a fall in mortality
death across European Union countries. Death rates          rates of over 50%. In contrast, declines in the Slovak
were lowest in Switzerland, Italy, Iceland and Spain, at    Republic and Lithuania have been small. Declines in a
520 deaths per 100 000 population or less (Figure 1.3.1).   number of Nordic countries (Sweden, Iceland) have also
Rates in northern, western and southern European            been modest, although these countries began the period
countries were lower than the EU average rate of 696.       with rates that were already low.
They were highest in central and eastern European                The leading causes of death in EU countries
countries – Lithuania and Latvia, for instance, had         include cardiovascular diseases (such as heart attack
age-standardised rates twice those of the lowest            and stroke), and cancer. Deaths from these diseases,
countries at over 1 000 deaths per 100 000 population.      plus selected external causes of death (transport
Rates in Bulgaria, Romania, Hungary and a number            accidents and suicide), are examined more closely in
of other central and eastern European countries were        the following four indicators.
above 800. Among these countries, only Slovenia had a
mortality rate that was lower than the EU average.
     Male mortality rates were lowest in Iceland,
Switzerland and Sweden, and high in Lithuania,
Latvia and Estonia. Female rates were low in France,                    Definition and deviations
Spain and Switzerland, and high in Bulgaria, Romania
                                                                 Mortality rates are based on numbers of
and Lithuania. A significant gender gap exists in
                                                              deaths registered in a country in a year divided
mortality rates (Figure 1.3.1). Across all EU countries,
                                                              by the size of the corresponding population. The
the male mortality rate was, on average, 70% higher
                                                              rates have been directly age-standardised to the
than the female rate in 2008. But large differences
                                                              WHO European standard population to remove
exist among countries – in Estonia, Lithuania and
                                                              variations arising from differences in age struc-
Latvia, male rates were more than twice those of
                                                              tures across countries and over time. The source
females, whereas in Iceland, the United Kingdom and
                                                              is the Eurostat Statistics Database.
Greece they were around 40% higher.
                                                                Mathers et al. (2005) have provided a general
    Lower mortality rates translate into higher life
                                                              assessment of the coverage, completeness and
expectancies. In 2005-07, average life expectancy
                                                              reliability of data on causes of death.
across all EU countries was approximately 81 years for
females and 74 years for males (see Indicator 1.1).             Deaths from all causes are classified to ICD-10
However, the differences in life expectancy among             codes A00-Y89, excluding S00-T98.
countries with the lowest and highest mortality rates




30                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                              1.3. MORTALITY FROM ALL CAUSES



                            1.3.1. Mortality rates from all causes of death, 2008 (or nearest year available)
                                                                                                                                                     Males                                         Females
                                   Total population
                                                                                                                                         394
                                                         490                                                Switzerland                                614
                                                                                                                                         401
                                                     512                                                         Italy                                   658
                                                                                                                                           447
                                                     516                                                      Iceland                                 592
                                                                                                                                         387
                                                    520                                                         Spain                                        682
                                                                                                                                         381
                                                    522                                                        France                                        702
                                                                                                                                           451
                                                   541                                                        Sweden                                        652
                                                                                                                                           446
                                                549                                                           Norway                                         683
                                                                                                                                           451
                                                550                                                           Cyprus                                        661
                                                                                                                                           440
                                               557                                                            Austria                                         710
                                                                                                                                               475
                                               566                                                          Netherlands                                      688
                                                                                                                                               470
                                              568                                                              Ireland                                       685
                                                                                                                                               467
                                              582                                                            Germany                                          721
                                                                                                                                           439
                                             587                                                              Finland                                              771
                                                                                                                                               479
                                             590                                                                Malta                                             735
                                                                                                                                                496
                                          596                                                                  Greece                                         706
                                                                                                                                                504
                                          599                                                             United Kingdom                                      714
                                                                                                                                               487
                                         603                                                               Luxembourg                                              769
                                                                                                                                               478
                                        624                                                                  Portugal                                                  808
                                                                                                                                               472
                                        634                                                                   Slovenia                                                   849
                                                                                                                                                     567
                                  683                                                                        Denmark                                                    828
                                                                                                                                                 534
                                  696                                                                             EU                                                          912
                                                                                                                                                      577
                            747                                                                           Czech Republic                                                        968
                                                                                                                                                      589
                      819                                                                                      Poland                                                                 1 125
                                                                                                                                                           657
                888                                                                                       Slovak Republic                                                                  1 204
                                                                                                                                                       613
                894                                                                                           Estonia                                                                              1 324
                                                                                                                                                            686
              926                                                                                            Hungary                                                                          1 258
                                                                                                                                                                 740
          964                                                                                                Romania                                                                        1 237
                                                                                                                                                                  766
        996                                                                                                   Bulgaria                                                                        1 279
                                                                                                                                                             707
      1 007                                                                                                     Latvia                                                                                     1 467
                                                                                                                                                             712
    1 034                                                                                                    Lithuania                                                                                      1 504

1 200 1 000         800        600        400                                      200           0                          0             500                  1 000            1 500        2 000
Age-standardised rates per 100 000 population                                                                                                         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/10.1787/888932335495


1.3.2. Decline in all cause mortality rates, 1994-2008                                                                      1.3.3. Trends in all cause mortality rates,
              (or nearest year available)                                                                                       selected EU countries, 1994-2008
           Estonia                                                                                        54
                                                                                                                                                      Hungary                                              Ireland
            Ireland                                                                                  51
          Slovenia                                                                          47                                                        Italy                                                EU
   Czech Republic                                                                     38
                                                                                                                    Age-standardised rates per 100 000 population
          Portugal                                                                   37
                                                                                                                    1 400
          Hungary                                                                  36
            Austria                                                                36
         Germany                                                                 34
               Italy                                                            34
              Malta                                                           32                                    1 200
            Poland                                                           31
           Finland                                                          31
      Switzerland                                                           30
                 EU                                                        30                                       1 000
           Norway                                                         29
              Spain                                                      29
      Netherlands                                                        28
  United Kingdom                                                    26
          Bulgaria                                                25                                                  800
         Denmark                                                 24
     Luxembourg                                                  23
             Latvia                                            22
           Iceland                                            21                                                      600
            Greece                                          20
           Sweden                                          19
         Lithuania                                    16
  Slovak Republic                                   15
                                                                                                                      400
                       0                10                20         30             40      50       60                  1994     1996         1998               2000              2002           2004            2006 2008
                                                                                     Percentage decline

Source: Eurostat Statistics Database. Data are age-standardised to                                                  Source: Eurostat Statistics Database. Data are age-standardised to
the WHO European standard population.                                                                               the WHO European standard population.
           1 2 http://dx.doi.org/10.1787/888932335514                                                                          1 2 http://dx.doi.org/10.1787/888932335533




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                              31
1.4. MORTALITY FROM HEART DISEASE AND STROKE


     Cardiovascular diseases are the main cause of         of countries, however, have seen little or no decline
mortality in almost all European Union countries,          since 1994. In the Slovak Republic, mortality rates
accounting for 40% of all deaths in the region in 2008.    have increased slightly. Declines in Poland, Hungary
They cover a range of diseases related to the circula-     and Lithuania have been moderate, at under 20%.
tory system, including ischemic heart disease (known            Stroke is another important cause of mortality in
as IHD, or heart attack) and cerebro-vascular disease      EU countries, accounting for about 10% of all deaths
(or stroke). Together, IHD and stroke comprise 60% of      in 2008. It is caused by the disruption of the blood
all cardiovascular deaths, and caused one-quarter of       supply to the brain, and in addition to being an impor-
all deaths in EU countries in 2008.                        tant cause of mortality, the disability burden from
     Ischemic heart disease is caused by the accumu-       stroke is substantial (Moon et al., 2003). As with IHD,
lation of fatty deposits lining the inner wall of a        there are large variations in stroke mortality rates
coronary artery, restricting blood flow to the heart.      across countries (Figure 1.4.2). Again, the rates are
IHD alone was responsible for 15% of all deaths in EU      highest in central and eastern European countries,
countries in 2008. Mortality from IHD varies consider-     including Bulgaria, Romania, Latvia, Lithuania, the
ably, however, across EU countries (Figure 1.4.1).         Slovak Republic and Hungary. They are the lowest in
Central and eastern European countries report the          Switzerland, France, Iceland and the Netherlands.
highest IHD mortality rates, Lithuania for both males           Looking at trends over time, stroke mortality has
and females, followed by Latvia, the Slovak Republic       decreased in all EU countries (except the Slovak
and Estonia. IHD mortality rates are also relatively       Republic and Poland) since 1994, with a more
high in Finland, Malta and Ireland, with rates several     pronounced fall after 1999 (Figure 1.4.4). Rates have
times higher than in France, Portugal, the Netherlands     declined by one-half or more in Italy, Estonia,
and Spain. There are regional patterns to the variabil-    Portugal, Austria, Germany and the Czech Republic.
ity in IHD mortality rates. Besides the Netherlands,       As with IHD, the reduction in stroke mortality can be
the countries with the lowest IHD mortality rates are      attributed at least partly to a reduction in risk factors.
four countries located in Southern Europe: France,         Tobacco smoking and hypertension are the main
Portugal, Spain and Italy, with Greece also having low     modifiable risk factors for stroke. Improvements in
rates. This lends support to the commonly held             medical treatment for stroke have also increased
hypothesis that there are underlying risk factors, such    survival rates.
as diet, which explain differences in IHD mortality
across countries.
     Death rates are much higher for men than for
women in all countries (Figure 1.4.1). On average across               Definition and deviations
EU countries, IHD mortality rates for men in 2008 were
                                                               Mortality rates are based on numbers of
nearly two times greater than for women.
                                                             deaths registered in a country in a year divided
      Since the mid-1990s, IHD mortality rates have          by the size of the corresponding population. The
declined in nearly all countries (Figure 1.4.3). The         rates have been directly age-standardised to the
decline has been most remarkable in the Netherlands,         WHO European standard population to remove
Denmark and Norway among the Nordic countries,               variations arising from differences in age
Ireland, Slovenia and Estonia (although rates there are      structures across countries and over time. The
still high), with IHD mortality rates being cut by           source is the Eurostat Statistics Database.
one-half or more. A number of factors are responsible,
                                                               Mathers et al. (2005) have provided a general
with declines in tobacco consumption, and heavy
                                                             assessment of the coverage, completeness and
drinking in some countries reducing the incidence of
                                                             reliability of data on causes of death.
IHD, and consequently reducing IHD mortality rates.
Significant improvements in medical care for treating           Deaths from ischemic heart disease are classi-
IHD have also played a part (Moïse et al., 2003) (see        fied to ICD-10 codes I20-I25, and stroke to I60-I69.
Indicator 3.9 “Cardiac procedures”). A small number




32                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                           1.4. MORTALITY FROM HEART DISEASE AND STROKE



1.4.1. Ischemic heart disease, mortality rates, 2008                                                                        1.4.2. Stroke, mortality rates, 2008
             (or nearest year available)                                                                                         (or nearest year available)
                                                      Males                            Females                                                                  Males                                    Females

            France         21
                                 55                                                                                  Switzerland           27
                                                                                                                                                 31

          Portugal          32
                                     61                                                                                    France          24
                                                                                                                                                34

      Netherlands           31
                                      68                                                                                  Iceland               34
                                                                                                                                                     38

              Spain         30
                                      69                                                                             Netherlands                34
                                                                                                                                                     38

               Italy            44
                                           86                                                                              Austria              32
                                                                                                                                                     40

     Luxembourg                 45
                                           91                                                                              Ireland               39
                                                                                                                                                   40

      Switzerland               45
                                           93                                                                              Cyprus                  40
                                                                                                                                                  41
            Greece              41
                                            96                                                                          Germany                 36
                                                                                                                                                   42

         Denmark                 52
                                            98                                                                               Spain              34
                                                                                                                                                    43

           Norway               46
                                            99                                                                            Norway                 37
                                                                                                                                                     45

          Slovenia              42
                                                102                                                                       Sweden                 38
                                                                                                                                                     46

            Cyprus              44
                                                107                                                                 Luxembourg                      47
                                                                                                                                                        49

         Germany                     62
                                                 117                                                             United Kingdom                     47
                                                                                                                                                        50

           Sweden                    64
                                                      130                                                                 Finland                 40
                                                                                                                                                       53

            Austria                   73
                                                      131                                                                     Italy                43
                                                                                                                                                       53

  United Kingdom                     61
                                                      132                                                                    Malta                       57
                                                                                                                                                           61
           Iceland                   60
                                                      133                                                               Denmark                      47
                                                                                                                                                         59

            Ireland                   68
                                                       143                                                               Slovenia                         53
                                                                                                                                                                     76

            Poland                    69
                                                        147                                                                Greece                                     78
                                                                                                                                                                        83
              Malta                        86
                                                            162                                                                 EU                             64
                                                                                                                                                                      82

                 EU                        89
                                                              171                                                 Czech Republic                                71
                                                                                                                                                                          87

          Bulgaria                         88
                                                              174                                                        Portugal                               70
                                                                                                                                                                           89

           Finland                         88
                                                               183                                                         Poland                              64
                                                                                                                                                                           91

   Czech Republic                                     137
                                                                     228                                                  Estonia                              63
                                                                                                                                                                                97

         Romania                                        151
                                                                           248                                           Hungary                                    76
                                                                                                                                                                                      115

          Hungary                                           166
                                                                                 289                             Slovak Republic                                      83
                                                                                                                                                                                           124

           Estonia                                          163
                                                                                       330                              Lithuania                                                    110
                                                                                                                                                                                                 140

  Slovak Republic                                                    224
                                                                                             361                            Latvia                                                         123
                                                                                                                                                                                                             174

             Latvia                                            184
                                                                                                   397                  Romania                                                                    154
                                                                                                                                                                                                                     197

         Lithuania                                                    240
                                                                                                         449             Bulgaria                                                                      163
                                                                                                                                                                                                                           217

                       0              100       200        300        400      500                                                    0           50       100         150       200      250
                                      Age-standardised rates per 100 000 population                                                              Age-standardised rates per 100 000 population

Source: Eurostat Statistics Database. Data are age-standardised to                                             Source: Eurostat Statistics Database. Data are age-standardised to
the WHO European standard population.                                                                          the WHO European standard population.
           1 2 http://dx.doi.org/10.1787/888932335552                                                                     1 2 http://dx.doi.org/10.1787/888932335571



  1.4.3. Trends in ischemic heart disease mortality                                                                      1.4.4. Trends in stroke mortality rates,
        rates, selected EU countries, 1994-2008                                                                             selected EU countries, 1994-2008
                                 Denmark                                               Hungary                                                       Bulgaria                                                Italy
                                 Netherlands                                           EU                                                            Portugal                                                EU
Age-standardised rates per 100 000 population                                                                  Age-standardised rates per 100 000 population
  300                                                                                                            300


  250                                                                                                            250


  200                                                                                                            200


  150                                                                                                            150


  100                                                                                                            100


   50                                                                                                             50


    0                                                                                                              0
     1994       1996        1998                 2000               2002         2004          2006 2008            1994       1996       1998             2000                  2002             2004             2006 2008

Source: Eurostat Statistics Database. Data are age-standardised to                                             Source: Eurostat Statistics Database. Data are age-standardised to
the WHO European standard population.                                                                          the WHO European standard population.
           1 2 http://dx.doi.org/10.1787/888932335590                                                                     1 2 http://dx.doi.org/10.1787/888932335609


HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                      33
1.5. MORTALITY FROM CANCER


     Cancer is the second leading cause of mortality in          Prostate cancer has become the most commonly
EU countries (after diseases of the circulatory system),   occurring cancer among men in many EU countries,
accounting for 26% of all deaths in 2008. Cancer           particularly for those aged over 65 years of age, although
mortality rates for the total population were the lowest   death rates from prostate cancer remain lower than for
in Cyprus, Finland, Switzerland and Sweden, at under       lung cancer in all countries except Sweden. The rise in
150 deaths per 100 000 population. They were the           the reported incidence of prostate cancer in many coun-
highest in central and eastern European countries          tries during the 1990s and 2000s was largely due to the
(Hungary, Poland, the Czech and Slovak Republics,          greater use of prostate-specific antigen (PSA) diagnostic
Slovenia) and Denmark, above 200 deaths per                tests. Death rates from prostate cancer in 2008 varied
100 000 population.                                        from lows of less than 15 per 100 000 males in Malta and
     Cancer mortality rates are higher for men than        Romania, to highs of more than 30 per 100 000 males in
for women in all EU countries (Figure 1.5.1). In 2008,     a range of central and eastern European and Nordic
the gender gap in death rates from cancer was partic-      countries (Figure 1.5.4). The causes of prostate cancer
ularly wide in Latvia, Spain, Estonia, France, Lithuania   are not well-understood. Some evidence suggests
and Portugal, with mortality rates among men more          that environmental and dietary factors might influ-
than twice as high as for women. This gap can be           ence the risk of prostate cancer (Institute of Cancer
explained partly by the greater prevalence of risk         Research, 2009).
factors among men, as well as the lesser availability or         Death rates from all types of cancer for males
use of screening programmes for different types of         and females have declined at least slightly in most EU
cancers affecting men, leading to lower survival rates     countries since 1994, although the decline has been
after diagnosis.                                           more modest than for cardiovascular diseases,
     Lung cancer still accounts for the greatest num-      explaining why cancer accounts now for a larger share
ber of cancer deaths among men in all EU countries,        of all deaths. The exceptions to this declining pattern
except in Sweden. Lung cancer is also one of the main      are among central and eastern European countries
causes of cancer mortality among women. Tobacco            (Bulgaria, Romania, Latvia, Lithuania, Poland) and
smoking is the most important risk factor for lung         Greece, where cancer mortality has remained static or
cancer. In 2008, death rates from lung cancer among        increased between 1994 and 2008.
men were the highest in central and eastern European
countries (Hungary, Poland, Estonia, Latvia, Lithuania
and others) (Figure 1.5.2). These are all countries                    Definition and deviations
where smoking rates among men are relatively high.              Mortality rates are based on numbers of
Death rates from lung cancer among men are low               deaths registered in a country in a year divided
in Nordic countries (Sweden, Iceland, Finland                by the size of the corresponding population. The
and Norway) as well as in Cyprus, countries with             rates have been directly age-standardised to the
low smoking rates among men (see Indicator 2.6).             WHO European standard population to remove
Denmark and Iceland, however, have high rates of             variations arising from differences in age struc-
lung cancer mortality among women.                           tures across countries and over time. The source
     Breast cancer is the most common form of cancer         is the Eurostat Statistics Database.
among women in all EU countries (Ferlay et al., 2010).         The international comparability of cancer
It accounted for 31% of cancer incidence among               mortality data can be affected by differences
women, and 17% of cancer deaths in 2008. While there         in medical training and practices as well as in
has been an increase in incidence rates of breast            death certification procedures across countries.
cancer over the past decade, death rates have declined       Mathers et al. (2005) have provided a general
or remained stable, indicating increases in survival         assessment of the coverage, completeness and
rates due to earlier diagnosis and/or better treatments      reliability of data on causes of death.
(see Indicator 3.13). The lowest mortality rates from
                                                               Deaths from all cancers are classified to ICD-10
breast cancer are in Spain, Norway, Finland and
                                                             codes C00-C97, lung cancer to C32-C34, breast
Portugal (below 20 deaths per 100 000 females), while
                                                             cancer to C50 and prostate cancer to C61.
the highest mortality rates are in Ireland and
Denmark (above 30) (Figure 1.5.3).




34                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                              1.5. MORTALITY FROM CANCER



       1.5.1. All cancers mortality rates, males                                              1.5.2. Lung cancer mortality rates, males
     and females, 2008 (or nearest year available)                                           and females, 2008 (or nearest year available)
                                 Males                          Females                                                                     Males                          Females

            Cyprus              98
                                          151                                                      Sweden                         23
                                                                                                                                       29
           Iceland                       152
                                                171                                                Iceland                                   38
                                                                                                                                               41
           Finland                114
                                                172                                                 Cyprus         8
                                                                                                                                            39
           Sweden                      134
                                                172                                                Finland              14
                                                                                                                                              42
      Switzerland                  117
                                                   187                                             Norway                              28
                                                                                                                                                44
              Malta                  130
                                                    195                                       Switzerland                    19
                                                                                                                                                 45
           Norway                       137
                                                    196                                           Portugal         8
                                                                                                                                                  47
            Ireland                         157
                                                      204                                             Malta        9
                                                                                                                                                   48
         Germany                      131
                                                       206                                          Ireland                            28
                                                                                                                                                    49
            Greece                113
                                                        210                                         Austria                  20
                                                                                                                                                     51
            Austria                  128
                                                        211                               United Kingdom                                 32
                                                                                                                                                       53
  United Kingdom                           154
                                                        212                                      Germany                     20
                                                                                                                                                        55
          Portugal               109
                                                         218                                           Italy            14
                                                                                                                                                              64
               Italy                123
                                                          220                                       France              15
                                                                                                                                                              65
     Luxembourg                        137
                                                          221                                    Denmark                                           45
                                                                                                                                                               66
              Spain             102
                                                          222                                Luxembourg                                29
                                                                                                                                                               66
      Netherlands                           155
                                                           228                                           EU                  19
                                                                                                                                                               66
          Bulgaria                   127
                                                            230                               Netherlands                                33
                                                                                                                                                                68
                 EU                    136
                                                             236                                      Spain                 10
                                                                                                                                                                 69
            France                116
                                                             237                           Czech Republic                    20
                                                                                                                                                                  72
         Denmark                                 182
                                                               246                                Bulgaria             11
                                                                                                                                                                    73
         Romania                     128
                                                               246                                  Greece              13
                                                                                                                                                                    74
   Czech Republic                          153
                                                                   269                            Slovenia                   20
                                                                                                                                                                    74
          Slovenia                         152
                                                                    277                   Slovak Republic              14
                                                                                                                                                                     75
            Poland                         152
                                                                     284                         Romania               13
                                                                                                                                                                      77
  Slovak Republic                        144
                                                                      288                        Lithuania         9
                                                                                                                                                                           83
           Estonia                     136
                                                                       290                           Latvia        8
                                                                                                                                                                            86
         Lithuania                       142
                                                                       290                         Estonia             12
                                                                                                                                                                              89
             Latvia                                                     295                         Poland                                                                         99
                                       135                                                                                        23
          Hungary                               177                               337             Hungary                                     38                                            115

                       0     100           200           300        400                                        0              25        50         75         100     125
                           Age-standardised rates per 100 000 population                                                     Age-standardised rates per 100 000 population

Source: Eurostat Statistics Database. Data are age-standardised to                      Source: Eurostat Statistics Database. Data are age-standardised to
the WHO European standard population.                                                   the WHO European standard population.
           1 2 http://dx.doi.org/10.1787/888932335628                                              1 2 http://dx.doi.org/10.1787/888932335647


 1.5.3. Breast cancer mortality rates, females, 2008                                     1.5.4. Prostate cancer mortality rates, males, 2008
             (or nearest year available)                                                              (or nearest year available)
              Spain                             18.2                                                  Malta                                    12.8
           Norway                                18.7                                            Romania                                           14.9
           Finland                                 19.8                                                Italy                                         16.0
          Portugal                                 19.8                                               Spain                                            17.0
           Sweden                                  20.0                                             Greece                                              17.5
     Luxembourg                                      20.5                                         Bulgaria                                               18.1
   Czech Republic                                     21.2                                          Cyprus                                                 19.0
            Poland                                    21.2                                       Germany                                                      20.6
         Romania                                       21.6                                         France                                                      21.6
            Greece                                     21.7                                       Hungary                                                       21.8
            Austria                                    21.8                                         Poland                                                      21.9
  Slovak Republic                                       22.1                                        Austria                                                      22.5
      Switzerland                                       22.1                              Slovak Republic                                                        22.5
           Estonia                                       22.6                              Czech Republic                                                           23.6
            Cyprus                                        22.8                                      Ireland                                                         23.6
          Bulgaria                                         23.3                                   Portugal                                                           24.0
               Italy                                       23.6                                          EU                                                          24.0
                 EU                                         23.8                                   Finland                                                            24.3
            France                                          24.0                              Switzerland                                                             24.5
         Germany                                             24.6                            Luxembourg                                                                24.8
             Latvia                                          24.7                         United Kingdom                                                               24.8
         Lithuania                                             25.1                           Netherlands                                                               25.2
          Hungary                                                 26.6                            Slovenia                                                                         31.2
  United Kingdom                                                  26.8                             Iceland                                                                          32.1
           Iceland                                                  27.3                           Sweden                                                                               34.0
          Slovenia                                                  27.4                         Lithuania                                                                               34.4
              Malta                                                  27.9                        Denmark                                                                                 34.5
      Netherlands                                                      29.0                        Norway                                                                                34.7
         Denmark                                                           31.1                      Latvia                                                                               35.1
            Ireland                                                        31.1                    Estonia                                                                                    37.6

                       0      10           20            30         40                                         0                   10           20            30         40
                             Age-standardised rates per 100 000 females                                                             Age-standardised rates per 100 000 males

Source: Eurostat Statistics Database. Data are age-standardised to                      Source: Eurostat Statistics Database. Data are age-standardised to
the WHO European standard population.                                                   the WHO European standard population.
           1 2 http://dx.doi.org/10.1787/888932335666                                              1 2 http://dx.doi.org/10.1787/888932335685




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                  35
1.6. MORTALITY FROM TRANSPORT ACCIDENTS


     Worldwide, an estimated 1.2 million people are          EU countries since 1994 (Figures 1.6.2 and 1.6.3).
killed in transport accidents each year, mostly due to       Estonia has seen the largest decline in transport
road traffic accidents, and as many as 50 million            accident mortality of 78% between 1994 and 2008,
people are injured or disabled (WHO, 2009b). In EU           with most of the fall occurring in the mid-1990s
countries alone, they were responsible for approxi-          following independence. Reductions in Portugal,
mately 48 000 deaths in 2008. In 2008, Italy, Poland,        Sweden, Slovenia and Germany since 1994 are close
France and Germany each experienced around 5 000-            to 60%, although vehicle kilometers travelled have
6 000 transport accident deaths.                             increased by 2.7 times on average in European coun-
      Mortality from road accidents is the leading           tries in the same period (OECD/ITF, 2008). Death rates
cause of death among children and young people, and          have also declined in Greece, but at a slower pace, and
especially young men, in many countries. The fatality        therefore remain above the EU average. In Bulgaria
risk for motor cycles and mopeds is highest among all        and Romania there have been significant increases in
modes of transport, even though most fatal traffic           death rates from road accidents since 1994.
injuries occur in passenger vehicles (ETSC, 2003; Beck            Based on an extrapolation of past trends, projec-
et al., 2007).                                               tions from the World Bank indicate that between 2000
     Besides the social, physical and psychological          and 2020, road traffic deaths may decline further by
effects, the direct and indirect financial costs of trans-   about 30% in high-income countries, but may increase
port accidents are substantial; one estimate put these       substantially in low- and middle-income countries if
at 2% of gross national product annually in highly-          no additional road safety counter-measures are put in
motorised countries (Peden et al., 2004). Injury and         place (Peden et al., 2004).
mortality from transport accidents remains a serious
public health concern.
     Death rates were the highest in 2008 in Lithuania,                  Definition and deviations
Romania and Latvia, all in excess of 15 deaths per               Mortality rates are based on numbers of deaths
100 000 population (Figure 1.6.1). They were the               registered in a country in a year divided by the
lowest in Malta, the Netherlands, Iceland, Sweden and          size of the corresponding population. The rates
Switzerland, at five deaths per 100 000 population or          have been directly age-standardised to the WHO
less. A four-fold difference exists between the coun-          European standard population to remove varia-
tries with the lowest and highest rates. Deaths from           tions arising from differences in age structures
transport accidents are much higher for males than             across countries and over time. The source is the
for females in all EU countries, with disparities in           Eurostat Statistics Database.
rates ranging from three times higher for males in
                                                                 Mathers et al. (2005) have provided a general
Denmark, Sweden and Germany to five or more times
                                                               assessment of the coverage, completeness and
higher in the Slovak Republic, Slovenia and Poland. On
                                                               reliability of data on causes of death.
average, almost four times as many males than
females die in transport accidents (Figure 1.6.1).               Deaths from transport accidents are classified
                                                               to ICD-10 codes V01-V99. The majority of deaths
     Much transport accident injury and mortality is
                                                               from transport accidents are due to road traffic
preventable. Road security has increased greatly over
                                                               accidents.
the past decades in many countries through improve-
ments of road systems, education and prevention                  Mortality rates from transport accidents in
campaigns, the adoption of new laws and regulations            Luxembourg are biased upward because of the
and the enforcement of these new laws through                  large volume of traffic in transit, resulting in a
more traffic controls. As a result, death rates due to         significant proportion of non-residents killed.
transport accidents have been cut by around 40% in




36                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                        1.6. MORTALITY FROM TRANSPORT ACCIDENTS



                                   1.6.1. Transport accident mortality rates, 2008 (or nearest year available)
                                                                                                                                                       Males                                         Females
                                   Total population
                                                                                  3.6                        Malta            1.4
                                                                                                                                              6.0
                                                                                4.1                      Netherlands            2.0
                                                                                                                                               6.4
                                                                          4.9                              Iceland               2.3
                                                                                                                                                  7.4
                                                                         5.0                               Sweden                 2.5
                                                                                                                                                  7.5
                                                                         5.0                             Switzerland            1.9
                                                                                                                                                     8.3
                                                                        5.3                            United Kingdom             2.3
                                                                                                                                                     8.2
                                                                       5.4                                Germany                  2.7
                                                                                                                                                     8.2
                                                                     5.8                                  Denmark                   3.1
                                                                                                                                                      8.5
                                                                    6.0                                    Norway                 2.3
                                                                                                                                                              9.9
                                                                   6.2                                      Ireland                 3.0
                                                                                                                                                             9.6
                                                             6.9                                           Finland                  2.8
                                                                                                                                                                    11.4
                                                            7.2                                              Spain                  3.1
                                                                                                                                                                    11.3
                                                           7.4                                             Austria                    3.4
                                                                                                                                                                     11.6
                                                           7.4                                              France                    3.2
                                                                                                                                                                      11.8
                                                     8.7                                                Luxembourg                    1.7
                                                                                                                                                                                  15.6
                                                   9.1                                                    Portugal                      4.1
                                                                                                                                                                              14.4
                                                  9.2                                                         Italy                   3.3
                                                                                                                                                                                15.2
                                                9.7                                                            EU                       4.1
                                                                                                                                                                                  15.6
                                         10.3                                                          Czech Republic                      4.9
                                                                                                                                                                                  15.7
                                  11.4                                                                     Estonia                            5.6
                                                                                                                                                                                            18.2
                                  11.5                                                                     Slovenia                   3.6
                                                                                                                                                                                                19.5
                                 11.6                                                                       Cyprus                           5.4
                                                                                                                                                                                            18.2
                                 11.7                                                                      Hungary                         5.0
                                                                                                                                                                                               19.3
                          13.3                                                                             Bulgaria                           5.7
                                                                                                                                                                                                        21.4
                          13.3                                                                         Slovak Republic                    4.6
                                                                                                                                                                                                            22.7
                      14.1                                                                                  Greece                          5.2
                                                                                                                                                                                                             22.9
                    14.6                                                                                    Poland                      4.1
                                                                                                                                                                                                              23.4
             15.9                                                                                            Latvia                                  7.5
                                                                                                                                                                                                                     25.5
         16.6                                                                                             Romania                                   7.3
                                                                                                                                                                                                                        26.5
        16.8                                                                                              Lithuania                                    8.1                                                              26.4

20            15                10                                          5                      0                     0               5               10        15          20         25        30
Age-standardised rates per 100 000 population                                                                                                            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/10.1787/888932335704


 1.6.2. Trends in transport accident mortality rates,                                                             1.6.3. Change in transport accident mortality rates,
          selected EU countries, 1994-2008                                                                                1994-2008 (or nearest year available)

                                     Netherlands                                          Poland                             Estonia                  -78
                                                                                                                            Portugal                                  -59
                                     Portugal                                             EU                                 Sweden                                    -58
                                                                                                                            Slovenia                                     -56
Age-standardised rates per 100 000 population                                                                              Germany                                       -55
   25                                                                                                                  Luxembourg                                         -54
                                                                                                                              Austria                                      -53
                                                                                                                        Switzerland                                          -50
                                                                                                                        Netherlands                                          -49
                                                                                                                                Spain                                         -49
   20                                                                                                                         Ireland                                          -47
                                                                                                                           Denmark                                              -46
                                                                                                                               Latvia                                             -43
                                                                                                                             Iceland                                               -42
                                                                                                                              France                                               -42
   15                                                                                                                        Finland                                                -41
                                                                                                                     Czech Republic                                                  -39
                                                                                                                                   EU                                                -39
                                                                                                                            Hungary                                                   -38
                                                                                                                            Belgium                                                   -38
   10                                                                                                                           Malta                                                 -38
                                                                                                                           Lithuania                                                   -37
                                                                                                                              Poland                                                      -32
                                                                                                                                 Italy                                                     -31
                                                                                                                              Greece                                                         -29
    5                                                                                                                        Norway                                                           -28
                                                                                                                              Cyprus                                                           -27
                                                                                                                    United Kingdom                                                                    -18
                                                                                                                    Slovak Republic                                                                     -15
                                                                                                                           Romania                                                                                        5
                                                                                                                            Bulgaria                                                                                           19
    0
     1994           1996         1998              2000            2002            2004        2006 2008                               -100             -80             -60            -40             -20      0      20
                                                                                                                                                                                                        Percentage change

Source: Eurostat Statistics Database. Data are age-standardised to                                               Source: Eurostat Statistics Database. Data are age-standardised to
the WHO European standard population.                                                                            the WHO European standard population.
           1 2 http://dx.doi.org/10.1787/888932335723                                                                       1 2 http://dx.doi.org/10.1787/888932335742




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                    37
1.7. SUICIDE


      The intentional killing of oneself is evidence not    range of factors including rapid socio-economic tran-
only of personal breakdown, but also of a deteriora-        sition, increasing psychological and social insecurity
tion of the social context in which an individual lives.    and the absence of a national suicide prevention
Suicide may be the end-point of a number of different       strategy. Similarly in Hungary, societal factors includ-
contributing factors. It is more likely to occur during     ing employment and socio-economic circumstances,
crisis periods associated with divorce, alcohol and         as well as individual demographic and clinical factors
drug abuse, unemployment, clinical depression and           have been cited as determinants of suicide (Almasi
other forms of mental illness. Because of this, suicide     et al., 2009).
is often used as a proxy indicator of the mental health          Suicide is often linked with depression and the
status of a population. However, the number of              abuse of alcohol and other substances. Early detection
suicides in certain countries may be under-estimated        of these psycho-social problems in high-risk groups by
because of the stigma that is associated with the act,      families and health professionals must be part of
or because of data issues associated with reporting         suicide prevention campaigns, together with the
criteria (see “Definitions and deviations”).                provision of effective support and treatment. Many
     Suicide is a significant cause of death in many        countries are promoting mental health and developing
European Union countries, and there were approxi-           national strategies for prevention, focusing on at-risk
mately 55 000 such deaths in 2008. Rates of suicide         groups (Hawton and van Heeringen, 2009). In Finland
were low in southern European countries – Greece,           and Iceland, suicide prevention programmes have been
Cyprus, Italy, Malta, Spain and Portugal – as well as the   based on efforts to promote strong multisectoral
United Kingdom, at less than eight deaths per               collaboration and networking (NOMESCO, 2007).
100 000 population (Figure 1.7.1). They were highest in
the Baltic States and Central and Eastern Europe; in
Lithuania, Hungary and Latvia, as well as Finland, there
were more than 18 deaths per 100 000 population.                        Definition and deviations
There is more than a ten-fold difference between
Lithuania and Greece, the countries with the lowest             The World Health Organization defines
and high death rates.                                         “suicide” as an act deliberately initiated and
                                                              performed by a person in the full knowledge or
      In general, death rates from suicides are three-to-
                                                              expectation of its fatal outcome. Comparability
four times greater for men than for women across the
                                                              of suicide data between countries is affected by
European Union, except in those countries with the
                                                              a number of reporting criteria, including how a
highest rates, where rates are up to six times greater
                                                              person’s intention of killing themselves is ascer-
(Figure 1.7.1). The gender gap is narrower for attempted
                                                              tained, who is responsible for completing the
suicides, reflecting the fact that women tend to use less
                                                              death certificate, whether a forensic investi-
fatal methods than men. Suicide is also related to age,
                                                              gation is carried out, and the provisions for
with young people aged under 25 and elderly people
                                                              confidentiality of the cause of death. Caution is
especially at risk. While suicide rates among the latter
                                                              required therefore in interpreting variations
have generally declined over the past two decades,
                                                              across countries.
almost no progress has been observed among younger
people.                                                          Mortality rates are based on numbers of
                                                              deaths registered in a country in a year divided
     Since 1994, suicide rates have decreased in many
                                                              by the size of the corresponding population. The
EU countries, with pronounced declines of 40% or
                                                              rates have been directly age-standardised to the
more in Estonia, Latvia and Slovenia (Figure 1.7.2).
                                                              WHO European standard population to remove
Despite this progress, these three countries still have
                                                              variations arising from differences in age struc-
among the highest suicide rates in Europe. On the
                                                              tures across countries and over time. The source
other hand, death rates from suicides have increased
                                                              is the Eurostat Statistics Database.
since 1994 in Malta, Iceland and Portugal, though
rates in Malta and Portugal still remain below the              Mathers et al. (2005) have provided a general
EU average.                                                   assessment of the coverage, completeness and
                                                              reliability of data on causes of death.
     Following independence in 1990, suicide rates in
Lithuania increased steadily, especially among young            Deaths from suicide are classified to ICD-10
men, peaking in 1996 (Figure 1.7.3). The high suicide         codes X60-X84.
rates in Lithuania have been associated with a wide




38                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                                       1.7. SUICIDE



                                              1.7.1. Suicide mortality rates, 2008 (or nearest year available)
                                                                                                                                                          Males                             Females
                                 Total population
                                                                                        2.8                 Greece              1.0
                                                                                                                                      4.8
                                                                                  4.3                       Cyprus               1.7
                                                                                                                                           7.0
                                                                                5.2                           Italy               2.3
                                                                                                                                              8.4
                                                                             6.0                             Malta             0.3
                                                                                                                                                     11.8
                                                                             6.1                       United Kingdom              2.7
                                                                                                                                                9.7
                                                                            6.5                              Spain                 2.8
                                                                                                                                                  10.4
                                                                      7.9                                 Portugal                  3.4
                                                                                                                                                       13.2
                                                                      8.1                                Netherlands                   4.9
                                                                                                                                                    11.4
                                                                9.3                                         Ireland                   4.2
                                                                                                                                                          14.5
                                                                9.4                                       Germany                      4.4
                                                                                                                                                           14.9
                                                            10.1                                           Bulgaria                   4.6
                                                                                                                                                             16.3
                                                            10.2                                           Norway                         6.4
                                                                                                                                                         14.1
                                                            10.2                                       Slovak Republic             2.7
                                                                                                                                                                 18.5
                                                           10.6                                           Denmark                        5.7
                                                                                                                                                            16.0
                                                           10.6                                           Romania                   3.5
                                                                                                                                                                18.4
                                                        11.4                                               Sweden                          6.6
                                                                                                                                                             16.3
                                                       11.8                                            Czech Republic                 4.2
                                                                                                                                                                   20.2
                                                      12.0                                                     EU                      4.9
                                                                                                                                                                   20.0
                                                      12.2                                                 Iceland                          7.5
                                                                                                                                                              16.7
                                                    12.7                                                   Austria                       5.8
                                                                                                                                                                    20.7
                                                 13.9                                                       Poland                   3.7
                                                                                                                                                                           24.9
                                               14.6                                                         France                          7.4
                                                                                                                                                                       22.7
                                              15.1                                                       Switzerland                           9.1
                                                                                                                                                                      21.8
                                           16.0                                                         Luxembourg                                10.6
                                                                                                                                                                      22.0
                                          16.5                                                             Estonia                        6.2
                                                                                                                                                                                29.1
                                        17.3                                                               Slovenia                        6.7
                                                                                                                                                                                29.2
                                     18.4                                                                  Finland                            8.3
                                                                                                                                                                                29.0
                              20.9                                                                           Latvia                       6.5
                                                                                                                                                                                           38.3
                             21.5                                                                         Hungary                              8.6
                                                                                                                                                                                         37.1
    30.7                                                                                                  Lithuania                             9.1                                                            55.9

35      30       25        20       15        10                                    5         0                            0                10              20        30          40         50        60
Age-standardised rates per 100 000 population                                                                                                               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/10.1787/888932335761


           1.7.2. Change in suicide rates, 1994-2008                                                             1.7.3. Trends in suicide rates, selected EU countries,
                   (or nearest year available)                                                                                         1994-2008
           Estonia            -60
                                                                                                                                                           Greece                                 Hungary
             Latvia                   -44
          Slovenia                    -43                                                                                                                  Lithuania                              EU
         Denmark                        -39
            Austria                      -38
                                                                                                                 Age-standardised rates per 100 000 population
          Hungary                         -36
                                                                                                                    50
          Bulgaria                        -36
         Lithuania                        -35
         Germany                            -32
   Czech Republic                           -32
           Finland                           -30
                                                                                                                    40
               Italy                            -25
      Switzerland                                -23
                 EU                               -21
  Slovak Republic                                 -20
            Ireland                                -20
                                                                                                                    30
           Sweden                                   -17
      Netherlands                                    -16
           Norway                                     -16
  United Kingdom                                       -14
         Romania                                       -14
                                                                                                                    20
              Spain                                     -12
          Belgium                                        -10
            Greece                                       -10
            France                                         -9
                                                                                                                    10
     Luxembourg                                            -9
            Poland                                          -6
          Portugal                                                           11
           Iceland                                                                 24
              Malta                                                                               58
                                                                                                                         0
                       -80      -60        -40       -20         0            20      40     60 80                        1994         1996          1998           2000          2002       2004       2006 2008
                                                                                   Percentage change

Source: Eurostat Statistics Database. Data are age-standardised to                                               Source: Eurostat Statistics Database. Data are age-standardised to
the WHO European standard population.                                                                            the WHO European standard population.
           1 2 http://dx.doi.org/10.1787/888932335780                                                                       1 2 http://dx.doi.org/10.1787/888932335799




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                    39
1.8. INFANT MORTALITY


    Infant mortality, the rate at which babies of less        rate among the lowest in Europe in 2008 (Figure 1.8.2).
than one year of age die, reflects the effect of eco-         Large reductions in infant mortality rates have also
nomic and social conditions on the health of mothers          been observed in Luxembourg, Slovenia and Greece.
and newborns, as well as the quality of medical care          On the other hand, the reduction in infant mortality
and preventive services.                                      rates has been slower in Latvia, Malta, Bulgaria and
      In 2008, infant mortality rates in European coun-       the Netherlands. Infant mortality rates in Poland
tries ranged from a low of less than three deaths per         declined rapidly in the early 1990s to approach the
1 000 live births in Luxembourg, Slovenia, Nordic coun-       EU average.
tries (with the exception of Denmark), Greece and the              Numerous studies have used infant mortality
Czech Republic, up to a high of 11 and 17 deaths per          rates as a health outcome to examine the effect of a
1 000 live births in Romania and Turkey respectively          variety of medical and non-medical determinants of
(Figure 1.8.1). Infant mortality rates were also relatively   health (e.g. Joumard et al., 2008). Although most
high (more than six deaths per 1 000 live births) in          analyses show an overall negative relationship
Latvia, Bulgaria and Malta. The average across the            between infant mortality and health spending, the
27 European Union countries in 2008 was 4.6 deaths            fact that some countries with a high level of health
per 1 000 live births. Infant mortality rates tend to be      expenditure do not necessarily exhibit low levels of
higher than the EU average in central and eastern             infant mortality has led some researchers to conclude
European countries, with the exceptions of Slovenia           that more health spending is not necessarily required
and the Czech Republic, both of which have had consis-        to obtain better results (Retzlaff-Roberts et al., 2004). A
tently lower rates.                                           body of research also suggests that many factors
     Around two-thirds of the deaths that occur dur-          beyond the quality and efficiency of the health
ing the first year of life are neonatal deaths (i.e. during   system, such as income inequality, the social envi-
the first four weeks). Birth defects, prematurity and         ronment, and individual lifestyles and attitudes,
other conditions arising during pregnancy are the             influence infant mortality rates (Kiely et al., 1995).
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                        Definition and deviations
of pre-term births has tended to increase (see
Indicator 1.9). In a number of higher-income coun-                The infant mortality rate is the number of
tries, this has contributed to a leveling-off of the            deaths of children under one year of age in a
downward trend in infant mortality rates over the               given year, expressed per 1 000 live births.
past few years. For deaths beyond a month (post                 Neonatal mortality refers to the death of
neonatal mortality), there tends to be a greater range          children under 28 days.
of causes – the most common being SIDS (Sudden                     Some of the international variation in infant
Infant Death Syndrome), birth defects, infections and           and neonatal mortality rates may be due to
accidents. Advances in neonatal care for very preterm           variations among countries in registering
and growth-restricted babies are also associated with           practices of premature infants. Most countries
a higher proportion of infant deaths occurring after            have no gestational age or weight limits for
the neonatal period (EURO-PERISTAT, 2008).                      mortality registration. Minimal limits exist for
     All European countries have achieved remarkable            Norway (to be counted as a death following a live
progress in reducing infant mortality rates from the            birth, the gestational age must exceed 12 weeks)
levels of 1970, when the average was 25 deaths per              and in the Czech Republic, France, Malta (the
1 000 live births (Figure 1.8.1). This equates to a cumu-       National Mortality Register), the Netherlands
lative reduction of over 80% since 1970. Portugal has           and Poland a minimum gestational age of
seen its infant mortality rate reduced by over 7% per           22 weeks and/or a weight threshold of 500 grams
year on average since 1970, going from the country              is applied. Lithuania has a gestational age limit.
with the highest rate in Europe to an infant mortality




40                                                                               HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                      1.8. INFANT MORTALITY



                                             1.8.1. Infant mortality rates, 2008 and decline 1970-2008
                 2008 (or nearest year available)                                                                        Decline 1970-2008 (or nearest year available)
                                                                                  1.8           Luxembourg                                                                                            6.7
                                                                                 2.1               Slovenia                                                                                     6.3
                                                                            2.5                    Iceland                                                        4.3
                                                                            2.5                    Sweden                                                 3.8
                                                                            2.6                    Finland                                                       4.2
                                                                           2.7                      Greece                                                                                     6.1
                                                                           2.7                     Norway                                                   4.0
                                                                           2.8                 Czech Republic                                                                 5.1
                                                                        3.1                         Ireland                                                             4.7
                                                                      3.3                         Portugal                                                                                                  7.2
                                                                      3.4                          Belgium                                                              4.7
                                                                     3.5                          Germany                                                               4.8
                                                                     3.5                             Spain                                                                          5.3
                                                                     3.7                           Austria                                                                    5.0
                                                                     3.7                              Italy                                                                     5.3
                                                                  3.8                               France                                                  4.0
                                                                  3.8                            Netherlands                                  3.1
                                                                 4.0                              Denmark                                      3.3
                                                                 4.0                             Switzerland                                        3.4
                                                            4.6                                        EU                                                         4.3
                                                            4.7                                United Kingdom                                        3.5
                                                           4.9                                    Lithuania                                          3.5
                                                           5.0                                     Estonia                                     3.3
                                                       5.3                                         Cyprus                                                       4.1
                                                      5.6                                          Hungary                                                              4.8
                                                      5.6                                           Poland                                                               4.8
                                                     5.9                                       Slovak Republic                                            3.8
                                               6.7                                                   Latvia                           2.5
                                       8.6                                                         Bulgaria                                  3.0
                                 9.9                                                                 Malta                             2.7
                          11.0                                                                    Romania                                                  3.9
        17.0                                                                                        Turkey                                                                           5.5

20             15                  10                            5                       0                        0           2                           3               6                8
Deaths per 1 000 live births                                                                                                                              Average annual rate of decline (%)

Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                      1 2 http://dx.doi.org/10.1787/888932335818


                               1.8.2. Infant mortality rates, selected European countries, 1970-2008
                                       Portugal                                              Slovenia                        Sweden                                                       EU
Deaths per 1 000 live births
   60


   50


   40


   30


   20


   10


    0
         1970              1975                       1980                              1985               1990            1995                       2000                                 2005

Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                      1 2 http://dx.doi.org/10.1787/888932335837




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                       41
1.9. INFANT HEALTH: LOW BIRTH WEIGHT


     Low birth weight – defined here as newborns             birth weight babies in these countries is now above the
weighing less than 2 500 grams – is an important             European average (Figure 1.9.2). Low birth weight
indicator of infant health because of the close rela-        proportions in Hungary, Poland and Luxembourg have
tionship between birth weight and infant morbidity           declined over the same time period. Little change
and mortality. There are two categories of low birth         occurred in Nordic countries including Iceland, Finland,
weight babies: those occurring as a result of restricted     Sweden and Denmark, although a rise was observed in
foetal growth and those resulting from pre-term birth.       Norway.
Low birth weight infants have a greater risk of poor               Figure 1.9.3 shows some correlation between the
health or death, require a longer period of hospitalisa-     percentage of low birth weight infants and infant
tion after birth, and are more likely to develop signifi-    mortality rates. In general, countries reporting a low
cant disabilities (UNICEF and WHO, 2004).                    proportion of low birth weight infants also report
     Risk factors for low birth weight include adoles-       relatively low infant mortality rates. This is the case
cent motherhood, having a previous history of low            for instance for the Nordic countries. Greece, however,
weight births, harmful behaviours such as smoking,           is an exception, reporting a high proportion of low
excessive alcohol consumption and poor nutrition, a          birth weight infants but one of the lowest infant
low Body Mass Index, a background of low parental            mortality rates.
socio-economic status, and having in-vitro fertilisa-             Agreed-on norms for low birth weight do not
tion treatment.                                              exist (EURO-PERISTAT, 2008). Physiological variations
      One-in-16 babies born in Europe in 2008 – or 6.4%      in size occur among different countries and popula-
of all births – weighed less than 2 500 grams at birth. A    tion groups, and these need to be taken into account
north-south gradient is evident in Europe for low birth      when interpreting differences. Some populations may
weight, in that the Nordic countries – Iceland, Sweden       have lower than average birth weights than others
and Finland – along with Latvia reported the smallest        because of genetic differences. Comparisons of differ-
proportions of low weight births, with less than 4.5%        ent population groups within countries show that the
of live births defined as low birth weight. Countries        proportion of low birth weight infants is also be
from Southern Europe including Greece, Spain and             influenced by differences in education, income and
Portugal, as well as Turkey, Romania, Bulgaria and           associated living conditions.
Hungary, 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 more than two (Figure 1.9.1).
                                                                         Definition and deviations
      Since 1980 the prevalence of low birth weight
infants has increased in a number of European coun-               Low birth weight is defined by the World Health
tries, most notably in Spain, Portugal, Malta and the          Organization (WHO) as the weight of an infant
Netherlands (Figure 1.9.1). There are several reasons          at birth of less than 2 500 grams (5.5 pounds),
for this rise. First, the number of multiple births, with      irrespective of the gestational age of the infant.
the increased risks of pre-term births and low birth           This is based on epidemiological observations
weight, has risen steadily, partly as a result of the rise     regarding the increased risk of death to the infant
in fertility treatments. Other factors which may have          and serves for international comparative health
influenced the rise in low birth weight are older age at       statistics. The number of low weight births is
childbearing and increases in the use of delivery              then expressed as a percentage of total live births.
management techniques such as induction of labour                The majority of the data comes from birth
and caesarean delivery.                                        registers. A small number of countries supply
     Spain and Portugal have seen great increases in the       data for selected regions or from surveys.
past three decades. As a result, the proportion of low




42                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                   1.9. INFANT HEALTH: LOW BIRTH WEIGHT



                                                 1.9.1. Low birth weight infants, 2008 and change 1980-2008
                      2008 (or nearest year available)                                                                           Change 1980-2008 (or nearest year available)
                                                                      3.8                        Iceland                                           12
                                                                     4.1                         Finland                                       5
                                                                     4.1                         Sweden                          -2
                                                                    4.3                            Latvia                                  n.a.
                                                                4.6                              Estonia                                   n.a.
                                                                4.6                             Lithuania                                  n.a.
                                                                4.6                           Luxembourg                 -27
                                                              5.1                                Norway                                                          34
                                                          5.3                                     Ireland                                                        33
                                                        5.7                                       Poland                 -25
                                                       5.8                                      Denmark                                    0
                                                  6.2                                          Netherlands                                                                  55
                                                  6.3                                            Slovenia                                          9
                                                  6.3                                          Switzerland                                                  24
                                                 6.4                                                 EU                                                15
                                                6.7                                                 Italy                                               20
                                            6.8                                                    Malta                                                                      62
                                            6.8                                                   France                                                         31
                                            6.8                                                 Germany                                                     24
                                           7.1                                                   Austria                                                    25
                                           7.1                                               United Kingdom                                    6
                                          7.3                                                Czech Republic                                                 24
                                          7.3                                                Slovak Republic                                                24
                                     7.6                                                         Belgium                                                          36
                                     7.6                                                           Spain                                                                                                            171
                                     7.7                                                        Portugal                                                                         67
                                    7.9                                                         Romania                                        4
                               8.3                                                               Bulgaria                                                         36
                               8.3                                                               Hungary                   -20
                              8.4                                                                 Greece                                                               42
               11.0                                                                               Turkey                                   n.a.

15                  10                     5                                             0                         -50                 0                              50                 100             150        200
Percentage of newborns weighing less than 2 500 g                                                                                                                                                   % change over period

Source: OECD Health Data 2010; WHO HFA-DB.
                                                                                                                           1 2 http://dx.doi.org/10.1787/888932335856


         1.9.2. Trends in low birth weight infants,                                                     1.9.3. Low birth weight and infant mortality, 2008
          selected European countries, 1980-2008                                                                    (or nearest year available)
                                Finland                                        Hungary                 Infant mortality (deaths per 1 000 live births)
                                                                                                           20
                                Spain                                          EU
Percentage of newborns weighing less than 2 500 g                                                                         R 2 = 0.32
   12                                                                                                                                                                                                         TUR


                                                                                                          15
   10


                                                                                                                                                                                                    ROU
    8                                                                                                     10                                                                              MLT
                                                                                                                                                                                                      BGR

    6                                                                                                                                                   LVA                              SVK
                                                                                                                                                                   EST             POL                HUN
                                                                                                               5                                                                           GBR
                                                                                                                                                                      LTU
    4                                                                                                                                                        FIN
                                                                                                                                                   ISL                                                GRC
                                                                                                                                                                        LUX              CZE
                                                                                                                                                                                   SVN
    2                                                                                                          0
        1980          1985           1990                     1995          2000     2005                          0                                         4                                  8                      12
                                                                                                                                                                                                     Low birth weight (%)

Source: OECD Health Data 2010; WHO HFA-DB.                                                             Source: OECD Health Data 2010; WHO HFA-DB.
           1 2 http://dx.doi.org/10.1787/888932335875                                                             1 2 http://dx.doi.org/10.1787/888932335894




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                               43
1.10. SELF-REPORTED HEALTH AND DISABILITY


     Most European countries conduct regular health          illnesses or health problems more often than men (an
surveys which allow respondents to report on differ-         average of 32% versus 27% across EU countries), with
ent aspects of their health. A commonly-asked                the gender divide greatest in Latvia, Norway and the
question relates to self-perceived health status, of the     Slovak Republic. Reporting increased with age, from
type: “How is your health in general?”. Despite the          an average of 10% of young people aged 15-24 years,
subjective nature of this question, indicators of            to 70% of older persons aged 85 years or more. There
perceived general health have been found to be a good        is a moderate negative association between adults
predictor of people’s future health care use and             reporting good/very good health, and reporting a long-
mortality (for instance, see Miilunpalo et al., 1997). For   standing illness or health problem (R2 = –0.38).
the purpose of international comparisons however,                 When adults were asked whether they had been
cross-country differences in perceived health status         limited in their usual daily activities because of a
are difficult to interpret because responses may be          health problem – which is one definition of disability –
affected by social and cultural factors.                     24% answered that they had, with 8% of respondents
     Keeping these limitations in mind, a majority           “strongly limited” and 15% “limited to some extent”
of the adult population in almost all European               (Figure 1.10.2). Adults most commonly reported
countries rate their health to be good or very good          activity limitation in the Slovak Republic, Germany,
(Figure 1.10.1). In Switzerland, Ireland, Iceland and the    Latvia, Estonia and Portugal (30% or more of respon-
United Kingdom, more than eight out of ten people            dents), and less so in Malta, Iceland and Switzerland
report good or very good health. Across the European         (less than 15%). Severe activity limitation was more
Union, two-thirds (67%) of all adults rated their health     prevalent in Portugal, the Slovak Republic, Austria and
as good or better, with Germany, Finland and France          Germany (10% or more of respondents), and less so in
close to this average. Adults in central and eastern         Malta, Bulgaria and Switzerland (less than 5%). Adults
European countries, along with Portugal, report the          with activity limitations were also less likely to report
lowest rates of good or very good health. In Latvia,         good or very good health (R2 = 0.60).
Lithuania and Portugal, less than half of all adults
consider themselves to be in good health. These
differences, however, do not necessarily mean that
the general health of people in Switzerland or Ireland
is objectively better than that of citizens in Latvia or                   Definition and deviations
Portugal (Baert and de Norre, 2009).                              Self-reported health reflects people’s overall
     In all European countries, men are more likely            perceptions of their own health, including both
than women to rate their health as good or better,             p hy s i c a l a n d p s y ch o l o g i c a l d i m e n s i o n s .
with the largest differences in Portugal, Bulgaria and         Typically ascertained through health interview
the Slovak Republic. Unsurprisingly, people’s rating of        surveys, respondents are asked a number of
their own health tends to decline with age. In many            questions on their health and functioning. The
countries there is a particularly marked decline in a          three questions used in the EU-SILC survey, and
positive rating of one’s own health after age 45 and a         some other national surveys are: i) “How is your
further decline after age 65. People who are unem-             health in general? Is it very good, good, fair, bad,
ployed, retired or inactive more often report bad or           very bad”; ii) “Do you have any longstanding
very bad health (Baert and de Norre, 2009). People with        illness or health problem which has lasted, or is
a lower level of education or income do not rate their         expected to last for six months or more?”; and
health as positively as people with higher levels              iii) “For at least the past six months, have you
(Mackenbach et al., 2008).                                     been hampered because of a health problem in
                                                               activities people usually do? Yes, strongly
     Another common health interview survey ques-
                                                               limited/Yes, limited/No, not limited”.
tion asks whether respondents had any long-standing
illnesses or health problems. Three-in-ten adults in             Persons in institutions are not surveyed.
EU countries reported having illnesses or health               Caution is required in making cross-country
problems (Figure 1.10.1). Adults in Finland, Slovenia,         comparisons of perceived general health, since
Hungary and Estonia were more likely to report                 people’s assessment of their health is subjective
having illnesses or health problems, while these               and can be affected by their social and cultural
conditions were less commonly reported in Romania,             backgrounds.
Greece and Italy. Women reported long-standing




44                                                                                  HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                       1.10. SELF-REPORTED HEALTH AND DISABILITY



                                                                          1.10.1. Adults’ self-reported health status, 2008
                              Good or very good health                                                                                   Long-standing illness or health problem
         87                                                                                          Switzerland                                                 27
              84                                                                                        Ireland                                       24
                   81                                                                                  Iceland                                              26
                   80                                                                              United Kingdom                                                                 33
                        79                                                                             Sweden                                                                     33
                         77                                                                          Netherlands                                                             31
                         77                                                                            Cyprus                                              26
                         77                                                                            Norway                                                                   32
                             76                                                                         Greece                                   22
                              74                                                                      Denmark                                         25
                              74                                                                    Luxembourg                                        24
                              74                                                                         Malta                                        25
                              74                                                                       Belgium                                         25
                                  73                                                                     Spain                                                             30
                                       70                                                              Austria                                                                    33
                                       69                                                             Romania                               19
                                       69                                                               France                                                                            37
                                       69                                                              Finland                                                                                           41
                                            67                                                          Turkey        n.a.
                                            67                                                             EU                                                           30
                                                 65                                                   Germany                                                                             36
                                                  64                                                      Italy                                  23
                                                      63                                               Bulgaria                                       24
                                                       62                                          Czech Republic                                                28
                                                           60                                      Slovak Republic                                                     30
                                                            59                                         Slovenia                                                                                     39
                                                                58                                      Poland                                                              31
                                                                     55                                Hungary                                                                                 38
                                                                     55                                Estonia                                                                                 38
                                                                           49                         Portugal                                                                       33
                                                                           48                         Lithuania                                                       29
                                                                                 45                      Latvia                                                                      34

100     90        80       70                               60              50        40      30                     10                    20                         30              40             50
% of population aged 15 and over                                                                                                                                        % of population aged 15 and over

Source: EU-Statistics on Income and Living Conditions survey; OECD Health Data 2010; Swiss Federal Statistics Office.
                                                                                1 2 http://dx.doi.org/10.1787/888932335913


                                                       1.10.2. Adults reporting a limitation in usual activities, 2008
                                                                           Limited strongly                                            Limited to some extent
% of population aged 15 and over
   40




   30




   20




   10




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Source: EU-Statistics on Income and Living Conditions survey; Swiss Federal Statistics Office.
                                                                                                                             1 2 http://dx.doi.org/10.1787/888932335932




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                   45
1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES


      Communicable diseases such as measles, pertus-            Two-thirds of all pertussis cases in 2008 occurred
sis and hepatitis B still pose a major threat to the       among children aged under 15 years of age, although
health of European citizens. Measles, a highly infec-      the disease may be under-diagnosed in adolescents
tious disease of the respiratory system, is caused by a    and adults. The highest incidence occurred among
virus. Symptoms include fever, cough, runny nose, red      infants aged less than one year, many of whom are too
eyes and a characteristic rash. It can lead to severe      young to be vaccinated, and children aged 10-14 years,
health complications, including pneumonia, enceph-         who may have not had a full course of vaccination, or
alitis, diarrhoea and blindness. Pertussis (or whooping    who may have lost their immunity. Vaccination status
cough) is also highly infectious, and is caused by the     was known in only half of all reported cases, but of
bacterium Bordetella pertussis. The disease derives its    these 21% were unvaccinated (EUVAC.NET, 2010).
name from the sound made from the intake of air                 Around 6 000 hepatitis B cases were reported
after a cough. Hepatitis B is an infection of the liver    annually in EU countries during 2006-08. The highest
caused by the hepatitis B virus. The virus is trans-       incidence rates occurred among six countries:
mitted by contact with blood or body fluids of an          Iceland (13.2 notified cases per 100 000 population),
infected person. A small proportion of infections          Bulgaria (9.9), Turkey (9.1), Austria (8.1), Latvia (7.3) and
become chronic, and these people are at high risk of       Romania (5.1) (Figure 1.11.3). The notification rate has
death from cancer or cirrhosis of the liver. Protection    declined in EU countries since 1991-93, when it was
against each of these diseases is available through        8.3 cases per 100 000 population to 2.5 for 2006-08.
vaccination (see Indicator 3.3).                           Hepatitis B infection is more common in the southern
      An average of over 5 000 measles cases were          parts of Eastern and Central Europe, and low in preva-
reported annually in European Union countries              lence in most of Western Europe. Around twice as
during 2006-08, with the highest number of cases           many cases of hepatitis B occurred among males than
occurring in four countries: Germany, Romania, the         females in 2008, with the majority reported in the age
United Kingdom and Italy. The highest crude                group 25-44 years, followed by 15-24 year-olds. The
incidence during 2006-08 was in Switzerland, with          disease is increasingly seen as a sexually transmitted
15 cases reported per 100 000 persons (Figure 1.11.1).     disease, although the disease pattern and risk groups
A number of other western European countries,              differ widely across Europe (ECDC, 2009).
including the United Kingdom, Romania, France and
Italy, also had high incidences. Across the European
Union, average incidence for 2006-08 was 1.2 cases
per 100 000 population. This represents a marked
decline from the average rate in 1991-93, which was
27 cases per 100 000 population. In 2008, more than                     Definition and deviations
half of all cases (53%) occurred among children and
young people aged 5-19 years. Hospitalisation was               National mandatory notification systems for
necessary for 15% of cases. Among cases whose vacci-          communicable diseases, including measles,
nation status was known, the vast majority (91%) were         pertussis and hepatitis B, exist in most European
unvaccinated (EUVAC.NET, 2009).                               countries, although case definitions, laboratory
                                                              confirmation requirements and reporting systems
     Almost 13 000 pertussis cases were reported              may differ.
annually among EU countries, with an overall
incidence of six per 100 000 population (Figure 1.11.2).        In 2008, measles notification was voluntary
The highest incidences were reported in Norway                in Belgium, although mandatory in schools.
(113 cases per 100 000 population), Switzerland (45),         Pertussis notification was mandatory only in
the Netherlands (41), Estonia (26) and Slovenia (24).         parts of Belgium and Germany, and Switzerland
Most cases were reported from the Netherlands,                and France had sentinel surveillance systems.
Norway, Switzerland and Poland, which together                Hepatitis B notification was voluntary in France
contributed three-quarters (76%) of all cases reported        and Belgium, Italy had a sentinel surveillance
in 2008. Pertussis incidence has halved since 1991-93,        system, and reporting was not mandatory in
when the average rate among EU countries was                  Switzerland.
11.3 notified cases per 100 000 population.




46                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                            1.11. INCIDENCE OF SELECTED COMMUNICABLE DISEASES



           1.11.1. Incidence of measles, 2006-08                                                                                 1.11.2. Incidence of pertussis, 2006-08
      Switzerland                                                                         14.9                                    Norway                                                                                   112.9
  United Kingdom                                                7.2                                                          Switzerland                                              44.7
         Romania                                         5.5                                                                 Netherlands                                          41.1
            France                                4.0                                                                             Estonia                                26.0
               Italy                             3.6                                                                             Slovenia                               24.0
            Austria                    2.0
                                                                                                                                  Finland                   9.6
            Greece                   1.6
                                                                                                                                Denmark                    8.0
         Germany                     1.5
                                                                                                                                  Sweden                  7.1
            Ireland                 1.5
                                                                                                                                        EU                5.7
                 EU                1.2
           Estonia             0.7
                                                                                                                          Czech Republic              4.7

              Spain            0.7                                                                                                 Poland             4.6

     Luxembourg                0.6                                                                                               Bulgaria             3.5
          Belgium             0.5                                                                                        United Kingdom              2.0
              Malta           0.3                                                                                                  Ireland           1.9
         Denmark             0.3                                                                                                 Belgium             1.8
      Netherlands            0.2                                                                                                   Austria          1.6
            Poland           0.2                                                                                                     Spain          1.1
           Norway            0.2                                                                                                      Italy         1.1
           Sweden            0.2                                                                                                    Latvia          1.0
             Latvia          0.1                                                                                         Slovak Republic            0.9
            Cyprus           0.04
                                                                                                                                   Cyprus           0.8
   Czech Republic            0.03
                                                                                                                                Lithuania           0.7
           Finland           0.03
                                                                                                                                  Iceland           0.6
            Turkey           0.03
                                                                                                                            Luxembourg              0.4
         Lithuania           0.02
          Bulgaria           0.01
                                                                                                                                 Hungary            0.3

          Hungary          0.0                                                                                                       Malta          0.3

           Iceland         0.0                                                                                                     Greece           0.2
          Portugal         0.0                                                                                                   Portugal           0.2
  Slovak Republic          0.0                                                                                                  Romania             0.2
          Slovenia         0.0                                                                                                     Turkey           0.1

                       0                           5                   10             15          20                                           0                    25                50           75        100     125
                                                                              Per 100 000 population                                                                                               Per 100 000 population

Source: OECD Health Data 2010; WHO Europe (2010).                                                                  Source: OECD Health Data 2010; WHO Europe (2010).
           1 2 http://dx.doi.org/10.1787/888932335951                                                                         1 2 http://dx.doi.org/10.1787/888932335970


                                                                            1.11.3. Incidence of hepatitis B, 2006-08
Per 100 000 population
   15
         13.2


   12

                9.9
                       9.1
    9
                                 8.1
                                           7.3


    6
                                                   5.1

                                                          3.8
                                                                 3.5
                                                                        3.0   2.8   2.7
    3                                                                                     2.6    2.5   2.2   2.1
                                                                                                                   1.8    1.7   1.5   1.4     1.3     1.2         1.2    1.1    1.0    0.8   0.7   0.7   0.5   0.4   0.4
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Source: OECD Health Data 2010; WHO Europe (2010).
                                                                                                                                      1 2 http://dx.doi.org/10.1787/888932335989




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                 47
1.12. HIV/AIDS


     The first cases of Acquired Immunodeficiency           in tho se cou ntries wit h high A IDS incid ence
Syndrome (AIDS) were diagnosed almost 30 years ago.         rates – Estonia, Latvia, Portugal and Spain, along
The onset of AIDS is normally caused as a result of         with Switzerland – all at over 300 persons per
HIV (human immunodeficiency virus) infection and            100 000 population. Over 25 000 new cases of HIV were
can manifest itself as any number of different dis-         diagnosed in the European Union in 2008. The
eases, such as pneumonia and tuberculosis, as the           predominant mode of transmission of HIV is sex
immune system is no longer able to defend the body.         between men, followed by heterosexual contact.
There is a time lag between HIV infection, AIDS             However, among ea stern European countries,
diagnosis and death due to HIV infection, which can         injecting drug use is still the most common mode
be any number of years depending on the treatment           (ECDC and WHO Europe, 2009). Approximately 75% of
administered. Despite worldwide research, there is no       heterosexually acquired HIV infection in Western and
cure currently available.                                   Central Europe is among migrants.
     In 2008, the number of newly reported cases of              In recent years, the overall decline in AIDS cases
AIDS was approximately 5 300 across the European            has slowed down. This reversal has been accompanied
Union as a whole, representing an unweighted aver-          by evidence of increasing transmission of HIV in
age incidence rate of 12.7 per million population           several European countries, attributed to complacency
(Figure 1.12.1). Following the first reporting of AIDS in   regarding the effectiveness of treatment and a waning
the early 1980s, the number of cases rose rapidly to        of public awareness regarding drug use and sexual
reach an average of more than 37 new cases per              practice. Since 2000, the rate of newly diagnosed cases
million population across EU countries at its peak in       of HIV has more than doubled to 89 per million popula-
the middle of the 1990s, almost three times current         tion in 2008 (ECDC and WHO Europe, 2009). Further
incidence rates (Figure 1.12.2). Public awareness           inroads in AIDS incidence rates will require more
campaigns contributed to steady declines in reported        intensive evidence-based HIV prevention programmes
cases through the second half of the 1990s. In              that are focused and adapted to reach those most at
addition, the development and greater availability of       risk of HIV infection (UNAIDS, 2008).
antiretroviral drugs, which reduce or slow down the
development of the disease, led to a sharp decrease in
incidence from 1996.
     The highest AIDS incidence rates among                             Definition and deviations
EU countries in 2008 were reported in Estonia, Latvia,
Portugal and Spain, at 25-50 new cases per million              The incidence rate of acquired immunodefi-
population. Spain had the highest incidence rates in          ciency syndrome (AIDS) is the number of new
the first decade following the outbreak, although             cases per million population at year of diagnosis.
there was a sharp decline from 1994 onwards.                  Note that data for recent years are provisional
Incidence rates in Portugal peaked somewhat later,            due to reporting delays, which sometimes can be
towards the end of the 1990s. AIDS incidence rates in         for several years depending on the country.
Estonia have increased rapidly since the mid-2000s.             Estimates of the number of persons living with
Central European countries such as the Czech and              human Immunodeficiency virus (HIV) are calcu-
Slovak Republics, Hungary and Poland report the               lated by the Joint United Nations Programme on
lowest incidence rates of AIDS among EU countries.            HIV/AIDS (UNAIDS, 2008), and are based on
     In the European Union, approximately                     national research studies. These estimates
730 000 persons were living with HIV infection in 2007        include all people (adults and children) with HIV
(Figure 1.12.1). Italy, Spain and France had the greatest     infection in 2007, whether or not they have
number of persons, followed by the United Kingdom             developed symptoms of AIDS.
and Germany. HIV prevalence estimates were highest




48                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                    1.12. HIV/AIDS



           1.12.1. AIDS incidence rates in 2008, and estimated number of persons living with HIV in 2007
                         AIDS incidence                                                                                                                Persons living with HIV
 45.5                                                                                                Estonia                  9 900
    43.6                                                                                               Latvia                 10 000
             36.4                                                                                   Portugal                              34 000
                       29.1                                                                            Spain                                                                      140 000
                                      19.5                                                             Malta           < 500
                                          17.2                                                          Italy                                                                          150 000
                                             16.3                                                   Lithuania           2 200
                                                 14.7                                              Switzerland                        25 000
                                                    12.7                                                 EU                                                                                      // 730 000
                                                    12.6                                           Netherlands                   18 000
                                                    12.4                                          Luxembourg           n.a.
                                                        10.4                                        Romania                     15 000
                                                           10.0                                  United Kingdom                                             77 000
                                                           9.8                                        France                                                                      140 000
                                                            9.4                                      Belgium                    15 000
                                                             8.5                                     Sweden              6 200
                                                                  7.9                                 Greece                  11 000
                                                                  7.8                                Austria                  9 800
                                                                  7.6                                Cyprus            n.a.
                                                                    6.4                               Ireland            5 500
                                                                    6.3                              Iceland           < 500
                                                                        5.9                         Denmark              4 800
                                                                        5.5                          Finland            2 400
                                                                        5.5                          Slovenia          < 500
                                                                              3.8                    Bulgaria          n.a.
                                                                              3.8                    Norway             3 000
                                                                               3.0                  Germany                                        53 000
                                                                               3.0                    Poland                     20 000
                                                                               2.8               Czech Republic        1 500
                                                                                2.3                  Hungary            3 300
                                                                                     0.7              Turkey           < 2 000
                                                                                      0.2        Slovak Republic       < 500

50         40            30               20                   10                           0                      0                      50 000              100 000            150 000     200 000
New cases per million population                                                                                                                                                   Number of persons

Source: OECD Health Data 2010; ECDC and WHO Europe (2009); UNAIDS (2008).
                                                                                                                              1 2 http://dx.doi.org/10.1787/888932336008


                         1.12.2. Trends in AIDS incidence rates, selected EU countries, 1981-2008
                                    France                                                      Portugal                                       Spain                              EU
New cases per million population
 200




  150




  100




   50




    0
     1981                          1986                                         1991                               1996                                     2001                         2006

Source: OECD Health Data 2010.
                                                                                                                              1 2 http://dx.doi.org/10.1787/888932336027




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                             49
1.13. CANCER INCIDENCE


     Around 2.4 million new cases of cancer (excluding             countries such as Belgium, France, the Netherlands
non-melanoma skin cancers) were diagnosed in                       and Ireland, at over 90 cases per 100 000 population
EU countries in 2008 (Ferlay et al., 2010), with 55%               (Figure 1.13.3). Rates in Central, Eastern and Southern
occurring among males and 45% among females. The                   Europe were lower, with Turkey, Greece, Romania,
most common forms of the disease were prostate,                    Lithuania, Latvia and Poland all reporting less than
colorectal, breast and lung cancer. The risk of getting            50 new cases per 100 000 population. There has been
cancer before the age of 75 years is 26.5%, or around              an increase in measured incidence rates of breast
one in four. However, because the population of Europe             cancer over the past decade, although death rates
is ageing, the rate of new cases of cancer is also                 have declined or remained stable. Survival rates have
expected to increase (European Commission, 2008b).                 also increased, due to earlier diagnosis and/or better
     Large regional inequalities exist in cancer                   treatment (see Indicator 3.13).
incidence across the European Union. In 2008, the                       Prostate cancer is the most common form among
incidence rate for all cancers combined was highest                men in the European Union, particularly for those
i n N o r th er n a n d Wes t e r n E u ro p e – D e n m a r k ,   aged over 65 years of age, comprising one quarter
Ireland, Belgium, France, Norway and Iceland – at over             (25%) of all new diagnoses in 2008. Rates were highest
290 per 100 000 population, but was lower in some                  in Ireland, France, Belgium and northern European
Mediterranean countries such as Turkey, Greece, Cyprus             countries (Norway, Sweden, Iceland and Finland).
and Malta, at less than 220. Rates in Italy were above the         Rates were lower in a range of central, eastern and
EU average of 255 new cases per 100 000 population.                southern European countries, including Turkey,
Rates in central and eastern European countries varied,            Greece, Romania and Bulgaria. At least part of the
being highest in the Czech Republic and Hungary                    five-fold difference between countries with the
(around 290), similar to the EU average in Slovenia and            highest and lowest incidence rates is due to under-
the Slovak Republic (260), and below average in                    registration of prostate cancer in some countries, as
Romania, Bulgaria, Poland and other countries.                     well as the use of sensitive diagnostic tests for early
     Cancer incidence rates are higher for men than                detection in others (Ferlay et al., 2007).
for women in all EU countries (Figure 1.13.1). Here too
there is great variation between countries; in Spain
and Turkey, male incidence rates are 60% higher than                           Definition and deviations
female rates, whereas in Denmark and Cyprus they
are less than 10% higher. The average all cancer                       Cancer incidence rates are based on numbers
incidence rate among EU member states was 298 per                    of new cases of cancer registered in a country in
100 000 males and 226 per 100 000 females.                           a year divided by the size of the corresponding
                                                                     population. The rates have been directly
     In 2008, lung cancer was one of the most
                                                                     age-standardised to the WHO World standard
common cancers in EU countries, being responsible
                                                                     population to remove variations arising from
for around 12% of all new cancer diagnoses, 16% for
                                                                     differences in age structures across countries
males and 7% for females. Ten of the fifteen countries
                                                                     and over time. The source is GLOBOCAN 2008, at
with male rates higher than the EU average were
                                                                     http://globocan.iarc.fr.
located in Central and Eastern Europe (Figure 1.13.2).
Rates in Hungary, Poland and Slovenia were higher                      Cancer registration is well established in a
than 60 per 100 000 population. Male lung cancer                     majority of European Union member states,
incidence rates in Northern Europe (Sweden, Iceland,                 although the quality and completeness of cancer
Finland, Norway) and some southern European                          registry data may vary. In some countries, cancer
countries (Cyprus, Portugal, Malta) were less than                   registries only cover subnational areas. The
40 per 100 000 population. Among females, lung                       international comparability of cancer incidence
cancer incidence was especially high in Denmark, but                 data can also be affected by differences in
also Hungary, Iceland and the Netherlands, at over 25.               medical training and practice.

     Thirty per cent of all new cancer cases among                     The incidence of all cancers is classified to
women diagnosed in 2008 were cancers of the breast                   ICD-10 codes C00-C97, lung cancer to C33-C34,
– the most common form of cancer among women.                        breast cancer to C50 and prostate cancer to C61.
Incidence rates were high in western European




50                                                                                   HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                     1.13. CANCER INCIDENCE



             1.13.1. All cancers incidence rates,                                                            1.13.2. Lung cancer incidence rates,
                  males and females, 2008                                                                          males and females, 2008
                                              Males                            Females                                                                 Males                                    Females

            Turkey           113                                                                            Sweden                            18 19
                                                182
            Cyprus                           175                                                             Cyprus             5
                                                 187                                                                                            22
            Greece                 142                                                                     Portugal              6
                                                188                                                                                                 29
              Malta                                    200                                                  Iceland                                    28
                                                             233                                                                                    29
         Romania                              180                                                           Finland                    11
                                                              241                                                                                   30
          Bulgaria                                  204                                                        Malta            6
                                                                246                                                                                   33
          Portugal                               191                                                         Austria                      16
                                                                       267                                                                              36
           Finland                                           230                                            Norway                              25
                                                                       283                                                                               37
            Poland                              186                                                          Ireland                           24
                                                                        285                                                                               38
           Estonia                                     204                                             Switzerland                         17
                                                                        285                                                                               38
           Sweden                                            241                                   United Kingdom                              24
                                                                         287                                                                                 42
            Austria                                    219                                                Germany                         16
                                                                          294                                                                                42
                 EU                                       226                                             Denmark                                        36
                                                                           298                                                                                43
  United Kingdom                                               250                                              Italy                 11
                                                                           298                                                                                  45
             Latvia                              193                                                   Netherlands                               26
                                                                             304                                                                                46
              Spain                             187                                                   Luxembourg                            18
                                                                              310                                                                                46
               Italy                                            252                                               EU                     15
                                                                               310                                                                               47
      Switzerland                                           236                                              France                      15
                                                                               313                                                                                48
           Iceland                                                   273                                     Turkey             5
                                                                                315                                                                                49
          Slovenia                                         232                                     Slovak Republic                   11
                                                                                316                                                                                49
         Lithuania                                   208                                                    Estonia                 9
                                                                                 317                                                                                51
      Netherlands                                                    271                                   Bulgaria               8
                                                                                 318                                                                                 51
  Slovak Republic                                        223                                        Czech Republic                        16
                                                                                 320                                                                                  53
     Luxembourg                                                  254                                         Greece                9
                                                                                  324                                                                                 53
                                                              246                                              Spain              8
         Germany                                                                    331                                                                               53
                                                                               313                        Romania                   10
         Denmark                                                                      337                                                                               55
                                                                   266                                        Latvia              7
           Norway                                                                     341                                                                               55
                                                                253                                       Lithuania              7
   Czech Republic                                                                      344                                                                               56
                                                                        285                                Belgium                        16
            Ireland                                                                       356                                                                              58
                                                                      276                                  Slovenia                        17
          Belgium                                                                         357                                                                                 64
                                                             239                                             Poland                         18
          Hungary                                                                         358                                                                                                     71
                                                                 255                                       Hungary                                 28
            France                                                                         361                                                                                                            79

                       100                200               300             400                                             0                20        40         60         80      100
                                   Age-standardised rates per 100 000 population                                                            Age-standardised rates per 100 000 population

Source: OECD Health Data 2010; Ferlay et al. (2010).                                             Source: OECD Health Data 2010; Ferlay et al. (2010).
           1 2 http://dx.doi.org/10.1787/888932336046                                                       1 2 http://dx.doi.org/10.1787/888932336065


1.13.3. Breast cancer incidence rates, females, 2008                                             1.13.4. Prostate cancer incidence rates, males, 2008
            Turkey                      28                                                                  Turkey                   15
            Greece                               45                                                         Greece                    18
         Romania                                 45                                                      Romania                        20
         Lithuania                                46                                                      Bulgaria                       23
             Latvia                                48                                                     Hungary                              33
            Poland                                 49                                             Slovak Republic                                     40
           Estonia                                  50                                                     Estonia                                     43
  Slovak Republic                                     53                                                    Poland                                      44
          Bulgaria                                      57                                                  Cyprus                                       47
          Hungary                                       58                                                Portugal                                         50
          Portugal                                       60                                                   Malta                                        51
              Spain                                       61                                                  Spain                                             57
          Slovenia                                          66                                                 Italy                                            58
            Cyprus                                           68                                           Slovenia                                                62
   Czech Republic                                            68                                    Czech Republic                                                  63
            Austria                                           70                                                 EU                                                 65
                 EU                                            71                                            Latvia                                                  66
              Malta                                             72                                       Lithuania                                                   67
           Norway                                                 76                                     Denmark                                                          73
         Germany                                                       82                             Netherlands                                                         73
     Luxembourg                                                        82                            Luxembourg                                                            75
           Sweden                                                      83                         United Kingdom                                                                80
           Iceland                                                       86                              Germany                                                                 83
               Italy                                                     86                                 Austria                                                              83
           Finland                                                        87                          Switzerland                                                                     91
  United Kingdom                                                           88                              Finland                                                                         97
         Denmark                                                           89                              Iceland                                                                              102
      Switzerland                                                           89                            Belgium                                                                               102
            Ireland                                                           94                           Sweden                                                                                      114
      Netherlands                                                              97                          Norway                                                                                       116
            France                                                               100                        France                                                                                       118
          Belgium                                                                      109                  Ireland                                                                                            126

                        0          25         50       75       100      125   150                                      0             25           50       75       100      125   150
                                         Age-standardised rates per 100 000 females                                                             Age-standardised rates per 100 000 males

Source: OECD Health Data 2010; Ferlay et al. (2010).                                             Source: OECD Health Data 2010; Ferlay et al. (2010).
           1 2 http://dx.doi.org/10.1787/888932336084                                                       1 2 http://dx.doi.org/10.1787/888932336103




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                          51
1.14. DIABETES PREVALENCE AND INCIDENCE


      Diabetes is a chronic metabolic disease, charac-      Italy, Bulgaria and Greece have less than ten new
terised by high levels of glucose in the blood. It occurs   cases per 100 000 population. Alarmingly, there is
either because the pancreas stops producing the             evidence that type 1 diabetes is developing at an ear-
hormone insulin (type 1 diabetes), or through a             lier age among children.
combination of the pancreas having reduced ability to            The economic impact of diabetes is substantial.
produce insulin alongside the body being resistant to       Health expenditure to treat and prevent diabetes and
its action (type 2 diabetes). People with diabetes are at   its complications is estimated to total USD 93 billion,
a greater risk of developing cardiovascular diseases        or approximately 10% of total health expenditure in
such as heart attack and stroke if the disease is left      EU countries in 2010 (IDF, 2009). Around one-quarter
undiagnosed or poorly controlled. They also have            of medical expenditure is spent on controlling
elevated risks for sight loss, foot and leg amputation      elevated blood glucose, another quarter on treating
due to damage to the nerves and blood vessels, and          long-term complication of diabetes, and the remain-
renal failure requiring dialysis or transplantation.        der on additional general medical care. Increasing
     Diabetes was the principal cause of death of           costs reinforce the need to provide quality care for the
more than 100 000 persons in EU countries in 2008,          management of diabetes and its complications.
and is the fourth or fifth leading cause of death in             Type 2 diabetes is largely preventable. A number
most developed countries. However, only a minority          of risk factors, such as overweight and obesity and
of persons with diabetes die from diseases uniquely         physical inactivity are modifiable, and can also help
related to the condition – in addition, about 50% of        reduce the complications that are associated with
persons with diabetes die of cardiovascular disease,        diabetes. But in most countries, the prevalence of
and 10-20% of renal failure (IDF, 2006).                    overweight and obesity also continues to increase (see
     Diabetes is increasing rapidly in every part of the    Indicator 2.8).
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 countries, or
33 million people, have diabetes in 2010. Almost half                   Definition and deviations
of diabetic adults are aged less than 60 years. If left
unchecked, the number of people with diabetes in EU             The sources and methods used by the Inter-
countries will reach more than 37 million in less than        national Diabetes Federation for publishing
20 years (IDF, 2006).                                         national prevalence estimates of diabetes are
                                                              outlined in their Diabetes Atlas, 4th edition (IDF,
     Less than 5% of adults aged 20-79 years in
                                                              2009). Country data were derived from studies
Iceland, Norway and the United Kingdom have
                                                              published between 1980 and February 2009, and
diabetes, according to the International Diabetes
                                                              were only included if they met several criteria
Federation. This contrasts with Cyprus, Germany and
                                                              for reliability.
Turkey, where 8% or more of the population of the
same age have the disease (Figure 1.14.1). Among EU             Studies from several European countries
countries, abnormal glucose tolerance shows little            – France, Italy, Netherlands, Norway, Slovenia
association with affluence, and there was little              and the United Kingdom – only provided
evidence of an urban/rural divide in prevalence,              self-reported data on diabetes. To account for
except in a few countries (IDF, 2009).                        undiagnosed diabetes, the prevalence of
                                                              diabetes for the United Kingdom was multiplied
     Type 1 diabetes accounts for only 10-15% of all
                                                              by a factor of 1.5, in accordance with local rec-
diabetes cases. It is the predominant form of the
                                                              ommendations, and doubled for other countries,
disease in younger age groups in most developed
                                                              based on data from a number of countries.
countries. Based on disease registers and recent
studies, the annual number of new cases of type 1               Prevalence rates were adjusted to the World
diabetes in children aged under 15 years is high at 25        Standard Population to facilitate cross-national
or more per 100 000 population in Nordic countries            comparisons.
(Finland, Sweden and Norway) (Figure 1.14.2). Turkey,




52                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                         1.14. DIABETES PREVALENCE AND INCIDENCE



                                          1.14.1. Prevalence estimates of diabetes, adults aged 20-79 years, 2010
    %
    10
                                                                                                                                                                                                                                                                  9.1
                                                                                                                                                                                                                                                       8.9

                                                                                                                                                                                                                                           8.0
     8                                                                                                                                                                                               7.6         7.7          7.7

                                                                                                                                                                              6.7        6.8
                                                                                                                                          6.5        6.5          6.6
                                                                                                                               6.4
                                                                                                         5.9        6.0
     6                                                                            5.6        5.7
                                               5.2          5.2        5.3



     4                   3.6        3.6



     2        1.6



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Note: The data are age-standardised to the World Standard Population.
Source: IDF (2009).
                                                                                                                                                           1 2 http://dx.doi.org/10.1787/888932336122


                                1.14.2. Incidence estimates of type 1 diabetes, children aged 0-14 years, 2010
Cases per 100 000 population
   60                                                                                                                                                                                                                                                          57.4


   50

                                                                                                                                                                                                                                                      41.0
   40


   30                                                                                                                                                                                                                                  27.9
                                                                                                                                                                                                                          24.5
                                                                                                                                                                                                                22.2
   20                                                                                                                                                                        18.0       18.0        18.8
                                                                                                                                                 15.6            16.3
                                                                                                                           14.7       14.9
                                                                                12.9       13.0        13.2        13.6
                                                           11.1    12.2
                                    9.4       9.9
   10                    8.4

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                                                                                                                                                                                        y

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Source: IDF (2009).
                                                                                                                                                           1 2 http://dx.doi.org/10.1787/888932336141




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                                        53
1.15. DEMENTIA PREVALENCE


      Dementia describes a variety of brain disorders        One important cost driver is the increasing demand
which progressively damage and destroy brain cells.          for institutional and residential care.
Affecting mainly people over the age of 60 years,                 The prevention and treatment of dementia has
dementia results in the deterioration of mental ability      been recognised as a major public health priority. The
characterised by impairments in memory and cogni-            European Commission has supported several projects
tion. It is one of the most important causes of disability   to investigate and enhance the evidence base
in the elderly. The most common cause of dementia in         surrounding Alzheimer’s disease and other forms
the European Union is Alzheimer’s disease (around            of dementia. These have included the EuroCoDe
50-70%), followed by successive strokes that lead to         (European Collaboration on Dementia) project
multi-infarct dementia (around 30%). There is no cure        from 2006-08 which was co-ordinated by Alzheimer
for dementia, but drugs exist to alleviate and temporar-     Europe. The most recent initiative supports national
ily delay the symptoms.                                      efforts in the key areas of prevention, research
     In 2006, the number of people with dementia in          coordination and best practice in treatment and care
the European Union was estimated to be 7.3 million,          (European Commission, 2010b).
and because of their longer life expectancy, almost               At a national level, various countries including
68% (4.9 million) of those affected were women. The          France, Norway and the United Kingdom have put in
highest prevalence rates were found in Sweden, Italy,        place national plans and strategies to meet the future
Switzerland and Germany, where between 1.7-1.8% of           challenges posed by dementia. These plans include
the population suffer from dementia. This contrasts          measures to improve early diagnosis, treatment and
with less than 1.0% of the population in Turkey, the         the quality of care for people affected by dementia, as
Slovak Republic and Ireland (Figure 1.15.1). The aver-       well as providing support to carers of those afflicted
age dementia prevalence rate for the 27 EU countries         with dementia.
was 1.4%.
     Age is the main risk factor for the development of
dementia. Although early-onset dementia can occur
before the age of 65 years, prevalence rates increase                    Definition and deviations
steadily after that age, to reach 15% of males and 16%
of females at age 80-84 years, and one-third of males            Dementia prevalence rates are based on
(32.4%) and half of females (48.8%) at age 95 years and        estimates of the total number of persons living
over (Figure 1.15.2). There is a strong positive relation-     with dementia divided by the size of the corre-
ship between the prevalence of dementia and the                sponding population. The estimates of dementia
proportion of the population aged 65 years and over in         prevalence were derived by the EuroCoDe
European countries (Figure 1.15.3).                            (European Collaboration on Dementia) project,
                                                               co-ordinated by Alzheimer Europe from 2006-08.
     The population aged 65 years and older in the
European Union is predicted to double between 1995                In order to estimate prevalence rates for
and 2050, to reach 135 million. With the increased             dementia across European countries, the
ageing of the population, the absolute number of               EuroCoDe project undertook a systematic review
people with dementia will also continue to rise,               of papers reporting dementia prevalence esti-
placing greater demand on national health and social           mates. Papers were screened according to criteria
systems. Dementia places a large burden not only on            which stipulated that studies be community-
sufferers, but also on their carers. Patterns of care vary     based, use standardised diagnostic criteria, have
across EU countries, with different mixes of informal          a minimum sample size of 300 and a participa-
care by families and friends, and formal care either in        tion rate of over 50%, and be conducted in 1990 or
institutions or at home.                                       thereafter. In addition, it was necessary that raw
                                                               prevalence data be made available. Thirty-one
     The cost of illness associated with Alzheimer’s
                                                               studies met this criteria and raw data was
disease and other dementias in Europe was esti-
                                                               extracted from 17 studies for use in the collabora-
mated at EUR 177 billion in 2006, which is divided
                                                               tive analysis.
fairly evenly between costs directly attributable to
the diseases responsible for dementia, and estimates             Given the divergence in scale and accuracy of
of costs associated with informal care. The total              the sources used across countries, the preva-
costs of dementia are expected to increase to over             lence estimates should be used with caution.
EUR 250 billion by 2030 (Alzheimer Europe, 2009).




54                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                       1.15. DEMENTIA PREVALENCE



                                     1.15.1. Prevalence of dementia, population aged 30 years and over, 2006
    %
   2.0
                                                                                                                                                                                                                        1.8
                                                                                                                                                                                                                  1.7
                                                                                                                                                                                                 1.7    1.7
                                                                                                                                                                                    1.6    1.6
   1.6                                                                                                                                                     1.5        1.5    1.6
                                                                                                                                                     1.5
                                                                                                                                   1.5   1.5   1.5
                                                                                                                             1.4
                                                                                                                1.3    1.4
                                                                                       1.3   1.3   1.3   1.3
                                                                           1.2   1.3
                                                               1.2   1.2
   1.2                                             1.1   1.1
                               1.0    1.0    1.1
                 1.0    1.0

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Source: Alzheimer Europe (2009).
                                                                                                                              1 2 http://dx.doi.org/10.1787/888932336160


          1.15.2. Age- and sex-specific prevalence                                                                     1.15.3. Population aged 65 years and over,
             of dementia in EU countries, 2006                                                                             and prevalence of dementia, 2006
                                        Male                                Female                             Prevalence of dementia (%)
                                                                                                                  1.8                                                                   SWE
Prevalence (%)                                                                                                            R 2 = 0.89
                                                                                                                                                                                                            ITA
                                                                                                                                                                      ESP         CHE
   60                                                                                                                                                                 GBR                 FRA          DEU
                                                                                                                  1.6
                                                                                                                                                                            NOR           BEL
                                                                                                                                                                FIN                     AUT
                                                                                                                                                                        DNK                 GRC
   50                                                                                                            1.4                                                   BGR            PRT
                                                                                                                                                            LVA                       EST
                                                                                                                                                                                   HUN
                                                                                                                 1.2                                   LTU                        SVN
   40                                                                                                                                                    ISL           CZE        NLD
                                                                                                                                                 MLT
                                                                                                                                                                                  LUX
                                                                                                                                           CYP                        POL
                                                                                                                 1.0
   30                                                                                                                                                      SVK          ROU
                                                                                                                                                     IRL
                                                                                                                 0.8
   20
                                                                                                                 0.6

   10
                                                                                                                 0.4               TUR


    0                                                                                                            0.2
          60-64        65-69         70-74    75-79      80-84       85-89       90-94 95 and                          5                 10                15                      20                  25                30
                                                                                         over
                                                                                      Age group                                                                  Population aged 65 years and over (%)

Source: Alzheimer Europe (2009).                                                                               Source: Alzheimer Europe (2009); OECD Health Data 2010; Eurostat
                                                                                                               Statistics Database.
                1 2 http://dx.doi.org/10.1787/888932336179                                                                  1 2 http://dx.doi.org/10.1787/888932336198




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                             55
Health at a Glance: Europe 2010
© OECD 2010




                                                    Chapter 2




                          Determinants of Health


         2.1. Smoking and alcohol consumption among children . . . . . . . . . . . . . .                           58
         2.2. Nutrition among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   60
         2.3. Physical activity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       62
         2.4. Overweight and obesity among children . . . . . . . . . . . . . . . . . . . . . . . .                64
         2.5. Supply of fruit and vegetables for consumption . . . . . . . . . . . . . . . . . .                   66
         2.6. Tobacco consumption among adults. . . . . . . . . . . . . . . . . . . . . . . . . . . .              68
         2.7. Alcohol consumption among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . .             70
         2.8. Overweight and obesity among adults . . . . . . . . . . . . . . . . . . . . . . . . . .              72




                                                                                                                        57
2.1. SMOKING AND ALCOHOL CONSUMPTION AMONG CHILDREN


    Regular smoking or excessive drinking in adoles-      Figure 2.1.3. Countries above the 45 degree line have
cence has both immediate and long-term health             higher rates for girls, and countries below the line
consequences. Children who establish smoking habits       higher rates for boys. Countries with higher rates of
in early adolescence increase their risk of cardio-       smoking among boys also report higher rates for girls,
vascular diseases, respiratory illnesses and cancer.      with the same finding for drinking rates.
They are also more likely to experiment with alcohol           Rates of drunkenness are also available for
and other drugs. Alcohol misuse is itself associated      13-year-olds (Currie et al., 2008). At this age, over one
with a range of social, physical and mental health        in ten children in a range of countries including
problems, including depressive and anxiety disorders,     Estonia, the United Kingdom, Lithuania, Latvia,
obesity and accidental injury (Currie et al., 2008).      Bulgaria, the Czech and Slovak Republics and Finland
     Results from the Health Behaviour in School-         have experienced drunkenness at least twice. In
aged Children (HBSC) surveys, a series of collaborative   Romania, Denmark and Slovenia, high rates of
cross-national studies conducted in most EU coun-         repeated drunkenness at 13 are also seen for boys.
tries, allow for monitoring of smoking and drinking       Some of the largest increases in reported drunken-
behaviours among adolescents. Generally, girls smoke      ness between the ages of 13 and 15 are seen in
more than boys, but more boys get drunk. Between          Denmark, Finland and Lithuania.
13 and 15 years of age, the prevalence of smoking and           Risk-taking behaviours among adolescents are
drunkenness doubles in many EU countries.                 falling, with regular smoking for both boys and girls
     Boys and girls in central and eastern European       and drunkenness rates for boys showing some decline
countries (Bulgaria, Latvia, Estonia, Lithuania, the      from the levels of the late 1990s (Figure 2.1.4). Levels
Czech Republic, Hungary) as well as in Austria,           of smoking for both sexes are at their lowest for a
Finland and Italy smoke most often, with weekly rates     decade with, on average, fewer than one in five
around 20% or more (Figure 2.1.1). In contrast, 15% or    children of either sex smoking regularly. However,
less of 15-year-olds in Nordic countries (Denmark,        increasing rates of smoking and drunkenness among
Iceland, Norway and Sweden), Switzerland and              adolescents in Baltic and other eastern European
Portugal smoke weekly. Many countries report higher       countries are cause for concern.
rates of smoking for girls, although only Bulgaria,
Austria and Spain have differences in excess of 5%.
Smoking is more prevalent among boys in central and
eastern European countries.
     Drunkenness at least twice in their lifetime is                  Definition and deviations
reported by 40% or more of 15-year-olds in Denmark,
Lithuania, the United Kingdom, Finland, Bulgaria and          Estimates for smoking refer to the proportion
Estonia (Figure 2.1.2). Across all surveyed countries,      of 15-year-old children who self-report smoking
30% of girls and 38% of boys have been drunk on             at least once a week. Estimates for drunkenness
two or more occasions, with much lower rates in             record the proportions of 15-year-old children
Mediterranean countries such as Malta, Greece,              saying they have been drunk twice or more in
Portugal and Italy, as well as in Switzerland and           their lives.
France. Boys are more likely to report repeated drunk-        Data for 26 European Union and 3 non-EU
enness. Romania, Slovenia, Poland and Estonia have          countries are from the Health Behaviour in
the biggest differences, with rates of alcohol abuse        School-aged Children (HBSC) surveys under-
among boys being in excess of 15% higher than those         taken between 1992-93 and 2005-06. Data are
of girls. Norway, Spain and the United Kingdom are          drawn from school-based samples. France,
the only countries where more girls report repeated         Germany and the United Kingdom report results
drunkenness, and in each case rates are around 5%           for certain regions only. Turkey is included in
higher.                                                     the 2005-06 HBSC survey, but did not question
     The differences in recent smoking and drinking         children on drinking and smoking.
rates between 15-year-old boys and girls are shown in




58                                                                           HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                      2.1. SMOKING AND ALCOHOL CONSUMPTION AMONG CHILDREN



     2.1.1. Smoking among 15-year-olds, 2005-06                                                                          2.1.2. Drunkenness among 15-year-olds, 2005-06
                          Smoking at least once a week                                                                                            Drunk at least twice in life

                                                  Boys                                          Girls                                                                 Boys                                          Girls

          Bulgaria                                                                                          36                  Denmark                                                                              56
                                                                                                28                                                                                                                        59
            Austria                                                                                  30                         Lithuania                                                                      50
                                                                                    24                                                                                                                               57
              Malta                                                                   24                                 United Kingdom                                                                        50
                                                                        19                                                                                                                           44
   Czech Republic                                                                 23                                              Finland                                                            44
                                                                          20                                                                                                                              47
             Latvia                                                               23                                             Bulgaria                                                           42
                                                                                                     30                                                                                                        51
         Germany                                                               22                                                 Estonia                                                           42
                                                                   17                                                                                                                                                57
           Finland                                                           21                                                     Latvia                                                     39
                                                                                  23                                                                                                                           50
            France                                                           21                                                    Austria                                                36
                                                                   17                                                                                                                           41
          Hungary                                                            21                                                      Spain                                           33
                                                                               22                                                                                              29
     Luxembourg                                                              21                                                  Hungary                                            32
                                                                   17                                                                                                                          40
      Netherlands                                                            21                                                   Iceland                                             32
                                                              16                                                                                                                    31
            Ireland                                                       20                                                      Norway                                              32
                                                                        19                                                                                                25
               Italy                                                      20                                                       Ireland                                          31
                                                                            20                                                                                                            36
              Spain                                                       20                                             Slovak Republic                                            31
                                                        14                                                                                                                                     39
           Estonia                                                      19                                                Czech Republic                                        30
                                                                                            27                                                                                            36
                 EU                                                  19                                                                 EU                                      30
                                                                       19                                                                                                                  38
         Lithuania                                                  18                                                          Germany                                        28
                                                                                           26                                                                                       31
  United Kingdom                                                    18                                                             Poland                                  27
                                                       13                                                                                                                                           42
          Belgium                                                  17                                                            Slovenia                                  27
                                                             16                                                                                                                                     43
            Greece                                             16                                                                 Sweden                                  26
                                                                17                                                                                                             26
          Slovenia                                            16                                                                 Belgium                             22
                                                                          20                                                                                                        32
         Denmark                                            15                                                                                                      21
                                                              15                                                             Netherlands                                        30
  Slovak Republic                                           15                                                                                                  20
                                                                    18                                                      Luxembourg                                     27
      Switzerland                                           15                                                                                                  19
                                                              15                                                                Romania                                                                  45
            Poland                                      14                                                                                                     18
                                                                        19                                                         France                                      29
           Iceland                                  13                                                                                                         18
                                                      14                                                                              Italy                          22
           Norway                                 12                                                                                                           18
                                             9                                                                                   Portugal                                 25
          Portugal                                12                                                                                                           18
                                             9                                                                               Switzerland                                       29
         Romania                                  12                                                                               Greece                  17
                                                                          20                                                                                        21
           Sweden                            9                                                                                       Malta                15
                                         8                                                                                                                     18

                       0                 10                             20                       30              40                           0            20                              40                        60              80
                                                                                                                 %                                                                                                                   %

Source: Currie et al. (2008).                                                                                          Source: Currie et al. (2008).
              1 2 http://dx.doi.org/10.1787/888932336217                                                                            1 2 http://dx.doi.org/10.1787/888932336236


    2.1.3. Risk behaviours of 15-year-olds by sex,                                                                      2.1.4. Trends in repeated drunkenness and regular
                       2005-06                                                                                               smoking among 15-year-olds, EU average
                 Regular cigarette smoking                                Repeated drunkenness                                                           Boys                                                       Girls
Girls aged 15 (%)                                                                                                         %                             Repeated drunkenness
    65                                                                                                                    45                                                                    43
                                                                                                                                                          41
                                                                                                                                                                                                                               39

                                                                                                                                       35                                                       35
                                                                                                            DEN           35                                                                                                   33
   55                                                                                                                                                      31
                                                                             GBR
                                                                                                          LTU                          24
                                                                                                                          25
   45                                                                                   FIN
                                                                                                  BGR     EST
                                                               AUT
                                                   SVK                                          LVA                       15
                                    BGR                                                                                             1993-94             1997-98                           2001-02                          2005-06
   35                                            ISL
                                     ESP                    IRL
                              NOR                                         HUN                                             %                                Regular smoking
                             AUT DEU                                                                                      45
                                                            CZE
                           MLT                                     POL            SVN
                                         SWE
   25               DEU       CZE
                  NLD                                BEL                                                                  35
               ESP                                NLD
              GBR                                CHE                                  ROU
               CHE                               FRA                                                                                                       27                                   26
   15          DNK           POL
        PRT                                                                                                               25           22
        NOR         ISL       ROU                                                                                                                          24                                       25
                                                                                                                                                                                                                               19
              SWE
                                                                                                                                       18                                                                                      19
    5                                                                                                                     15
        5           15              25                  35                       45             55        65                        1993-94             1997-98                           2001-02                          2005-06
                                                                                            Boys aged 15 (%)

Source: Currie et al. (2008).                                                                                          Source: Currie et al. (2000, 2004, 2008); WHO (1996).
              1 2 http://dx.doi.org/10.1787/888932336255                                                                          1 2 http://dx.doi.org/10.1787/888932336274




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                          59
2.2. NUTRITION AMONG CHILDREN


     Nutrition is important for children’s develop-                 The gap between the fruit consumption of boys
ment and long-term health. Eating fruit during                and girls is largest at age 15, for most countries. At
adolescence, for example, in place of high-fat, sugar         age 11, boys and girls in Lithuania as well as Italy,
and salt products, can protect against health prob-           France and Estonia have similar rates of fruit
lems such as obesity, diabetes, and heart problems.           consumption. Poland, Germany and the Netherlands
Moreover, eating fruit when young can be habit form-          have the biggest gaps at this age. As children reach
ing, promoting healthy eating behaviours for later life.      age 15, gaps in Finland, Austria and Latvia grow to a
     A number of factors influence the amount of fruit        level where fewer than six boys for every ten girls eat
consumed by adolescents, including family income,             fruit regularly.
the cost of alternatives, preparation time, whether               Average reported rates of daily fruit consumption
parents eat fruit, and the availability of fresh fruit        across EU countries showed some increase
which can be linked to the country or local climate           between 2001-02 and 2005-06. This was most evident
(Rasmussen et al., 2006). Fruit (and vegetable)               among girls aged 11 (Figure 2.2.3).
consumption have a high priority as indicators of                  Effective strategies are required in order to
healthy eating in most EU countries.                          ensure that children are eating enough fruit to
     In 2005-06, only around one-third of boys and            conform with recommended dietary guidelines.
two-fifths of girls aged 11-15 years ate at least one         Children generally hold a positive attitude toward
piece of fruit daily, according to the latest Health          fruit intake, and report good availability of fruit at
Behaviour in School-aged Children (HBSC) survey               home, but lower availability at school and during
(Currie et al., 2008). Overall, boys in Italy, and girls in   leisure time. Increased accessibility to fruit, combined
the United Kingdom had the highest rates of daily             with educational and motivational activities, can help
fruit consumption. Fruit consumption was relatively           in increasing fruit consumption (Sandvik et al., 2005).
low among Baltic and some Nordic countries, includ-
ing Latvia, Lithuania and Finland, with rates around
one in four girls and one in five boys. At all ages and in
most countries, girls were more likely to eat fruit daily.
At age 11, girls in Norway, Portugal and Slovenia, as                     Definition and deviations
well as boys in Portugal, Italy and Bulgaria were more
likely to eat fruit daily. By age 15, girls in Italy,             Nutrition is measured here in terms of the
Denmark and the United Kingdom, and boys in Italy,              proportions of children who report eating fruit at
Portugal and Malta ate most (Figure 2.2.1).                     least every day or more than once a day. In
                                                                addition to fruit, healthy nutrition also involves
     In almost all EU countries, daily fruit consump-
                                                                other types of foods.
tion falls between ages 11 and 15 (Figure 2.2.2).
Among girls, the EU average fell from 44% at age 11, to           Data for 26 European Union and four non-EU
39% at age 13 and 34% at age 15. For boys, the fall was         countries are from the Health Behaviour in
from 37% to 32% and then 25%. In Bulgaria and                   School-aged Children (HBSC) surveys under-
Iceland, rates fell by up to half between ages 11               taken in 2001-02 and 2005-06. Data are drawn
and 15, and severe falls were also seen in Austria              from school-based samples. France, Germany
(boys). Italy and Belgium are among the most success-           and the United Kingdom report results for
ful countries in maintaining healthy eating habits as           certain regions only.
children get older.




60                                                                              HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                              2.2. NUTRITION AMONG CHILDREN



                                                              2.2.1. Daily fruit eating among 11- and 15-year-olds, 2005-06
                                                                                                                Age 15                                     Age 11

                                                        Girls                                                                                                                                           Boys
                                          41                                                                                                                                                           32
  57                                                                                                                                 Norway                                                                                          43
                                            40                                                                                                                                                                    36
     56                                                                                                                             Portugal                                                                                                48
                                            40                                                                                                                                          26
       55                                                                                                                            Slovenia                                                                                   41
                                       42                                                                                                                                                    28
          54                                                                                                                       Switzerland                                                                                    42
                                                                             27                                                                                                     25
                 51                                                                                                                  Bulgaria                                                                                          44
                            46                                                                                                                                                                29
                 51                                                                                                                 Denmark                                                                                  40
                                                                            28                                                                                     18
                 51                                                                                                                  Iceland                                                                               39
                                            40                                                                                                                                                    30
                 51                                                                                                                 Romania                                                                                       42
                                                        35                                                                                                                     23
                  50                                                                                                                Germany                                                                       36
                                 44                                                                                                                                                                         33
                  50                                                                                                             United Kingdom                                                                                   42
                                          41                                                                                                                                             27
                      49                                                                                                          Luxembourg                                                                           38
                                                                 32                                                                                                18
                       48                                                                                                            Austria                                                                           38
                                          41                                                                                                                                        25
                       48                                                                                                        Czech Republic                                                                        38
                                               39                                                                                                                                             29
                       48                                                                                                             Ireland                                                                           38
                          47                                                                                                                                                                                          37
                       48                                                                                                               Italy                                                                                          44
                                     43                                                                                                                                                                      34
                           47                                                                                                        Belgium                                                                           38
                                                                        29                                                                                                     23
                            46                                                                                                       Hungary                                                                           38
                                                            34                                                                                                                                                   35
                            46                                                                                                         Malta                                                                                      42
                                                                      30                                                                                                 20
                                45                                                                                                 Netherlands                                                              33
                                                            34                                                                                                                     24
                                45                                                                                                    Poland                                                           31
                                       42                                                                                                                                               26
                                45                                                                                                    Turkey                                                                 34
                                                            34                                                                                                                22
                                 44                                                                                                  Sweden                                                                           37
                                                            34                                                                                                                      25
                                 44                                                                                                      EU                                                                           37
                                                                             27                                                                                                    24
                                     43                                                                                                Spain                                                                               39
                                                                                      24                                                                                           24
                                            40                                                                                        Greece                                                                 34
                                                                        29                                                                                                         24
                                                 38                                                                                   France                                                                     35
                                                                      30                                                                                           18
                                                      36                                                                             Estonia                                                                33
                                                              33                                                                                                              22
                                                        35                                                                       Slovak Republic                                                  30
                                                                                 26                                                                          15
                                                                            28                                                         Latvia                             21
                                                                                         23                                                                  15
                                                                            28                                                      Lithuania                                            27
                                                                            28                                                                              14
                                                                              27                                                     Finland                                       24

60                    50                       40                       30                          20                      10                      10             20                        30                         40                  50            60
%                                                                                                                                                                                                                                                         %

Source: Currie et al. (2008).
                                                                                                                                                          1 2 http://dx.doi.org/10.1787/888932336293


                       2.2.2. Regular fruit consumption                                                                                             2.2.3. Average proportion of children
                            at ages 11 and 15 years,                                                                                         in EU countries reporting daily fruit consumption,
                                    2005-06                                                                                                                 2001-02 and 2005-06
                                                     Girls                                          Boys                                                                Age 11                               Age 13                          Age 15
Children aged 15 (%)                                                                                                                          %
   60                                                                                                                                         60


                                                                                                                                                                   Boys                                                                     Girls
     50                                                                                                                                       50
                                                                                                    PRT         ITA
                                                                                                                        DNK
                                                                                                          BEL
                                                                                                                      GBR CHE
                                                                                                                              NOR
                                                                                                 TUR
     40                                                                                                               SVN
                                                                                                                                              40
                                                                                            MLT        ITA                   PRT
                                                                   SVK             BEL                                DEU
                                                                                      GBR           NOR         AUT
     30                                               FIN              EST                                             NLD                    30
                                                             LVA       TUR                               HUN           ISL
                                                               POL                                                     BGR
                                                                                                       BGR             ESP
                                                 LTU                                          GRC
                                                                      NLD
     20                                                      SVK             SWE                                                              20
                                                                            AUT            ISL
                                               FIN                    EST
                                 LVA                       LTU

     10                                                                                                                                        10
            10                       20                      30                       40                     50          60                              2001-02          2005-06                                                 2001-02           2005-06
                                                                                                       Children aged 11 (%)

Source: Currie et al. (2008).                                                                                                              Source: Currie et al. (2004, 2008).
                      1 2 http://dx.doi.org/10.1787/888932336312                                                                                      1 2 http://dx.doi.org/10.1787/888932336331



HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                               61
2.3. PHYSICAL ACTIVITY AMONG CHILDREN


     Undertaking physical activity in adolescence is         than half of those at age 11, and in Iceland, Romania,
beneficial for health, and can set standards for adult       Ireland and Finland, rates of physical activity among
physical activity levels, thereby influencing health         girls fall by over 60%.
outcomes in later life. Research supports the role that           To compare levels of exercise between 2001-02
physical activity in adolescence has in the prevention       and 2005-06 for 15-year-old children, results are
and treatment of a range of youth health issues              reported in relation to the EU average (Figure 2.3.3).
including asthma, mental health, bone health and             In 2001-02, rates refer to 15-year-olds reporting an
obesity. More direct links to adult health are found         hour of moderate to vigorous exercise five days a
between physical activity in adolescence and its effect      week, but in 2005-06 figures refer to exercise of this
on overweight and obesity and related diseases,              type seven days a week. Boys’ rates were above the
breast cancer rates and bone health in later life. The       EU average in the Netherlands, the United Kingdom,
health effects of adolescent physical activity are           Greece, Spain and Switzerland in 2001-02, but fell
sometimes dependent on the activity type, e.g. water         below the average in 2005-06. Latvia, Belgium and
physical activities in adolescence are effective in the      Denmark are countries where rates of physical
treatment of asthma, and exercise is recommended in          activity were below the EU average in 2001-02, but
the treatment of cystic fibrosis (Hallal et al., 2006;       were among the higher performers in 2005-06. For
Currie et al., 2008).                                        15-year-old boys, only the Czech Republic, Ireland and
     Some of the factors influencing the levels of           Poland have been consistently high performers on
physical activity undertaken by adolescents include          measures of physical activity in both waves. For girls,
the availability of space and equipment, the child’s         Latvia, Belgium and Malta have moved from below
present health conditions, their school curricula and        average performances in 2001-02 to above average
other competing pastimes.                                    in 2005-06. In Sweden, Poland, the United Kingdom,
     Only one in five children in EU countries undertake     Switzerland and Slovenia, rates of physical activity
moderate-to-vigorous exercise regularly, according to        among 15-year-old girls have fallen below the EU
results from the 2005-06 HBSC survey. Children in            average since 2001-02.
Switzerland, Luxembourg and Italy are least likely to
exercise regularly, whereas the Slovak Republic and
Ireland stand out as strong performers with over 40 and
30% respectively of children aged 11 to 15 exercising for                Definition and deviations
a total of at least 60 minutes per day over the past week
(Figure 2.3.1). The country rankings reported vary               Data for physical activity considers the
according to the child’s age. France appears at the lower      regularity of moderate-to-vigorous physical activ-
end, especially for girls, at both ages. Boys consistently     ity as reported by 11- and 15-year-olds for the
undertake more physical activity than girls, across all        years 2001-02 and 2005-06. Moderate-to-vigorous
countries and all age groups.                                  physical activity refers to exercise undertaken for
                                                               at least an hour which increases both heart rate
     It is of concern that physical activity tends to
                                                               and respiration (and leaves the child out of breath
fall between ages 11 to 15 for most EU countries
                                                               sometimes) on five or more days per week
(Figure 2.3.2), with boys in the Czech Republic and
                                                               in 2001-02, and seven days a week in 2005-06.
Luxembourg the only exceptions. In Portugal, Norway,
Sweden, Austria, and Finland, the rates of exercising            Indicators are taken from the Health Behaviour
among boys more than halve between ages 11 and 15.             in School-aged Children Survey (HBSC). Data are
The rates of girls exercising to recommended levels            drawn from school-based samples, but some
also falls between the ages of 11 and 15 years. In             countries report regional results only.
many countries, rates for 15-year-old girls are less




62                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                       2.3. PHYSICAL ACTIVITY AMONG CHILDREN



       2.3.1. Children aged 11 and 15 years                                                                             2.3.2. Comparing physical activity
 doing moderate-to-vigorous physical activity daily                                                                   of 11- and 15-year-old children by sex,
             in the past week, 2005-06                                                                                               2005-06
                                             15 years                          11 years                                                              Boys             Girls

  Slovak Republic          37.5                                                             47.0             Czech Republic
            Ireland        20.0                                                                44.5            Luxembourg
           Finland         12.0                                                             42.5            Slovak Republic
          Bulgaria         20.0                                               32.5                                    Poland
         Denmark           18.0                                        28.5                                            Latvia
              Spain        15.5                                       28.0                                          Belgium
             Latvia        21.0                                     26.5                                            Slovenia
            Austria        11.5                                    26.0                                              Estonia
           Iceland         12.5                                    26.0                                            Lithuania
                 EU        15.7                                   25.5                                                  Malta
      Netherlands          16.5                                  25.0                                                    Italy
            Turkey         14.0                                  25.0                                           Switzerland
          Hungary          15.0                                23.5                                                 Hungary
         Lithuania         16.0                                23.5                                         United Kingdom
          Slovenia         14.0                               23.0                                                         EU
           Estonia         13.5                              22.5                                                  Denmark
         Germany           13.0                              22.5                                                  Germany
              Malta        16.0                              22.5                                                     Greece
         Romania           11.0                              22.5                                                   Bulgaria
  United Kingdom           13.5                              22.5                                               Netherlands
          Belgium          18.3                             22.3                                                        Spain
   Czech Republic          21.5                             22.0                                                      France
           Norway          10.0                             22.0                                                     Iceland
            Poland         15.5                            21.5                                                    Romania
           Sweden          10.5                            21.5                                                       Turkey
          Portugal         10.0                           21.0                                                        Ireland
            Greece         11.5                          20.5                                                       Portugal
            France         9.5                       18.0                                                            Norway
               Italy       11.5                      18.0                                                            Sweden
     Luxembourg            15.0                  15.5                                                                 Austria
      Switzerland          11.5                 15.0                                                                 Finland
                       0                10          20               30                40         50                             0        20         40       60    80      100     120
                                                                                                  %                                                                  11 years-old = 100

Source: Currie et al. (2008).                                                                             Source: Currie et al. (2008).
             1 2 http://dx.doi.org/10.1787/888932336350                                                                1 2 http://dx.doi.org/10.1787/888932336369

 2.3.3. Standardised rates of physical activity for 15-year-old children (EU average = 1), 2001-02 and 2005-06
                                                                                     2005-06                            2001-02

                                         Boys                                                                                                         Girls
                                                                                                Slovak Republic
                                                                                                Czech Republic
                                                                                                     Ireland
                                                                                                      Latvia
                                                                                                    Bulgaria
                                                                                                     Poland
                                                                                                    Belgium
                                                                                                   Denmark
                                                                                                    Hungary
                                                                                                   Lithuania
                                                                                                 Luxembourg
                                                                                                      Malta
                                                                                                    Slovenia
                                                                                                      Spain
                                                                                                    Estonia
                                                                                                  Netherlands
                                                                                                United Kingdom
                                                                                                   Germany
                                                                                                     Greece
                                                                                                    Iceland
                                                                                                       Italy
                                                                                                   Romania
                                                                                                     Turkey
                                                                                                    Finland
                                                                                                   Portugal
                                                                                                     France
                                                                                                    Austria
                                                                                                    Norway
                                                                                                  Switzerland
                                                                                                    Sweden
2.5        2.0                    1.5             1.0                 0.5                   0                     0              0.5           1.0            1.5      2.0         2.5
EU average = 1.0                                                                                                                                                      EU average = 1.0

Source: Currie et al. (2004, 2008).
                                                                                                                        1 2 http://dx.doi.org/10.1787/888932336388


HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                        63
2.4. OVERWEIGHT AND OBESITY AMONG CHILDREN


     Children who are overweight or obese are at            obesity increased between 2001-02 and 2005-06 from
greater risk of poor health in adolescence and also in      12% to 16% for 15-year-old boys, and from 7% to 9% for
adulthood. Being overweight in childhood increases          girls. Between 2001-02 and 2005-06, every surveyed
the risk of developing cardiovascular disease or            country reported an increase in overweight or obesity
diabetes, as well as related social and mental health       for boys aged 15. The largest increases during the four
problems. Excess weight problems in childhood are           year period were found in Austria, Lithuania and
associated with an increased risk of being an obese         Poland. A similar pattern of increases is seen for girls,
adult, at which point certain forms of cancer, osteoar-     with rates in Portugal and Germany almost doubling.
thritis, a reduced quality of life and premature death      Only Ireland, Norway and the United Kingdom report
can be added to the list of health concerns (OECD,          reductions in the proportion of overweight or obese
2010c; Currie et al., 2008).                                girls at age 15 between 2001-02 and 2005-06. However,
     Evidence suggests that even if excess childhood        because non-response rates to questions of self-
weight is lost, adults who were obese children retain       reported height and weight were high in these
an increased risk of cardiovascular problems. And           countries, cautious interpretation is required.
although dieting can combat obesity, children who                Childhood is an important period for forming
diet are at a greater risk of putting on weight following   healthy behaviours. Schools provide an opportunity to
periods of dieting. Eating disorders, symptoms of           ensure that children understand the importance of
stress and postponed physical development can also          good nutrition and physical activity, and can benefit
be products of dieting.                                     from both. Studies show that locally focussed actions
     Across most EU countries, one in seven children        and interventions, targeting 0-12 year-olds can be
are overweight or obese (Figure 2.4.1). Aggregate           effective in changing behaviours.
figures for 2005-06 show that nearly one in five
children in southern European countries (Malta,
Greece, Portugal, Italy and Spain), are overweight or
obese. Fewer than one in ten children in selected
eastern European countries (Lithuania, Latvia, the
                                                                        Definition and deviations
Slovak Republic and Estonia) as well as in the                  Estimates of overweight and obesity are based
Netherlands, Switzerland and Denmark are                      on Body Mass Index (BMI) calculations using
overweight or obese.                                          child self-reported height and weight. Over-
     There is no clear association between weight             weight and obese children are those whose BMI
problems and weight reduction behaviours at the               is above a set of age- and sex-specific cut-off
national level. In most countries, the number of              points (Cole et al., 2000). Data on weight reduc-
children who say that they are trying to lose weight          tion record children who report being on a diet
is greater than the number with excess weight                 or doing something else to lose weight.
problems. Generally, countries where few children               Indicators are taken from the Health Behaviour
report excess weight problems also report weight              in School-aged Children Surveys in 2001-02
reduction behaviours close to the EU average. Many of         and 2005-06. Aggregate country estimates are
the countries with the highest rates of overweight and        crude rates of overweight and obese 11-, 13- and
obese children have similar levels of weight reduction        15-year-olds in each country. Some countries
behaviour, each around the EU average of 13%.                 report regional data only. Data are drawn from
     There are important differences among children           school-based samples.
with excess weight problems, according to their age.            Self-reported height and weight is subject to
In some countries older children have more excess             under-reporting and error, and requires cautious
weight than younger children, for other countries the         interpretation. In the 2005-06 survey, England and
opposite is true. A number, including the Netherlands,        Norway have missing data for over 30% of
Norway, Sweden, Iceland and Switzerland, report               respondents for 11-year-olds. The same is true for
increases in overweight and obesity rates for both            England, Ireland and Belgium for 13-years-olds,
boys and girls as children get older.                         and in England and Ireland for 15-year-olds.
     Rates of overweight and obesity among boys and           In 2001-02, BMI data are missing for over 30% of
girls are increasing across the European Union                respondents in Ireland.
(Chart 2.4.2). Average reported rates of overweight and




64                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                      2.4. OVERWEIGHT AND OBESITY AMONG CHILDREN



             2.4.1. Children aged 11-15 years who are overweight or obese, and children who are involved
                                        in weight-reduction behaviour, 2005-06

     %                                              Children who are overweight or obese                                                       Children involved in weight-reduction behaviour
     30


     25


     20


     15


     10


      5
                                                                                                 13.3
           29.5




                                                                                                        13.2
                                 18.3




                                                                                         14.2




                                                                                                                                                             10.5

                                                                                                                                                                        10.5

                                                                                                                                                                               10.5
                   18.8

                          18.8




                                                                    15.3




                                                                                  14.5




                                                                                                               12.5
                                                            15.5
                                                     15.8




                                                                                                                                                                                      10.0

                                                                                                                                                                                             10.0
                                                                           15.0




                                                                                                                      12.0

                                                                                                                             12.0

                                                                                                                                    12.0
                                             16.7




                                                                                                                                                      11.2
                                                                                                                                               11.6




                                                                                                                                                                                                                      8.2
                                                                                                                                                                                                                8.8
                                                                                                                                                                                                    9.8




                                                                                                                                                                                                                             8.0
                                                                                                                                                                                                          9.7




                                                                                                                                                                                                                                         7.5
                                                                                                                                                                                                                                   7.8
      0
                            ta

                  Po c e

                               l
                             ly

                   F i in




                   Ic i c




                                                                                                           i t z lic
                  Hu d

          C z Sl r y
                  Re i a



                   Ir e d
                           nd

                                                                                                            B EU

                                                                                                             m a
                                                                                                U n G e ur g

                                                                                                           K i any

                                                                                                               Au m
                                                                                                           Ro r i a

                                                                                                               Po i a

                                                                                                                Fr d
                                                                                                             Sw ce
                                                                                                            Be en

                                                                                                              No m

                                                                                                                Tu y
                                                                                                                      ey




                                                                                                          th nd
                                                                                                Sl D e ni a

                                                                                                           Re ar k




                                                                                                                        s
                                                                                                                       ia

                                                                                                                        a
                          ga




                                                                                                                      a




                                                                                                                    nd
                                                                                                         xe ar i




                                                                                                                     ni
                         an




                         an




                                                                                                                      n
                         bl
                        en




                                                                                                                   an
                        It a




                                                                                                                    tv
                          a
                         al




                                                                                                                    iu
                                                                                                                   do
                          a




                                                                                                                   rk
                                                                                                                  rw
                        ee




                                                                                                                  an




                                                                                                       S w pub
                                                                                                                  ed
                        la




                                                                                                       N e er l a
                                                                                                                   la
                                                                                                                   st




                                                                                                                  to
                      Sp
                     r tu




                                                                                                                 ua
                                                                                                                nm
                      ng




                                                                                                                 bo
                                                                                                    i te rm
                     pu
      M




                                                                                                                 la
                      nl




                      el




                                                                                                                La
                                                                                                      L u ul g




                                                                                                                 lg
             e c ov




                                                                                                                 m
                                                                                                               ng
           Gr




                                                                                                              Es




                                                                                                              th
                                                                                                              er


                                                                                                          Li
                h




                                                                                                       ak
                                                                                                        d




                                                                                                   ov
Source: Currie et al. (2004, 2008).
                                                                                                                                                      1 2 http://dx.doi.org/10.1787/888932336407


                  2.4.2. Change in obesity rates between 2001-02 and 2005-06, for 15-year-old boys and girls
                                                                                                2005-06                                               2001-02

                                                    Boys                                                                                                                                       Girls
                                                                                                                    Greece
                                                                                                                      Italy
                                                                                                                   Iceland
                                                                                                                  Portugal
                                                                                                                   Slovenia
                                                                                                                   Austria
                                                                                                                   Finland
                                                                                                                     Spain
                                                                                                                   Bulgaria
                                                                                                                   Hungary
                                                                                                                  Germany
                                                                                                                Luxembourg
                                                                                                                   Norway
                                                                                                                       EU
                                                                                                                    Ireland
                                                                                                                   Sweden
                                                                                                               Czech Republic
                                                                                                                    France
                                                                                                                 Switzerland
                                                                                                                    Turkey
                                                                                                                   Belgium
                                                                                                                  Denmark
                                                                                                               United Kingdom
                                                                                                                    Poland
                                                                                                                   Estonia
                                                                                                               Slovak Republic
                                                                                                                 Netherlands
                                                                                                                  Romania
                                                                                                                     Latvia
                                                                                                                  Lithuania
25                20                    15                     10                   5                   0                                  0                        5                  10                 15                20             25
%                                                                                                                                                                                                                                          %

Source: Currie et al. (2004, 2008).
                                                                                                                                                      1 2 http://dx.doi.org/10.1787/888932336426




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                              65
2.5. SUPPLY OF FRUIT AND VEGETABLES FOR CONSUMPTION


     Nutrition is an important determinant of health.        little in Greece, but levels per capita vegetable remain
Inadequate consumption of fruit and vegetables is            the highest. In contrast, the supply of vegetables in
one factor that can play a role in increased morbidity       Bulgaria has declined recently to one of the lowest
and premature death. A recent European Commission            levels among member states.
White Paper advocated increasing the consumption                    Many factors play a role in ensuring an adequate
of fruit and vegetables as one of a number of tools          supply of fruit and vegetables. In recent years, the
to offset a worsening trend of poor diets and low            harvested production of the main types of fruit and
physical activity. Proper nutrition assists in preventing    vegetables in the European Union has remained
a number of obesity-related chronic conditions,              relatively stable, although there was growth in
including cardiovascular disease, hypertension, type 2       imports from non-EU countries (Martinez-Palou and
diabetes, stroke, certain cancers, musculoskeletal           Rohner-Thielen, 2008). The majority of suppliers
disorders and a range of mental health conditions            growing fresh vegetables are located in Romania,
(European Commission, 2007).                                 Poland and Lithuania. Most citrus farms are located in
     Estimates of the supply of fruit and vegetables         Mediterranean countries (Spain, Greece, Italy), with
available for consumption in different countries are         Poland and Romania also large fruit-producing
calculated by the Food and Agriculture Organization of       countries. The price of fruit and vegetables varies
the United Nations (FAO). In 2007, levels of the supply of   considerably among member states. In 2006, for
both fruit and vegetables differed substantially across      example, it was almost half the EU average in Bulgaria
European countries (Figure 2.5.1). The per capita fruit      and a number of other eastern European countries
supply in a number of central and eastern European           adjusted by purchasing power parity, but more
countries, including Poland, Bulgaria, Romania, Latvia,      t h a n 20 % h i gh e r i n I re la n d , L u x em b o u rg a n d
the Slovak Republic, the Czech Republic and Estonia,         Nord ic countries (Denmark, Finland, Sweden)
was below 80 kg per person, contrasting with an              (Martinez-Palou and Rohner-Thielen, 2008).
EU average of 105. Fruit supply was greater in Western
and Southern Europe, with estimates for Luxembourg
and Greece above 160 kg per person, more than twice
                                                                           Definition and deviations
the amount of those countries reporting the lowest
supply.                                                           Estimates of food available for consumption are
     The per capita availability of vegetables was              based on annual production and trade of food
highest in Mediterranean countries, including Greece,           commodities figures as supplied by national
Turkey, Malta, Portugal, Spain, Italy and Cyprus, all at        Ministries of Agriculture and Trade to the FAO
150 kg per person or more. Supply was lower than the            (Food and Agriculture Organization of the
EU average in Nordic countries, as well as in some              United Nations). Gross apparent consumption =
central and eastern European countries (Bulgaria,               (Commercial production + estimated own
the Czech Republic, Slovenia). The spread between               account production for self-consumption +
countries with the lowest and highest per capita                imports + opening stocks) – (exports + usage for
supply of vegetables is three-fold.                             processed food + feed + non-food usage + wastage
                                                                + closing stocks).
     The supply of fruit and vegetables for consump-
tion has increased across the European Union in the               Per person consumption is derived from
three decades since 1980 (Figures 2.5.2 and 2.5.3).             dividing the total amount of fruit and vegetables
Fruit supply increased from an average of 88 kg per             available for human consumption by the total
capita in 1980 to 105 in 2007. Greece and Poland both           population actually partaking of food supplies
increased per capita fruit supply, although large abso-         during the reference period. Per person figures
lute differences remain. Fruit supply in Ireland                represent the average supply available for the
increased rapidly from the late 1990s. The supply of            population as a whole, and do not necessarily
vegetables increased more modestly, from an average             indicate what is actually consumed by indivi-
of 102 to 116 kg per capita across all EU countries             duals. Actual food consumption may be lower
during the years 1980 to 2007. Vegetable supply                 than the quantity shown, depending on wastage
increased substantially in Finland, although the                and losses of food in the household.
amount remains relatively low. Supply has changed




66                                                                                HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                   2.5. SUPPLY OF FRUIT AND VEGETABLES FOR CONSUMPTION



                                              2.5.1. Supply of fruit and vegetables for consumption, 2007
                                     Fruit                                                                                                               Vegetables
                                                                             50                            Poland                                                         130
                                                                        58                                Bulgaria                           75
                                                                        59                               Romania                                                                151
                                                                        61                                  Latvia                                            107
                                                                    65                                Slovak Republic                              90
                                                                   71                                 Czech Republic                         75
                                                              78                                          Estonia                                       96
                                                              80                                        Switzerland                                 91
                                                          85                                              Belgium                                                   118
                                                          85                                              Hungary                                             110
                                                         88                                              Germany                                        94
                                                         88                                                 Spain                                                                  156
                                                     91                                                  Lithuania                                      96
                                                     94                                                   Finland                             79
                                                    98                                                      Malta                                                                                         221
                                              105                                                             EU                                                   116
                                         111                                                               Turkey                                                                                          224
                                         112                                                             Denmark                                        98
                                        117                                                                France                                        98
                                      117                                                                 Sweden                                   88
                                     118                                                                 Portugal                                                                        170
                                     119                                                                  Cyprus                                                                150
                                     121                                                                  Slovenia                           77
                                  127                                                                 United Kingdom                                92
                               136                                                                      Netherlands                                          103
                            141                                                                            Ireland                            79
                           142                                                                            Norway                              78
                           144                                                                               Italy                                                                152
                         148                                                                              Iceland                            76
                     156                                                                                  Austria                                       96
                   164                                                                                     Greece                                                                                         241
            190                                                                                        Luxembourg                                  87

250       200              150                      100                       50                0                         0           50           100                      150                 200          250
Kg/capita                                                                                                                                                                                               Kg/capita

Source: FAOSTAT Database; OECD Health Data 2010.
                                                                                                                                 1 2 http://dx.doi.org/10.1787/888932336445


              2.5.2. Trends in supply of fruit,                                                                                 2.5.3. Trends in supply of vegetables,
             selected EU countries, 1980-2007                                                                                     selected EU countries, 1980-2007
                                  Greece                                             Ireland                                                Bulgaria                                           Greece
                                  Poland                                             EU                                                     Finland                                            EU
Kg/capita/year                                                                                                  Kg/capita/year
  200                                                                                                             400




  150                                                                                                             300




  100                                                                                                             200




   50                                                                                                             100




    0                                                                                                                   0
     1980         1985            1990                   1995                     2000         2005                      1980       1985     1990                   1995                2000            2005

Source: FAOSTAT Database; OECD Health Data 2010.                                                                Source: FAOSTAT Database; OECD Health Data 2010.
           1 2 http://dx.doi.org/10.1787/888932336464                                                                      1 2 http://dx.doi.org/10.1787/888932336483




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                     67
2.6. TOBACCO CONSUMPTION AMONG ADULTS


     Tobacco is directly responsible for about one in ten    at an even faster pace than male rates. However, in
adult deaths worldwide, equating to about 6 million          seven countries, female smoking rates have been
deaths each year (Shafey et al., 2009). It is a major risk   increasing since the mid-1990s (Lithuania, Portugal,
factor for at least two of the leading causes of premature   Greece, Bulgaria, France, Germany and Austria), but
mortality – circulatory diseases and a range of cancers.     even in these countries women are still less likely to
In addition, it is an important contributory factor for      smoke than men. In 2008, the gender gap in smoking
respiratory diseases, while smoking among pregnant           rates was particularly large in Baltic countries (Latvia,
women can lead to low birth weight and illnesses             Lithuania and Estonia), as well as in Turkey and
among infants. It remains the largest avoidable risk to      Romania (Figure 2.6.1).
health in EU countries.                                           Several studies provide strong evidence of socio-
     The proportion of daily smokers among the adult         economic differences in smoking and mortality
population varies greatly across countries, even             (Mackenbach et al., 2008). People in lower social groups
between neighboring countries (Figure 2.6.1). In 2008,       have a greater prevalence and intensity of smoking,
rates were lowest in Sweden, Iceland, Slovenia and           a higher all-cause mortality rate and lower rates of
Portugal, all at less than 20% of the adult population       cancer survival (Woods et al., 2006). The influence of
smoking daily. On average, smoking rates have                smoking as a determinant of overall health inequa-
decreased by about 5 percentage points in EU coun-           lities is such that, in a non-smoking population,
tries since 1995, with a bigger decline in men than in       mortality differences between social groups would be
women. Large declines occurred in Turkey (47% to             halved (Jha et al., 2006).
27%), Luxembourg (33% to 20%), Norway (33% to 21%)                Figure 2.6.3 shows the correlation between tobacco
and Denmark (36% to 23%). Greece maintains the               consumption (as measured by grams per capita) and
highest level of smoking (40%), along with Bulgaria          incidence of lung cancer across EU countries for which
and Ireland, with close to 30% or more of the adult          data are available, with a time lag of two decades. Higher
population smoking daily.                                    tobacco consumption at the national level is also gener-
     In the post-war period, most EU countries tended        ally associated with higher mortality rates from lung
to follow a general pattern – very high smoking rates        cancer one or two decades later across EU countries.
among men (50% or more) through to the 1960s
and 1970s, while the 1980s and the 1990s were charac-
terised by a marked downturn in tobacco consumption.
Much of this decline can be attributed to policies aimed                 Definition and deviations
at reducing tobacco consumption through public
awareness campaigns, advertising bans and increased              The proportion of daily smokers is defined as
taxation (World Bank, 1999). In addition to government         the percentage of the population aged 15 years
policies, actions by anti-smoking interest groups were         and over reporting smoking every day.
very effective in reducing smoking rates by changing             International comparability is limited due to
beliefs about the health effects of smoking.                   the lack of standardisation in the measurement
     Although large disparities remain, this pattern of        of smoking habits in health interview surveys
a decline in smoking rates is found across most                across EU countries. Variations remain in the
EU countries (Figure 2.6.2). Smoking prevalence among          age groups surveyed, wording of questions,
men continues to be higher than among women in all             response categories and survey methodologies,
EU countries except Sweden. Female smoking rates               e.g. in a number of countries, respondents are
continue to decline in most countries, and in a number         asked if they smoke regularly, rather than daily.
of cases (Turkey, Iceland, Belgium, Latvia and Ireland)




68                                                                              HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                       2.6. TOBACCO CONSUMPTION AMONG ADULTS



                                               2.6.1. Daily smoking rates, 2008 (or nearest year available)
                                                                                                                                                      Males                                                         Females
                                    All adults
                                                             14.5                                            Sweden                                             17
                                                                                                                                                 12
                                                                                                                                                           15
                                                    17.8                                                     Iceland                                                          20
                                                                                                                                                           16
                                                 18.9                                                        Slovenia                                                               22
                                                                                                                                                11
                                                19.6                                                        Portugal                                                                                    29
                                                                                                                                                               16
                                               20.0                                                          Belgium                                                                   24
                                                                                                                                                                     18
                                               20.0                                                       Luxembourg                                                                 23
                                                                                                                                            9
                                              20.2                                                          Romania                                                                                            32
                                                                                                                                                                    18
                                              20.4                                                           Finland                                                                     24
                                                                                                                                                                    18
                                              20.4                                                         Switzerland                                                                  23
                                                                                                                                                               16
                                              20.4                                                             Malta                                                                          26
                                                                                                                                                                                   22
                                             21.0                                                            Norway                                                           21
                                                                                                                                                                                   21
                                           22.0                                                          United Kingdom                                                              22
                                                                                                                                                               16
                                          22.4                                                                  Italy                                                                                   29
                                                                                                                                                                                   22
                                         23.0                                                               Denmark                                                                      24
                                                                                                                                                                          19
                                         23.2                                                                Austria                                                                               27
                                                                                                                                                                         19
                                         23.2                                                               Germany                                                                                 28
                                                                                                                                                                         19
                                       24.2                                                                      EU                                                                                       30
                                                                                                                                                                          19
                                       24.3                                                              Czech Republic                                                                                  30
                                                                                                                                                      14
                                      24.7                                                                   Cyprus                                                                                                       36
                                                                                                                                                                                  23
                                     25.0                                                                Slovak Republic                                                                      26
                                                                                                                                                                               21
                                   25.9                                                                      Hungary                                                                                          31
                                                                                                                                                                                 22
                                  26.2                                                                        France                                                                                         31
                                                                                                                                                                    17
                                  26.2                                                                       Estonia                                                                                                            39
                                                                                                                                                                          19
                                  26.3                                                                        Poland                                                                                                 34
                                                                                                                                                                               22
                                  26.4                                                                         Spain                                                                                           32
                                                                                                                                                          15
                                  26.5                                                                      Lithuania                                                                                                                       43
                                                                                                                                                12
                                27.4                                                                          Turkey                                                                                                                         44
                                                                                                                                                     13
                               27.9                                                                            Latvia                                                                                                                             46
                                                                                                                                                                                           25
                               28.0                                                                        Netherlands                                                                                          32
                                                                                                                                                                                                   27
                             29.0                                                                             Ireland                                                                                         31
                                                                                                                                                                         19
                             29.1                                                                            Bulgaria                                                                                                                40
                                                                                                                                                                                                                     34
          39.7                                                                                                Greece                                                                                                                              46

50          40           30            20                                  10                        0                     0            10                           20                 30           40          50
% of population aged 15 years and over                                                                                                                                        % of population aged 15 years and over

Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                1 2 http://dx.doi.org/10.1787/888932336502


       2.6.2. Change in smoking rates by gender,                                                                                2.6.3. Tobacco consumption, 1990
          1995-2008 (or nearest year available)                                                                                 and incidence of lung cancer, 2008
                                               Males                                   Females                     Lung cancer (incidence per 100 000 population)
                                                                                                                      50
                             -57                                                                                                                                                                        HUN
             Turkey                         -35
                                      -43
           Iceland                                    -24                                                                      R 2 = 0.22
                                             -33
          Belgium                                  -27
                                             -33
         Denmark                           -37
                                               -31
           Norway                          -36
                                               -31
     Luxembourg                        -43
                                                                                                                      40
                                                 -29
           Sweden                     -44                                                                                                                            DNK
                                                  -29
             Latvia                                                -9
                                                  -28
      Switzerland                               -30
                                                    -26                                                                                                                                                  BEL
           Estonia                                  -26                                                                                                                                                                                   NLD
                                                        -22
  United Kingdom                                     -24                                                                                                                                  GBR
                                                        -21
          Hungary                                -29                                                                                                                                         IRL                          CZE
      Netherlands                                         -19                                                                                                                 FRA
                                                       -22                                                            30                                  NOR
                                                              -13
                 EU                                       -19                                                                                                                                                                             GRC
                                                               -12                                                                                                                         ISL               DEU
              Spain                                -27
                                                                 -10
           Finland                                         -18                                                                                                                                                                  CHE
                                                                     -6
            Poland                                     -23                                                                                                                TUR                      AUT
               Italy                                                 -6
                                                            -16
   Czech Republic                                                     -4
                                                                 -10
            Ireland                                                   -4
                                                                                       7
            Austria                                                                3                                  20
                                                                 -9                                                                     FIN
         Germany                                                                       6                                                                             SWE
                                                               -11
            France                                          -15
                                                                                       6
          Bulgaria                                                                 5
                                                                                           13
            Greece                                                             1
                                                                                                20
                                                                                                           47
          Portugal                                            -12                                        // 142
         Lithuania                                                             1                                      10
                       -75          -50                -25                 0          25         50                    1 000          1 500                         2 000        2 500       3 000     3 500
                                                                               % change over period                                                                    Tobacco consumption (grams per capita)

Source: OECD Health Data 2010; Eurostat Statistics Database; WHO                                                   Source: OECD Health Data 2010.
Global Infobase.
           1 2 http://dx.doi.org/10.1787/888932336521                                                                           1 2 http://dx.doi.org/10.1787/888932336540




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                        69
2.7. ALCOHOL CONSUMPTION AMONG ADULTS


      The global health burden related to excessive         while falls in consumption in France, Italy and Spain
alcohol consumption, both in terms of morbidity and         may be associated with the voluntary and statutory
mortality, is considerable (Rehm et al., 2009; WHO,         regulation of advertising, partly following a 1989
2004). It is associated with numerous harmful health        European directive. In 2010, the World Health
and social consequences. High alcohol intake increases      Organization endorsed a global strategy to combat the
the risk for heart, stroke and vascular diseases, as well   harmful use of alcohol, through direct measures
as liver cirrhosis and certain cancers. Foetal exposure     such as medical services for alcohol-related health
to alcohol increases the risk of birth defects and intel-   problems, and indirect ones, such as the dissemi-
lectual impairments. Alcohol also contributes to death      nation of information on alcohol-related harm
and disability through accidents and injuries, assault,     (WHO, 2010c).
violence, homicide and suicide, and is estimated to              Although adult alcohol consumption per capita
cause more than 2 million deaths annually.                  gives useful evidence of long-term trends, it does not
      Alcohol consumption across EU countries is            identify sub-populations at risk from harmful drink-
10.8 litres per adult per year. Leaving aside Luxembourg    ing patterns. The consumption of large quantities of
– because of the high volume of purchases by non-           alcohol at a single session, termed “binge drinking”,
residents in that country – Estonia, Hungary and            is a particularly dangerous pattern of consumption
France reported the highest consumption of alcohol,         (Institute of Alcohol Studies, 2007), which is on the
with more than 12.5 litres per adult in 2007-08. At the     rise in some countries and social groups, especially
other end of the scale, Turkey, Malta and some of the       among young males (see Indicator 2.1 “Smoking and
Nordic countries (Norway, Sweden and Iceland) have          alcohol consumption at age 15”).
relatively low levels of alcohol consumption, ranging            Figure 2.7.3 shows the relationship between
from one to seven litres per adult (Figure 2.7.1).          alcohol consumption in 2005 and deaths from liver
     Although average alcohol consumption has grad-         cirrhosis in 2008. In general, countries with high levels
ually fallen in many EU countries over the past three       of alcohol consumption tend to experience higher
decades, it has risen in some others (Figure 2.7.1).        death rates from liver cirrhosis. In most EU countries,
There has been a degree of convergence in drinking          death rates from liver cirrhosis have fallen over the
habits across the European Union, with wine                 past two decades, following quite closely the overall
consumption increasing in many traditional beer-            reduction in alcohol consumption.
drinking countries and vice versa. The traditional
wine-producing countries of Italy, France and Spain,
as well as the Slovak Republic, Greece and Germany
have seen their alcohol consumption per capita fall                     Definition and deviations
substantially since 1980 (Figures 2.7.1 and 2.7.2). On
the other hand, alcohol consumption per capita in               Alcohol consumption is defined as annual
Iceland, Cyprus, Finland and Ireland rose by as much          sales of pure alcohol in litres per person aged
as 30% or more since 1980 although, in the case of            15 years and over. The methodology to convert
Iceland and Cyprus, it started from a low level and           alcohol drinks to pure alcohol may differ across
therefore remains relatively low.                             countries.

      Variations in alcohol consumption across coun-            Italy reports consumption for the population
tries and over time reflect not only changing drinking        14 years and over, and Sweden for 16 years and
habits but also the policy responses to control alcohol       over. In some countries (e.g. Luxembourg),
use. Curbs on advertising, sales restrictions and             national sales do not accurately reflect actual
taxation have all proven to be effective measures to          consumption by residents, since purchases by
reduce alcohol consumption (Bennett, 2003). Strict            non-residents may create a significant gap
controls on sales and high taxation are mirrored by           between national sales and consumption.
overall lower consumption in most Nordic countries,




70                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                          2.7. ALCOHOL CONSUMPTION AMONG ADULTS



                                    2.7.1. Alcohol consumption among population aged 15 years and over
                    2008 (or nearest year available)                                                                                                    Change per capita, 1980-2008
                                                                                        1.4               Turkey                                           -22
                                                                     5.3                                   Malta                                                                           n.a.
                                                               6.8                                       Norway                                                                                                    28
                                                              6.9                                        Sweden                                                                              3
                                                             7.3                                         Iceland                                                                                                                    70
                                                       8.1                                                 Italy                    -50
                                                 9.0                                                     Greece                                 -32
                                               9.3                                                       Cyprus                                                                                                                50
                                            9.6                                                       Netherlands                                                -17
                                            9.6                                                      Slovak Republic                           -34
                                           9.7                                                          Romania                                                        -11
                                           9.9                                                          Germany                                     -30
                                        10.2                                                               Latvia                                          -22
                                        10.2                                                           Switzerland                                        -24
                                        10.3                                                             Finland                                                                                                    30
                                    10.7                                                                Belgium                                            -21
                                   10.8                                                                     EU                                                    -13
                                   10.8                                                                   Poland                                                                                               24
                                   10.8                                                              United Kingdom                                                                                     15
                                   10.9                                                                  Bulgaria                                                                 -2
                                   10.9                                                                 Denmark                                                              -7
                                   10.9                                                                  Slovenia                                                                          n.a.
                                 11.4                                                                   Portugal                                          -23
                             11.7                                                                          Spain                              -36
                            12.1                                                                     Czech Republic                                                                          3
                          12.4                                                                            Ireland                                                                                                   29
                          12.5                                                                           Austria                                                  -14
                          12.5                                                                          Lithuania                                                                          n.a.
                          12.6                                                                           France                               -35
                          12.6                                                                          Hungary                                                  -15
                   14.0                                                                                  Estonia                                                                           n.a.
            15.5                                                                                      Luxembourg                                                                                        16

20               15                            10                          5                    0                          -75         -50                  -25                        0                     25          50         75
Litres per capita                                                                                                                                                                                                 % change over period

Source: OECD Health Data 2010; Eurostat Statistics Database; WHO (2010).
                                                                                                                                  1 2 http://dx.doi.org/10.1787/888932336559


          2.7.2. Trends in alcohol consumption,                                                                 2.7.3. Alcohol consumption, 2005 and chronic liver
             selected EU countries, 1980-2008                                                                     disease deaths, 2008 (or nearest year available)
                                        France                                        Hungary                  Chronic liver disease (deaths per 100 000 population)
                                                                                                                  50
                                        Sweden                                        EU
Alcohol consumption (litres per capita)                                                                                          R 2 = 0.30                                                      ROU
                                                                                                                                                                                                               HUN
   20
                                                                                                                  40
                                                                                                                                                                                                             LTU



                                                                                                                  30
   15
                                                                                                                                                                       SVK                       SVN              EST

                                                                                                                                                                                       FIN
                                                                                                                  20                                                                              BGR
                                                                                                                                                                        POL                              CZE
                                                                                                                                                                                       LVA
                                                                                                                                                                                                            DNK
   10                                                                                                                                                                         DEU                GBR       AUT
                                                                                                                  10                                             ITA
                                                                                                                                                                                        ESP                   FRA
                                                                                                                                                                           GRC                          IRL              PRT
                                                                                                                                                    SWE                                  CHE
                                                                                                                                                                        CYP
                                                                                                                                                    NOR                                 NLD
                                                                                                                                                                       ISL                                   BEL
    5                                                                                                                  0
     1980          1985                 1990                 1995              2000           2005                         0                        5                            10              15               20
                                                                                                                                                                              Alcohol consumption (litres per capita)

Source: OECD Health Data 2010; Eurostat Statistics Database; WHO                                               Source: OECD Health Data 2010; Eurostat Statistics Database; WHO
(2010).                                                                                                        (2010).
           1 2 http://dx.doi.org/10.1787/888932336578                                                                     1 2 http://dx.doi.org/10.1787/888932336597




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                              71
2.8. OVERWEIGHT AND OBESITY AMONG ADULTS


     The growth in overweight and obesity rates               lower rates. Again, the gradient in obesity is stronger in
among adults is a major public health concern. Obesity        women than in men (OECD, 2010c).
is a known risk factor for numerous health problems,                A number of behavioural and environmental
including hypertension, high cholesterol, diabetes,           factors have contributed to the rise in overweight and
cardiovascular diseases, respiratory problems                 obesity rates in industrialised countries, including
(asthma), musculoskeletal diseases (arthritis) and            falling real prices of food and more time spent being
some forms of cancer. Mortality also increases sharply        physically inactive. Overweight and obesity has risen
once the overweight threshold is crossed (OECD, 2010c).       rapidly in children in recent decades, reaching double-
     More than half (50.1%) of the adult population in        figure rates in most EU countries (see Indicator 2.4).
the European Union are overweight or obese. The                    Because obesity is associated with higher risks of
prevalence of overweight and obesity among adults             chronic illnesses, it is linked to significant additional
exceeds 50% in no less than 15 of 27 EU countries. In         health care costs. There is a time lag between the
contrast, overweight and obesity rates are much lower         onset of obesity and related health problems, suggest-
in France, Italy and Switzerland, although rates are          ing that the rise in obesity over the past two decades
also increasing in these countries. The prevalence of         will mean higher health care costs in the future. A
obesity – which presents greater health risks than            recent study estimated that total costs linked to
overweight – varies threefold among countries, from a         overweight and obesity in England in 2015 could
low of less than 10% in Romania, Switzerland and              increase by as much as 70% relative to 2007 and could
Italy to over 20% in the United Kingdom, Ireland,             be 2.4 times higher in 2025 (Foresight, 2007).
Malta and Iceland (Figure 2.8.1). Across the European
Union, 15.5% of the adult population is obese.
     There is little difference in the average obesity
rate of men and women in the European Union, with
                                                                          Definition and deviations
both at around 15% (Figure 2.8.1). However, there is
some variation among individual countries, with men               Overweight and obesity are defined as exces-
generally being more obese than women in Norway,                sive weight presenting health risks because of
Malta and Italy, whereas women are more obese                   the high proportion of body fat. The most
in Latvia, Turkey and the Netherlands. The largest              frequently used measure is based on the body
disparities in obesity between men and women were               mass index (BMI), which is a single number that
in Latvia, whereas there was little, if any difference in       evaluates an individual’s weight in relation to
male and female obesity rates in the Czech Republic,            height (weight/height2, with weight in kilograms
Poland and Sweden.                                              and height in metres). Based on the WHO
     The rate of obesity has more than doubled over             classification (WHO, 2000), adults with a BMI
the past 20 years in most EU countries for which data           between 25 and 30 are defined as overweight,
are available (Figure 2.8.2). The rapid increase occurred       and those with a BMI over 30 as obese. This clas-
regardless of what the levels of obesity were two               sification may not be suitable for all ethnic
decades ago. Obesity more than doubled in both the              groups, who may have equivalent levels of risk
Netherlands and the United Kingdom between 1988                 at lower or higher BMI. The thresholds for adults
and 2008, even though the rate in the Netherlands is            are not suitable to measure overweight and
currently less than half that of the United Kingdom.            obesity among children.

     In most countries the rise in obesity has affected           For most countries, overweight and obesity
all population groups regardless of sex, age, race,             rates are self-reported through estimates of
income or education level, but to varying extents.              height and weight from population-based health
Evidence from a number of countries, including                  interview surveys. The exceptions are Ireland,
Austria, England, France, Italy and Spain, indicates that       Luxembourg, the Slovak Republic (2008) and the
obesity tends to be more common among individuals               United Kingdom, where estimates are derived
in disadvantaged socio-economic groups, with this               from health examinations. These differences
relationship being particularly strong among women              limit data comparability. Estimates from health
(Sassi et al., 2009b). There is also a relationship between     examinations are generally higher and more
the number of years spent in full-time education and            reliable than from health interviews.
obesity, with the most educated individuals displaying




72                                                                               HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                              2.8. OVERWEIGHT AND OBESITY AMONG ADULTS



                                                    2.8.1. Obesity rates among adults, 2008 (or nearest year available)
                                                                                                                                                                                             Males                                                     Females
                                                All adults
                                                                                         7.9                                              Romania                                            8
                                                                                                                                                                                           8
                                                                                        8.1                                              Switzerland                                        8
                                                                                                                                                                                                 9
                                                                   9.9                                                                       Italy                                                   9
                                                                                                                                                                                                            11
                                                                 10.0                                                                      Norway                                           8
                                                                                                                                                                                                             11
                                                                10.2                                                                       Sweden                                                        10
                                                                                                                                                                                                           10
                                                              11.1                                                                      Netherlands                                                              12
                                                                                                                                                                                                          10
                                                             11.2                                                                           France                                                             12
                                                                                                                                                                                                             11
                                                            11.4                                                                          Denmark                                                               12
                                                                                                                                                                                                               11
                                                            11.5                                                                          Bulgaria                                                           11
                                                                                                                                                                                                               12
                                                         12.4                                                                              Austria                                                                 13
                                                                                                                                                                                                                12
                                                        12.5                                                                                Poland                                                                 13
                                                                                                                                                                                                                  13
                                                     13.6                                                                                 Germany                                                                    13
                                                                                                                                                                                                                                  14
                                                    13.8                                                                                  Belgium                                                                              14
                                                                                                                                                                                                                          13
                                                14.9                                                                                        Spain                                                                               15
                                                                                                                                                                                                                                   15
                                                                                                                                                                                                                                                19
                                               15.2                                                                                         Turkey                                                                   12
                                                                                                                                                                                                                                     16
                                              15.4                                                                                        Portugal                                                                              15
                                                                                                                                                                                                                                    16
                                             15.5                                                                                             EU                                                                                   15
                                                                                                                                                                                                                                15
                                             15.6                                                                                          Cyprus                                                                                       17
                                                                                                                                                                                                                                     16
                                             15.7                                                                                          Finland                                                                                15
                                                                                                                                                                                                                                     16
                                          16.4                                                                                            Slovenia                                                                                        17
                                                                                                                                                                                                                                       17
                                         16.9                                                                                         Slovak Republic1                                                                                   17
                                                                                                                                                                                                                                                      21
                                         16.9                                                                                               Latvia                                                               12
                                                                                                                                                                                                                                          17
                                        17.1                                                                                           Czech Republic                                                                                     17
                                                                                                                                                                                                                                              18
                                     18.0                                                                                                  Estonia                                                                                         18
                                                                                                                                                                                                                                               19
                                     18.1                                                                                                   Greece                                                                                         18
                                                                                                                                                                                                                                              18
                                   18.8                                                                                                   Hungary                                                                                                  20
                                                                                                                                                                                                                                                19
                                19.7                                                                                                      Lithuania                                                                                                  21
                                                                                                                                                                                                                                                19
                               20.0                                                                                                     Luxembourg1                                                                                                  21
                                                                                                                                                                                                                                                        21
                               20.1                                                                                                        Iceland                                                                                              19
                                                                                                                                                                                                                                                     21
                    22.3                                                                                                                    Malta                                                                                                                       24
                                                                                                                                                                                                                                                                   24
                  23.0                                                                                                                     Ireland1                                                                                                          22
                                                                                                                                                                                                                                                                            25
          24.5                                                                                                                        United Kingdom1                                                                                                                  24

30                    20                                                       10                                                0                                0                                  10                                          20                       30
% of adult population                                                                                                                                                                                                                                  % of adult population

1. Ireland, Luxembourg, Slovak Republic and United Kingdom figures are based on health examination surveys, rather than health
   interview surveys.
Source: OECD Health Data 2010; Eurostat Statistics Database; WHO Global Infobase.
                                                                                                                                                                            1 2 http://dx.doi.org/10.1787/888932336616


                                                          2.8.2. Increasing obesity rates among adults in EU countries
             %
             30


             25                                                                                                                                                                                                                                                                             25
                                                                                                                                                                                                                                                                             23
                                                                                                                                                                                                                                                                                  22
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                                                                                                                                                                                                                                        18
                                                                                                                                                                                                 17             17             17
                                                                                                                                                                                      16                      16                                        16
                                                                                                                                                                        15     16
                                                                                                                                                                  15
             15                                                                                                                                   14    14
                                                                                                                                                                                             15                           14
                                                                                                                                                                       13                                                            13
                                                                                                                  12             12     13                                    12                                                                                  12
                                                                                                   11        11     12                11     12                  12
                                                                                   11                                                                  11
                                               10        10           10                                                                                                                                                                                                               10
             10        9                   9
                                                                                                        10
                                                                                                                         9
                                                                                                                             9                                                       10
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1. Luxembourg, Slovak Republic (2008) and United Kingdom figures are based on health examination surveys, rather than health
   interview surveys.
Source: OECD Health Data 2010; Eurostat Statistics Database; WHO Global Infobase.
                                                                                                                                                                            1 2 http://dx.doi.org/10.1787/888932336635




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                                                                 73
Health at a Glance: Europe 2010
© OECD 2010




                                                        Chapter 3




            Health Care Resources, Services
                    and Outcomes


         3.1.    Practising physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        76
         3.2.    Practising nurses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      78
         3.3.    Childhood vaccination programmes . . . . . . . . . . . . . . . . . . . . . . . . . . .                       80
         3.4.    Influenza vaccination for older people . . . . . . . . . . . . . . . . . . . . . . . . .                     82
         3.5.    Medical technologies: CT scanners and MRI units . . . . . . . . . . . . . . .                                84
         3.6.    Hospital beds. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   86
         3.7.    Hospital discharges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        88
         3.8.    Average length of stay in hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  90
         3.9.    Cardiac procedures (coronary angioplasty) . . . . . . . . . . . . . . . . . . . . .                          92
         3.10. Cataract surgeries. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        94
         3.11. Hip and knee replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                 96
         3.12. Screening, survival and mortality for cervical cancer . . . . . . . . . . . .                                  98
         3.13. Screening, survival and mortality for breast cancer . . . . . . . . . . . . . . 100




                                                                                                                                   75
3.1. PRACTISING PHYSICIANS


    Access to high-quality services depends crucially        the 1980s and 1990s, the number of doctors per capita
on the size, skill mix, geographic distribution and          in Italy peaked in 2002, and has declined since then.
productivity of the health workforce. Health workers,        In France, the number peaked in 2005, and the decline
and in particular doctors and nurses, are the corner-        is expected to continue to 2020 (DREES, 2009).
stone of health systems.                                          In nearly all countries, the balance between
     In 2008, Greece had, by far, the highest number of      general practitioners and specialists has changed over
doctors per capita, with six doctors per 1 000 population,   past decades, with the number of specialists increas-
nearly twice the EU average. Following Greece were           ing much more rapidly than generalists. As a result,
Austria, Italy and Norway, with four doctors or more per     there are more specialists than generalists in all
1 000 population. The number of doctors per capita was       countries, except Romania and Portugal (Figure 3.1.2).
the lowest in Turkey, followed by Poland and Romania.        A number of reasons explain this trend. There may be
Doctor numbers are also relatively low in the                less interest in the traditional mode of practice of
United Kingdom and Finland (Figure 3.1.1).                   general/family practitioner and the workload and
     Since 2000, the number of physicians per capita         constraints attached to it. In addition, in many coun-
has increased in all European countries, except the          tries, there is a growing remuneration gap between
Slovak Republic. On average across EU countries,             generalists and specialists (Fujisawa and Lafortune,
physician density grew at a rate of 1.5% per year, rising    2008). The slow or negative growth in the number of
from 3.0 doctors per 1 000 population to 3.3. The            generalists per capita raises concerns about access
growth rate was particularly rapid in Turkey, which          to primary care for certain population groups. In
started from the lowest level in 2000, thereby narrow-       response to this shortage, many countries are consid-
ing the gap with other countries.                            ering ways to improve the attractiveness of general
                                                             practice as well as the development of new roles
     The number of doctors also increased rapidly
                                                             for other health care providers, such as nurses
in Ireland, rising by nearly 50% (from 2.2 per
                                                             (Delamaire and Lafortune, 2010).
1 000 population in 2000 to 3.2 in 2008). A large part of
this increase is due to the recruitment of foreign-
trained physicians. The share of foreign-trained
physicians in Ireland more than tripled during this
                                                                        Definition and deviations
period, rising from 11% of all physicians in 2000 to 35%
in 2008 (OECD and WHO, 2010). There has also been a              Practising physicians are defined as doctors
substantial rise in the number of students graduating          who are providing care directly to patients.
from medical schools in Ireland (OECD, 2010a).                 In some countries, the numbers also include
     A similar pattern has been observed in the                doctors working in administration, manage-
United Kingdom, where the number of doctors went               ment, academic and research positions (“profes-
up from 2.0 per 1 000 population in 2000 to 2.6 in 2008,       sionally active” physicians), adding another
an increase of 30%. The number of new registrations            5-10% of doctors. Ireland, the Netherlands and
of foreign-trained doctors in the United Kingdom               Portugal report all physicians entitled to
increased to 2003 when it peaked at about 14 000, but          practice, resulting in an over-estimation.
has declined since then to just over 5 000 in 2008               Not all countries are able to report all physi-
(OECD and WHO, 2010). At the same time, the number             cians as generalists or specialists, and in some
of new graduates from medical schools in the                   countries (e.g. the Netherlands), most physicians
United Kingdom increased, from about 4 600 in 2003             are not reported in either of these two broad
to 5 600 in 2008, gradually exceeding the number of            categories. In some countries, data on medical
new registrations of foreign-trained physicians.               specialty may not be available for interns/
     In contrast, in France and Italy there was                residents (physicians in training) or for those
virtually no growth. Following the reduction in the            working in private practice.
number of new entrants in medical schools during




76                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                                               3.1. PRACTISING PHYSICIANS



                                                                      3.1.1. Practising physicians per 1 000 population
                                 2008 (or nearest year available)                                                                                                      Change 2000-08 (or nearest year available)
 6.0                                                                                                                          Greece1                                                                                                         4.2
                    4.6                                                                                                       Austria                                                                                   2.2
                             4.2                                                                                                Italy1                                                        0.1
                                4.0                                                                                           Norway                                                                                                          4.1
                                   3.8                                                                                      Switzerland                                                      n.a.
                                    3.7                                                                                       Iceland                                                                  1.0
                                     3.7                                                                                   Netherlands 2                                                                                    2.7
                                     3.7                                                                                     Lithuania                                                         0.3
                                     3.7                                                                                     Portugal 2                                                                           1.8
                                       3.6                                                                                Czech Republic                                                              0.8
                                       3.6                                                                                     Spain                                                         n.a.
                                       3.6                                                                                    Bulgaria                                                                0.9
                                       3.6                                                                                    Sweden                                                                                       2.5
                                       3.6                                                                                   Germany                                                                    1.1
                                          3.4                                                                                Denmark                                                                                      2.3
                                           3.4                                                                                Estonia                                                           0.3
                                           3.3                                                                                    EU                                                                           1.5
                                           3.3                                                                                France 1                                                         0.2
                                             3.2                                                                              Ireland 2                                                                                                              4.8
                                               3.1                                                                             Latvia                                                                  1.0
                                               3.1                                                                            Hungary                                                        n.a.
                                                3.0                                                                            Malta                                                         n.a.
                                                 3.0                                                                      Slovak Republic                                   -1.0
                                                 3.0                                                                          Belgium                                                                 0.8
                                                   2.9                                                                        Cyprus                                                                        1.3
                                                   2.8                                                                     Luxembourg                                                        n.a.
                                                     2.7                                                                      Finland                                                                  1.1
                                                       2.6                                                                United Kingdom                                                                                               3.6
                                                          2.4                                                                 Slovenia                                                                      1.4
                                                             2.2                                                             Romania                                                                           1.7
                                                              2.2                                                              Poland                                                        n.a.
                                                                              1.5                                             Turkey1                                                                                                                4.8

6                    4                                                2                                             0                                 -4                                 0                                  4                     8
Per 1 000 population                                                                                                                                                                                                 Average annual growth rate (%)

1. Data include not only physicians providing direct care to patients, but also those working in the health sector as managers, educators,
   researchers, etc. (adding another 5-10% of doctors).
2. Data refer to all physicians who are licensed to practice.
Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                                              1 2 http://dx.doi.org/10.1787/888932336654


            3.1.2. General practitioners, specialists and other physicians as a share of total physicians, 2008
                                                 (or nearest year available)

    %                                                          GPs                                                               Specialists                                                        Other physicians
   100



       80



       60



       40



       20
                                                                                                   25.0
                                                        33.2

                                                               33.2
                          50.2




                                                 33.5
             54.5




                                                                                                                         22.8
                                          39.2




                                                                                                             22.9
                                                                       28.8




                                                                                                                                        20.8
                                                                                                                                 20.9
                                                                                           25.6




                                                                                                                                               20.0
                                   48.7




                                                                                    28.7




                                                                                                                                                                                                        16.9
                                                                                                                                                              18.8




                                                                                                                                                                                                                                       14.3
                                                                                                                                                                     18.4

                                                                                                                                                                               18.4




                                                                                                                                                                                                                                                    13.8
                                                                                                                                                       19.9




                                                                                                                                                                                                                   15.7

                                                                                                                                                                                                                                15.7




                                                                                                                                                                                                                                                           12.1
                                                                                                                                                                                      17.4

                                                                                                                                                                                               17.0




                                                                                                                                                                                                                                                                        4.5
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           ite Tu

          L u ing




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Note: Specialists include paediatricians, obstetricians/gynaecologists, psychiatrists, medical specialists and surgical specialists. Other
physicians include interns/residents if not reported in the field in which they are training, and doctors not elsewhere classified.
1. Data are not available for specialists.
Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                                              1 2 http://dx.doi.org/10.1787/888932336673


HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                                             77
3.2. PRACTISING NURSES


     Nurses are usually the most numerous health           particularly large in Portugal and Spain, where the
profession, outnumbering physicians in most                number of nurses per population increased by 45%
European countries. Nurses play a critical role in         and 33% respectively. In France and Switzerland, there
providing health care not only in traditional settings     was also a fairly large increase in the supply of nurses,
such as hospitals and long-term care institutions but      rising by 15-20% between 2000 and 2008.
increasingly in primary care (especially in offering            In 2008, the number of nurses per doctor ranged
care to the chronically ill) and in patients’ homes.       from about six in Ireland and Finland to under one nurse
However, there are concerns in many countries              per doctor in Greece and Turkey (Figure 3.2.2). The
about shortages of nurses, and these concerns may          average across European countries is over two-and-a-
well intensify in the future as the demand for nurses      half nurses per doctor, with many countries reporting
continues to increase and the ageing of the “baby          between two to four nurses per doctor. Beyond Greece
boom” generation precipitates a wave of retirements        and Turkey, the nurse-to-doctor ratio is also relatively
among nurses. These concerns have prompted many            low in other southern European countries, such as Italy,
countries to increase the training of new nurses           Spain, Portugal and Cyprus. In Greece and Italy, there is
combined with efforts to increase retention rates in       evidence of an over-supply of doctors and under-supply
the profession (OECD, 2008b).                              of nurses, resulting in an inefficient allocation of
    This section presents data on the number of            resources (OECD, 2009; Chaloff, 2008).
nurses, including both “professional nurses” and
“associate professional nurses” in those countries
where two such levels of nurses exist. It also provides
data on other lower-skilled caring personnel such as
nursing aides.
                                                                       Definition and deviations
      In 2008, there were about 15 professional and
associate professional nurses per 1 000 population in          The data refer to nurses and other caring
Finland, Iceland, Ireland and Switzerland, and slightly      personnel providing direct care to patients,
fewer in Denmark and Norway. Turkey had the fewest           although in some countries they also include
nurses, followed by Greece, Bulgaria and Cyprus, with        nurses working in management, research and
all these countries having fewer than five nurses per        other roles. This adds another 5-10% to nursing
1 000 population.                                            numbers.

     The mix between different categories of nurses            “Professional nurses” are defined by ISCO-08
varies widely across European countries. In some             code 2221, and include categories of nurses such
countries such as France, Portugal and Poland, a             as registered nurses, clinical nurses, nurse
lower-level category of “associate professional nurses”      anaesthetists, nurse practitioners, public health
does not exist, and all nurses are reported to be at the     nurses, and specialist nurses. “Associate
same level. In other countries such as the United            professional nurses” are defined by ISCO-08
Kingdom, Germany and Austria, the vast majority of           code 3221, and include categories of nurses
nurses are considered to be professional nurses, but a       such as “enrolled nurses” and “practical nurses”.
minority are considered to be at a lower-level. In yet       “Caring personnel” includes two categories of
another group of countries including the Netherlands         workers defined in ISCO-08: 1) “health care
and Slovenia, the number of lower-level nurses is            assistants” (code 5321) who “provide direct
greater than higher-level nurses (Figure 3.2.1).             personal care and assistance with activities of
                                                             daily living to patients and residents in a variety
     In addition to different categories of recognised
                                                             of health care settings”; and 2) “home-based
nurses, other categories of caring personnel such as
                                                             personal care workers” (code 5322), including
nursing aides play an important role in supporting
                                                             home care aides, nursing aides at home, and
nurses in providing care in some countries. However,
                                                             personal care providers.
because these personnel are usually not part of a
registered profession, the availability and coverage           Midwives are usually excluded from nurses.
of data is more limited. Based on the available data,        However, about half of European countries
the number of such additional caring personnel is the        report midwives together with nurses, as they
highest in the Netherlands, Norway and Denmark. In           are considered specialist nurses.
the Netherlands and France, there are in fact more             Austria reports only nurses working in hospi-
caring personnel than nurses.                                tals. The data for Germany does not include
     Since 2000, the number of nurses per capita             nurses who have three years of education and
has increased in all European countries, except in           are providing services for the elderly.
Lithuania and the Slovak Republic. The increase was



78                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                          3.2. PRACTISING NURSES



  3.2.1. Professional nurses, associate professional nurses and caring personnel per 1 000 population, 2008
                                           (or nearest year available)
                                            Professional nurses                                   Associate professional nurses                                     Caring personnel
Per 1 000 population
   25
                            23.0
              24.6

                     24.5




                                   21.4

   20

                                          16.5 16.2
                                                      15.5
                                                             14.8
   15

                                                                    10.9 10.8 10.7
                                                                                   10.4
                                                                                            9.8   9.7   9.5
   10                                                                                                         9.3
                                                                                                                    8.7   8.7
                                                                                                                                8.0   7.7
                                                                                                                                            7.1
                                                                                                                                                  6.5   6.3   6.3
                                                                                                                                                                    5.7    5.5   5.2
    5                                                                                                                                                                                  4.7   4.3   4.2

                                                                                                                                                                                                         1.3

    0
                  Ir e c e 1

                                   4




                   Ge en 4




                   K i lic 4




                                   2


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1. Data include not only nurses providing direct care to patients, but also those working in the health sector as managers, educators,
   researchers, etc. (adding another 5-10% of nurses).
2. Austria reports only nurses employed in hospitals.
3. In Italy, data refer to all nurses who are licensed to practice.
4. The breakdown between professional and associate professional nurses is not available.
Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                1 2 http://dx.doi.org/10.1787/888932336692


                                           3.2.2. Ratio of nurses to physicians, 2008 (or nearest year available)
     7
            6.4

     6               5.7


     5
                            4.2
                                   4.0    4.0   4.0   3.9
     4                                                       3.7
                                                                    3.5
                                                                          3.3
                                                                                3.0   3.0   3.0
     3
                                                                                                  2.6   2.5   2.4   2.4
                                                                                                                          2.2
                                                                                                                                2.0   2.0   1.9   1.9   1.9
     2                                                                                                                                                        1.7   1.6    1.5
                                                                                                                                                                                 1.3   1.2
                                                                                                                                                                                             1.0   0.9
     1
                                                                                                                                                                                                         0.6

     0
                        Sl ay




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Note: Nurses only include professional and associate professional nurses and exclude other caring personnel.
Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                1 2 http://dx.doi.org/10.1787/888932336711




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                              79
3.3. CHILDHOOD VACCINATION PROGRAMMES


     Childhood vaccination continues to be one of the             Figure 3.3.3 shows that the average percentage of
most cost-effective public health interventions. All        children aged 2 years vaccinated for hepatitis B across
European countries, or in some cases sub-national           countries with national programmes is also over 95%.
jurisdictions, have established vaccination pro-            However, some European countries do not currently
grammes based on their interpretation of the risks          require children to be vaccinated by age 2, or do not
and benefits of each vaccine.                               have routine programmes, and consequently the rates
     Vaccination against pertussis (often adminis-          for these countries are significantly lower. For example,
tered in connection with vaccination against diph-          in Denmark and Sweden, vaccination against
theria and tetanus) and measles is part of almost all       hepatitis B is not an obligatory part of vaccination
programmes. Reviews of the evidence supporting the          programmes, and is only recommended to specific risk
efficacy of vaccines against these diseases have            groups. In France, hepatitis B vaccination remains
concluded that the respective vaccines are safe and         controversial, given ongoing speculation over possible
highly effective. In the European Union, the gradual        side effects.
take-up of the measles vaccine has meant that                   Figure 1.11.3 in Chapter 1 indicates that the inci-
measles incidence is around twenty times lower              dence of hepatitis B is low in the majority of European
than the rate of the early 1990s (see Indicator 1.11),      countries, at less than 2 per 100 000 population.
although outbreak can still occur.                          However, in Iceland, Bulgaria, Turkey, Austria, Latvia
     A vaccination for hepatitis B has been available       and Romania, the rates are more than two times the
since 1982 and is considered to be 95% effective in         EU average.
preventing infection and its chronic consequences,
such as cirrhosis and liver cancer. In 2004, it was esti-
mated that over 350 million people were chronically
infected with the hepatitis B virus worldwide and at
risk of serious illness and death (WHO, 2009a). In 2007,                 Definition and deviation
more than 170 countries had already begun to follow
                                                                 Vaccination rates reflect the percentage of
the WHO recommendation to incorporate hepatitis B
                                                              children at age 1 or 2 receiving the respective
vaccine as an integral part of their national infant
                                                              vaccination. Childhood vaccination policies differ
immunisation programme.
                                                              across countries. Some countries administer
     Figures 3.3.1 and 3.3.2 demonstrate that the overall     combination vaccines (e.g. DTP for diphtheria,
vaccination of children against pertussis (including          tetanus and pertussis) while others administer
diphtheria and tetanus) and measles is high in most           the vaccinations separately. Schedules for admin-
European countries. On average, about 95% of 2-year-old       istering vaccines also differ.
children receive the recommended pertussis and
                                                                Some countries ascertain vaccinations based
measles vaccination, a level that is high enough to
                                                              on surveys and others based on encounter data,
provide effective immunity. Vaccination rates are the
                                                              which may influence the results.
lowest in Malta and Austria, with less than 85% of
children vaccinated against these diseases.




80                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                               3.3. CHILDHOOD VACCINATION PROGRAMMES



                          3.3.1. Vaccination rates for pertussis, children aged 2, 2008 (or nearest year available)
    %
   100                                                         98.0 98.0 97.4 97.3 97.0 97.0 97.0 97.0 97.0 96.8
                                                                                                                 96.7 96.7 96.5 96.1 96.0 96.0 96.0
             99.9

                      99.6

                                    99.4

                                                99.0

                                                        98.7
                                                                                                                                                                                                            95.0 95.0 94.6 94.5
    95                                                                                                                                                                                                                          94.0 93.0

                                                                                                                                                                                                                                                       90.0
    90                                                                                                                                                                                                                                                        89.0

    85                                                                                                                                                                                                                                                                83.0

    80

    75
                                                                                                                                                                                                                                                                             72.0
    70
               Re b l i c

                    Po ic




                    Au r k


                             ta
               Re ar y




                 Be nd
                             m

                  Sw ce

                    Fi n
               Ge d

                    Ic y

                     ov d
                    C y ia

                     La s
               Ro i a

                Po ni a

                                l
                              ly

                  m n

                   Es rg
                i t z ni a




                    Ir e y
                            nd

               De ece


                            ria
                     Tu d
                   th ey
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    Un B E U

               K i ar i a
              t h om

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                      ng




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                      pu
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                       nl


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                      m




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Source: OECD Health Data 2010; WHO vaccine-preventable diseases: monitoring system 2010 global summary.
                                                                              1 2 http://dx.doi.org/10.1787/888932336730


                             3.3.2. Vaccination rates for measles, children aged 2, 2008 (or nearest year available)
    %
   100
                                                                         97.6 97.0 97.0 97.0 97.0 96.6
             99.9

                      99.5




                                                                                                       96.2 96.0 96.0 96.0 96.0
                                    98.9

                                                98.7




                                                                                                                                95.4 95.4
                                                        98.0

                                                                97.9




                                                                                                                                                                                         94.0 93.7 93.0 93.0
    95
                                                                                                                                                                                                                   90.0 89.5
                                                                                                                                                                                                                             89.0 89.0
    90                                                                                                                                                                                                                                        87.0 87.0
                                                                                                                                                                                                                                                              85.9
    85                                                                                                                                                                                                                                                                83.0

    80                                                                                                                                                                                                                                                                       78.0

    75
    70
                  Fi ce
                  Gr i c




                            ic




               it z ay




                  Ir e k

                   Fr d
              Re r y




                  Po d
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                   Tu n


              Li t via



               P ni a

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                Sw ia
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                  Ic y
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                 N m




              De l y




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              K i us


                          ria

                           ta
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              Ro n i a




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                Be EU




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                  Au m
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                        an
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Source: OECD Health Data 2010; WHO vaccine-preventable diseases: monitoring system 2010 global summary.
                                                                              1 2 http://dx.doi.org/10.1787/888932336749


                      3.3.3. Vaccination rates for hepatitis B, children aged 2, 2008 (or nearest year available)
    %
   100                                                                                                                                                                                    95.2      94.5    93.0    92.0     90.2
              99.8


                             99.4


                                           99.4


                                                        99.3


                                                                  99.0


                                                                              97.5


                                                                                      97.0


                                                                                                  96.8


                                                                                                              96.5


                                                                                                                          96.2


                                                                                                                                    96.1


                                                                                                                                                96.0


                                                                                                                                                          96.0


                                                                                                                                                                      96.0


                                                                                                                                                                                  95.3




                                                                                                                                                                                                                                      83.0    82.0
    80

    60

    40                                                                                                                                                                                                                                                  33.1

    20                                                                                                                                                                                                                                                             15.7

                                                                                                                                                                                                                                                                             0.3
     0
                                                                                                                                                                                           1




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                                                                                                                                   ly

                                                                                                                                                ia

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                                                                                                                                                                  a

                                                                                                                                                                              ce




                                                                                                                                                                                                    g

                                                                                                                                                                                                            us

                                                                                                                                                                                                                    y

                                                                                                                                                                                                                             y

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                                                                                                                                                                                         EU
                                                                                                                      ni




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                                pu

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                                                                                 ov
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                                                                                                                                                                                                                                 Au
                                                                                                                                                                                                       Cy
                                                                                                                                                                        Gr
                                                                                                               Es




                                                                                                                                                            th




                                                                                                                                                                                                                                                  Fr

                                                                                                                                                                                                                                                         Sw
                                                                                                                                    Bu
                                                                    Be
              Hu




                                                                                                                                                                                              m
                                                                                      Po
                                                        Ro
                          Re

                                           Re




                                                                                                                                                                                                                       Ge
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                                                                                                                                                                                                                                                                De
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1. EU average only includes countries with required or routine immunisation.
2. In France, Sweden and Denmark, vaccination for hepatitis B is not required or routinely provided.
Source: OECD Health Data 2010; WHO vaccine-preventable diseases: monitoring system 2010 global summary.
                                                                              1 2 http://dx.doi.org/10.1787/888932336768




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                                                  81
3.4. INFLUENZA VACCINATION FOR OLDER PEOPLE


      Influenza is a common infectious disease world-       care providers other than physicians. However, a
wide and affects persons of all ages. Most people with      number of barriers need to be overcome in some
the illness recover quickly, but elderly people and those   countries if they wish to increase their coverage rates
with chronic medical conditions are at higher risk          further. For example, possible reasons put forward for
for complications and even death. For example,              the relatively low vaccination rates in Austria include
between 2000 and 2008, influenza along with other           poor public awareness, inadequate insurance cover-
acute upper respiratory infections accounted for about      age of related costs, and lack of consensus within the
44 000 hospitalisations per year in France and 77 000 in    Austrian medical profession about the importance of
Germany. The impact of influenza on the employed            vaccination (Kunze et al., 2007).
population is substantial, even though most influenza            New types of influenza, such as the H1N1 “swine
morbidity and mortality occurs among the elderly and        flu”, have emerged in recent years and prompted
those with chronic conditions (e.g. 85-90% of people        rapid responses to contain the pandemic. While
who die from influenza in France and Germany are            symptoms of the H1N1 influenza are mild in most
over 65 years of age).                                      people, a minority have suffered severe disease with
     Immunisation against seasonal influenza (or flu)       some dying from it. The majority of those people who
for older people has become increasingly widespread         have suffered severely from the disease have other
in many European countries over the past decade.            chronic medical conditions such as asthma or heart
Influenza vaccination for patients with chronic             disease. But there have also been cases of people who
conditions and other at-risk groups is also strongly        became severely ill without any underlying condition
recommended in many countries.                              (European Commission, 2010c). A series of public
     In 2008, more than half of the population              health measures used to combat seasonal flu have
aged 65 years and over were vaccinated for influenza        been used to combat new strains of influenza in
in 14 European countries (Figure 3.4.1). There is a wide    Europe, including massive vaccination campaigns for
variation in vaccination rates, ranging from lows of        risk groups (European Commission, 2010c).
21% in the Czech Republic and 26% in Slovenia, to over
75% in the Netherlands and the United Kingdom.
    Figure 3.4.2 indicates that while the European
average increased markedly between 1998 and 2003, it
                                                                       Definitions and deviations
remained relatively stable between 2003 and 2008.
From 2003, some countries marginally increased their            Influenza vaccination rate refers to the
coverage whereas others reduced it, most notably in           number of people aged 65 and older who have
countries which were already below the EU average,            received an annual influenza vaccination,
such as Slovenia, the Slovak Republic and Hungary.            divided by the total number of people over
     A number of factors contributed to the rise in           65 years of age. The main limitation in terms of
influenza immunisation rates in most European                 data comparability arises from the use of differ-
countries over the past decade, including greater             ent data sources, whether survey or programme,
acceptance of preventive health services by patients          which are susceptible to different types of errors
and practitioners, improved public health insurance           and biases.
coverage for vaccines, and wider delivery by health




82                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                             3.4. INFLUENZA VACCINATION FOR OLDER PEOPLE



         3.4.1. Influenza vaccination coverage, population aged 65 and over, 2008 (or nearest year available)
   %
   80         77.0        75.1
                                        70.1        70.0
                                                                  66.2         65.4             65.0
                                                                                                             62.5
   60                                                                                                                    57.0          56.0         56.0
                                                                                                                                                                  54.2            54.1
                                                                                                                                                                                              51.0          50.4



   40                                                                                                                                                                                                                       37.8
                                                                                                                                                                                                                                        36.1            35.5


                                                                                                                                                                                                                                                                    26.0
                                                                                                                                                                                                                                                                                 21.2
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1. Population aged 60 and over.
Source: OECD Health Data 2010.
                                                                                                                                                                      1 2 http://dx.doi.org/10.1787/888932336787


  3.4.2. Vaccination rates for influenza, population aged 65 and over, 1998-2008 (or nearest year available)

   %                                                                                         1998                                                  2003                                                  2008
   80
                                                         70.0
                                           70.1
                  77.0




                                                                       66.2
                              75.1




                                                                                                 65.0



                                                                                                                 62.5




                                                                                                                                            57.0
                                                                                                                              57.0
                                                                                    65.4




                                                                                                                                                         56.0




   60
                                                                                                                                                                                      54.1


                                                                                                                                                                                                  51.0


                                                                                                                                                                                                                50.4
                                                                                                                                                                      56.0




                                                                                                                                                                                                                                                36.1

   40
                                                                                                                                                                                                                                37.8




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1. Population aged 60 and over.
Source: OECD Health Data 2010.
                                                                                                                                                                      1 2 http://dx.doi.org/10.1787/888932336806




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                                                          83
3.5. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS


     New medical technologies are improving diagno-           has the highest number of these two types of
sis and treatment, but they are also increasing health        scanners (Figures 3.5.3 and 3.5.4). The number of CT
spending. This section presents data on the availability      and MRI exams per capita is also above average in
and use of two diagnostic technologies: computed              Belgium, Luxembourg and Iceland. It is the lowest in
tomography (CT) scanners and magnetic resonance               the Slovak Republic and Czech Republic, as well as in
imaging (MRI) units. CT scanners and MRI units help           the Netherlands for CT exams.
physicians diagnose a range of conditions by producing             In Greece, most CT and MRI scanners are installed
images of internal organs and structures of the body.         in the growing number of private diagnostic centres,
Unlike conventional radiography and CT scanning,              and only a minority are found in public hospitals.
newer imaging technology used in MRI units do not             There is no regulation concerning the purchase of MRI
expose patients to ionising radiation.                        units in Greece, while the purchase of CT scanners
     The availability of CT scanners and MRI units has        requires a licence that is granted following a review
increased rapidly in most European countries over the         based on a criteria of population density. There are also
past two decades. For example, in the Netherlands, the        no guidelines concerning the use of CT and MRI
number of MRI units per capita multiplied by ten              scanners (Paris et al., 2010). The current situation has
between 1990 and 2008, while the number of CT scan-           led the Greek Ministry of Health and Social Solidarity to
ners also increased. Similarly, in Italy, the number of MRI   establish an expert’s committee to review regulations
scanners per capita multiplied by five between 1997           and propose new criteria for the purchase of CT and
and 2007, and the number of CT scanners doubled.              MRI scanners.
     In 2008, Greece had the highest number of MRI                 Many other European countries are also examin-
and CT scanners per capita (together with Cyprus for          ing ways to promote more rational purchase and use
CT scanners). Switzerland, Iceland, Italy and Austria         of such diagnostic technologies (OECD, 2010b). In the
also had significantly more MRI and CT scanners than          United Kingdom, the National Institute for Health and
the EU average (Figures 3.5.1 and 3.5.2). However, the        Clinical Excellence has recently set up a Diagnostics
number of MRI and CT scanners in all European                 Advisory Committee to evaluate and make recom-
countries remains much lower than in Japan and the            mendations for the appropriate use of diagnostic
United States (OECD, 2010a). The number of MRI units          technologies within the NHS in England (NICE, 2009).
and CT scanners per population were the lowest in
Romania and Hungary.
     There is no general guideline regarding an ideal                     Definition and deviations
number of CT scanners or MRI units per population.
However, if there are too few such items of equip-                The figures relate to the number of CT and MRI
ment, this may lead to access problems, either in               scanners per million population.
terms of geographic proximity or waiting times. On                The data generally cover the equipment
the other hand, if there are too many, this may result          installed in hospitals and ambulatory settings,
in an overuse of these costly diagnostic procedures,            with the exception of Belgium, Germany and
with little if any benefits to patients.                        Spain where the equipment outside hospitals is
     Data on the use of these diagnostic equipment              not included, and France where only a small
are available only for a smaller group of countries.            number of equipment in ambulatory settings is
Based on this more limited country coverage, the                included. In the United Kingdom, the data refer
number of CT and MRI exams per capita is the highest            only to scanners in the public sector.
in Greece, consistent with the fact that Greece also




84                                                                               HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                  3.5. MEDICAL TECHNOLOGIES: CT SCANNERS AND MRI UNITS



                3.5.1. Number of MRI units, 2008                                                                               3.5.2. Number of CT scanners, 2008
                    (or nearest year available)                                                                                      (or nearest year available)
                                        Hospital                Outside hospital                       Total                                            Hospital               Outside hospital                        Total

           Greece                                                                                      21.8                 Cyprus                                                                                  35.5
              Italy                                                                         20.0                            Greece                                                                               33.9
          Iceland                                                                        18.8                          Switzerland                                                                           32.0
          Austria                                                                      18.0                                   Malta                                                                          31.7
           Cyprus                                                                  16.5                                    Iceland                                                                          31.3
          Finland                                                                 16.2                                         Italy                                                                        31.0
         Denmark                                                                15.4                                       Austria                                                                        29.9
     Switzerland1                                                           14.0                                      Luxembourg                                                                      27.6
     Luxembourg                                                         12.7                                              Portugal                                                                  26.0
           Ireland                                                     12.3                                                  Latvia                                                         22.9
         Belgium1                                               10.6                                                      Bulgaria                                                         22.4
      Netherlands                                              10.4                                                       Denmark                                                         21.5
            Spain1                                            9.9                                                                EU                                                   19.2
                EU                                           9.5                                                         Lithuania                                             16.6
         Portugal                                          8.9                                                             Finland                                             16.5
        Germany1                                          8.6                                                            Germany1                                              16.4
          Estonia                                        8.2                                                                 Spain1                                          15.3
             Malta                                    7.3                                                                   Ireland                                         15.1
           Turkey                                   6.9                                                                    Estonia                                          14.9
            Latvia                                 6.6                                                             Slovak Republic                                        13.7
          France1                                 6.1                                                                     Belgium1                                        13.6
  Slovak Republic                                 6.1                                                              Czech Republic                                         13.5
 United Kingdom 2                               5.6                                                                        France1                                 11.0
  Czech Republic                               5.1                                                                          Poland                                 10.9
        Lithuania                           4.2                                                                           Slovenia                                 10.9
         Slovenia                        3.5                                                                           Netherlands                                10.3
         Bulgaria                       3.1                                                                                 Turkey                                10.2
           Poland                      2.9                                                                        United Kingdom 2                          7.4
         Hungary                       2.8                                                                                Hungary                          7.1
         Romania                 1.3                                                                                      Romania                    4.0

                         0                 5               10          15          20        25                                            0                 10                  20           30            40
                                                                Scanners per million population                                                                                Scanners per million population

Note: The EU average does not include countries which only                                                       Note: The EU average does not include countries which only
report equipment in hospital.                                                                                    report equipment in hospital.
1. Data for equipment outside hospital are not available.                                                        1. Data for equipment outside hospital are not available.
2. In the United Kingdom, any equipment in the private sector is                                                 2. In the United Kingdom, any equipment in the private sector is
   not included in the data.                                                                                        not included in the data.
Source: OECD Health Data 2010; Eurostat Statistics Database.                                                     Source: OECD Health Data 2010; Eurostat Statistics Database.
           1 2 http://dx.doi.org/10.1787/888932336825                                                                       1 2 http://dx.doi.org/10.1787/888932336844


                3.5.3. Number of MRI exams, 2008                                                                                  3.5.4. Number of CT exams, 2008
                     (or nearest year available)                                                                                      (or nearest year available)
Exams per 1 000 population                                                                                       Exams per 1 000 population
  100                                                                                                              350
         98.1                                                                                                             320.9

                                                                                                                   300
   80
                  72.3
                                                                                                                   250
                             62.8
   60                                  53.7                                                                        200             182.6 175.5
                                                48.5     47.6                                                                                        164.0
                                                                     38.8     37.8                                 150                                        139.8 139.4
   40                                                                                  36.5                                                                                        130.0

                                                                                                27.8
                                                                                                          24.2     100                                                                       83.8     83.3      82.7
   20                                                                                                                                                                                                                     60.3
                                                                                                                    50

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Source: OECD Health Data 2010.                                                                                   Source: OECD Health Data 2010.
           1 2 http://dx.doi.org/10.1787/888932336863                                                                       1 2 http://dx.doi.org/10.1787/888932336882




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                85
3.6. HOSPITAL BEDS


     The number of hospital beds provides an indica-        the share of beds in public hospitals from 44% to 41%.
tion of the resources available for delivering services     The remaining 30% were beds in private not-for-profit
to in-patients in hospitals. This section presents data     hospitals, whose share also declined slightly. In
on the total number of hospital beds, including those       Austria also, the share of beds in private for-profit
allocated for curative, psychiatric, long-term and          hospitals has increased over the past decade, from 7%
other types of care. It does not capture the capacity of    in 1995 to just over 10% in 2008, although the vast
hospitals to furnish same-day emergency or elective         majority of beds continue to be in publically-owned
interventions.                                              hospitals. In France, the allocation of beds in public
     Over the past 15 years, the number of hospital         and private hospitals has remained fairly stable
beds per population has decreased in all European           since 1997, with about 65% of beds located in public
countries. On average across EU countries, the              hospitals, 15% in private not-for-profit hospitals, and
number fell from 7.3 beds per 1 000 population in 1995      the remaining 20% in private for-profit hospitals
to 5.7 in 2008 (Figure 3.6.1). This reduction in the        (OECD, 2010a).
number of hospital beds has been accompanied by a               In several countries, the reduction in the overall
reduction in average length of stays in hospitals           number of hospital beds has been accompanied by an
(Indicator 3.8) and, in some countries, a reduction in      increase in their occupancy rates. Since 1995, the
hospital admissions (Indicator 3.7). The reduction in       occupancy rate of curative care beds increased signif-
the number of hospital beds per population has been         icantly in Ireland, Italy, Norway and Switzerland
particularly pronounced in Latvia, Lithuania and            (OECD, 2010a).
Bulgaria.
    In all countries, progress in medical technologies
has enabled a move to day-surgery and a reduced                         Definition and deviations
need for long hospitalisation. In addition, in many
countries, cost-containment policies over the past              Hospital beds are defined as all beds that are
decade or so have targeted the hospital sector, as it         regularly maintained and staffed and are imme-
remains the largest health spending category in most          diately available for use. They include beds in
European countries.                                           general hospitals, mental health and substance
                                                              abuse hospitals, and other specialty hospitals.
     In 2008, Germany and Austria had the highest
                                                              Beds in nursing and residential care facilities are
number of hospital beds per capita, with about 8 beds
                                                              excluded.
per 1 000 population (Figure 3.6.1). The high supply of
hospital beds in these two countries is associated with         Curative care beds are beds accommodating
a large number of hospital admissions/discharges, as          patients where the principal intent is to do
well as long average length of stays in Germany.              one or more of the following: manage labour
Turkey had the lowest number of beds per capita,              (obstetric), cure non-mental illness or provide
followed by Spain, the United Kingdom and Portugal.           definitive treatment of injury, perform surgery,
                                                              relieve symptoms of non-mental illness or injury
     Two-thirds of hospital beds are allocated for cura-
                                                              (excluding palliative care), reduce severity of
tive care on average across EU countries. The rest of
                                                              non-mental illness or injury, protect against
the beds are allocated for psychiatric (14%), long-term
                                                              exacerbation and/or complication of non-
(10%) and other types of care (8%). In some countries,
                                                              mental illness and/or injury which could
the share of beds allocated for psychiatric care and
                                                              threaten life or normal functions, perform
long-term care is much greater than the average. In
                                                              diagnostic or therapeutic procedures.
Finland, a greater proportion of hospital beds are
allocated for long-term care (35%) than for curative            Psychiatric care beds are beds accommodating
care (30%). This is because local governments in              patients with mental health problems. They
Finland are responsible for managing both health and          include beds in psychiatric departments of
long-term care services, and use hospitals to provide         general hospitals, and all beds in mental health
at least some of the institution-based long-term care         and substance abuse hospitals.
(OECD, 2005). In Ireland, just over half of hospital beds       Long-term care beds are hospital beds accom-
are allocated for acute care, with 30% devoted to             modating patients requiring long-term care due
long-term care (Figure 3.6.2).                                to chronic impairments and a reduced degree of
     The share of beds in private for-profit hospitals        independence in activities of daily living. They
has increased in some countries over the past few             include beds in long-term care departments of
years, while it has remained stable in others. In             general hospitals, beds for long-term care in
Germany, the share increased from 23% of all beds             specialty hospitals, and beds for palliative care.
in 2002 to 29% in 2008, accompanied by a decline in



86                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  0
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         2
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HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                          iu                                                                                                                                                                                                                                                                                                                                                                                                                       6.7
                                                                                                                                                          Sl                 m                                                                                                                                                                                                                                                                                                                                          ov Po
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          ak la
                                                                                                                                                             ov Po
                                                                                                                                                               ak la                                                                                                                                                                                                                                                                                                                                                          Re nd               n.a.
                                                                                                                                                                  Re nd                                                                                                                                                                                                                                                                                                                                                            pu                                                              6.6
                                                                                                                                                                       pu                                                                                                                                                                                                                                                                                                                                                     Ro b l i c                                                                            8.3
                                                                                                                                                                          b                                                                                                                                                                                                                                                                                                                                                        m                                                               6.6
                                                                                                                                                                  Ro l i c                                                                                                                                                                                                                                                                                                                                                           an
                                                                                                                                                                       m                                                                                                                                                                                                                                                                                                                                                                                                                                      7.6
                                                                                                                                                                         an                                                                                                                                                                                                                                                                                                                                                      Fi ia                                                             6.6




                                                                                           Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                                                                                                                                                                                                                                                                                                                                      Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   nl
                                                                                                                                                                     Fi ia                                                                                                                                                                                                                                                                                                                                                            a
                                                                                                                                                                       nl                                                                                                                                                                                                                                                                                                                                                      Bu nd                                                                            8.1
                                                                                                                                                                          a                                                                                                                                                                                                                                                                                                                                                        lg                                                             6.5
                                                                                                                                                                   Bu nd                                                                                                                                                                                                                                                                                                                                                              ar
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              1995




                                                                                                                                                              Lu lg                                                                                                                                                                                                                                                                                                                                                                      ia                                                                                     10.3
                                                                                                                                                                xe ar i                                                                                                                                                                                                                                                                                                                                                  L u Ic el                                                                6.5
                                                                                                                                                                   m a                                                                                                                                                                                                                                                                                                                                                      xe a n                n.a.




                                                                                                                                                                                                                 Psychiatric care beds
                                                                                                                                                                       bo                                                                                                                                                                                                                                                                                                                                                      m d
                                                                                                                                                                           ur                                                                                                                                                                                                                                                                                                                                                      bo                                                       5.8
                                                                                                                                                                              g                                                                                                                                                                                                                                                                                                                                                        ur
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          g       n.a.
                                                                                                                                                                                  EU                                                                                                                                                                                                                                                                                                                                                                                                        5.8
                                                                                                                                                                        Es                                                                                                                                                                                                                                                                                                                                                                   EU                                                          7.3
                                                                                                                                                                             to                                                                                                                                                                                                                                                                                                                                                    Es                                                       5.7
                                                                                                                                                                               ni                                                                                                                                                                                                                                                                                                                                                       to
                                                                                                                                                                        I          a                                                                                                                                                                                                                                                                                                                                                         ni                                                                     8.3
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    I         a
                                                                                                                                                               S w r ela                                                                                                                                                                                                                                                                                                                                                   S w r ela                                                        5.7
                                                                                                                                                                    i t z nd                                                                                                                                                                                                                                                                                                                                                    i t z nd                                                                7.0
                                                                                                                                                                          er
                                                                                                                                                                             la                                                                                                                                                                                                                                                                                                                                                       er                                                5.2
                                                                                                                                                                                n                                                                                                                                                                                                                                                                                                                                                        la
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            n                                                      6.6
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              2008




                                                                                                                                                                        Gr d
                                                                                                                                                                            ee                                                                                                                                                                                                                                                                                                                                                      Gr d                                                5.2
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        ee
                                                                                                                                                                    Sl c e                                                                                                                                                                                                                                                                                                                                                      Sl c e                                             4.9
                                                                                                                                                               Ne ove                                                                                                                                                                                                                                                                                                                                                     N e ove                                                  4.8
                                                                                                                                                                  t h ni a                                                                                                                                                                                                                                                                                                                                                    t h ni a                                                      5.8
                                                                                                                                                                       er                                                                                                                                                                                                                                                                                                                                                          er
                                                                                                                                                                           la                                    Long-term care beds                                                                                                                                                                                                                                                                                                   la                                          4.8
                                                                                                                                                                              nd                                                                                                                                                                                                                                                                                                                                                          nd
                                                                                                                                                                                   s                                                                                                                                                                                                                                                                                                                                                          s                                         5.3
                                                                                                                                                                             It a                                                                                                                                                                                                                                                                                                                                                                                               4.3
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         It a
                                                                                                                                                                                  ly                                                                                                                                                                                                                                                                                                                                                                                                              6.3
                                                                                                                                                                                                                                         Countries ranked by declining order of hospital beds per 1 000 population




                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           3.8
                                                                                                                                                                        Cy                                                                                                                                                                                                                                                                                                                                                          C y ly
                                                                                                                                                                            p                                                                                                                                                                                                                                                                                                                                                           p
                                                                                                                                                                   De r us                                                                                                                                                                                                                                                                                                                                                     De r us                                                5.1
                                                                                                                                                                         nm                                                                                                                                                                                                                                                                                                                                                          nm                                    3.8
                                                                                                                                                                               a                                                                                                                                                                                                                                                                                                                                                           a                                      4.6
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   No r k
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          3.6
                                                                                                                                                                       No r k
                                                                                                                                                                            rw                                                                                                                                                                                                                                                                                                                                                          rw
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            4.0
                                                                                                                                                                                                                                                                                                                     3.6.2. Hospital beds by function of health care, 2008 (or nearest year available)




                                                                                                                                                          Un P ay                                                                                                                                                                                                                                                                                                                                                    Un P ay
                                                                                                                                                            i te or t                                                                                                                                                                                                                                                                                                                                                  i t e or t                                        3.5
                                                                                                                                                                             u                                                                                                                                                                                                                                                                                                                                              d            u
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     3.6.1. Hospital beds per 1 000 population, 1995 and 2008 (or nearest year available)




                                                                                                                                                                d                                                                                                                                                                                                                                                                                                                                                              K i gal                                      3.9
                                                                                                                                                                   K i gal
                                                                                                                                                                        ng                                                                                                                                                                                                                                                                                                                                                          ng                                   3.4
                                                                                                                                                                            do                                                                                                                                                                                                                                                                                                                                                          do
                                                                                                                                                                                 m                                                                                                                                                                                                                                                                                                                                                           m    n.a.
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       Sp                                3.4
                                                                                                                                                                                                                 Other hospital beds




                                                                                                                                                                           Sp
                                                                                                                                                                               ai                                                                                                                                                                                                                                                                                                                                                          ai                               3.9
                                                                                                                                                                                   n                                                                                                                                                                                                                                                                                                                                                 Tu n                                3.3
                                                                                                                                                                         Tu                                                                                                                                                                                                                                                                                                                                                              rk
                                                                                                                                                                             rk                                                                                                                                                                                                                                                                                                                                                              ey   n.a.
                                                                                                                                                                                 ey
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   2.3
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            3.6. HOSPITAL BEDS




87
                                              1 2 http://dx.doi.org/10.1787/888932336920
                                                                                                                                                                                                                                                                                                                                                                                                         1 2 http://dx.doi.org/10.1787/888932336901
3.7. HOSPITAL DISCHARGES


     Hospital discharges measure the number of peo-       overnight stays in hospitals to same-day procedures. In
ple who need to stay overnight in a hospital each year.   the group of countries where discharge rates have
Together with the average length of stay, they are        decreased over the past decade, the reduction can be
important indicators of hospital activities. Hospital     explained at least partly by a strong rise in the number
activities are affected by a number of factors, includ-   of day surgeries (see Indicator 3.10, for example, for
ing the demand for hospital services, the capacity of     evidence on the rise in day surgeries for cataracts).
hospitals to treat patients, the ability of the primary        Lithuania has the highest discharge rate for
care sector to prevent avoidable hospital admissions,     circulatory diseases, followed by Latvia, Bulgaria,
and the availability of post-acute care settings to       Germany and Austria (Figure 3.7.2). The high rates in
provide rehabilitative and long-term care services.       Lithuania, Latvia and Bulgaria are associated with
     In 2008, hospital discharge rates were the highest   high mortality rates from circulatory diseases, which
in Austria and France, although the high rate in France   may also be used as a proxy indicator for the occur-
is partly explained by the inclusion of some same-day     rence of these diseases (see Indicator 1.4). This is not
separations (Figure 3.7.1). Discharge rates were also     the case however for Germany and Austria, suggesting
high in Bulgaria, Germany and Romania. They were          that different clinical practices may play a role.
the lowest in Cyprus, Malta and Turkey.                        Austria and Germany have the highest discharge
     In general, countries that have a greater number     rates for cancer, followed by Hungary (Figure 3.7.3).
of hospital beds also tend to have higher discharge       While the high rate in Hungary is associated with a
rates. For example, the number of hospital beds per       high mortality rate from cancer (which may also be
capita in Austria and Germany is more than twice          used as a proxy for the occurrence of the disease; see
than Spain and the United Kingdom, and discharge          Indicator 1.5), this is not the case for Austria and
rates are also twice as large (see Indicator 3.6).        Germany. In Austria, the high rate is associated with a
     Trends in hospital discharge rates vary widely       high rate of hospital readmissions for further investi-
across European countries. In about one-third of          gation and treatment of cancer patients (European
EU countries (including Austria, Germany and Greece),     Commission, 2008a).
discharge rates have increased over the past ten years.
In a second group of countries (including Belgium,
France, Spain, Sweden and the United Kingdom), they
have remained stable, while in the third group (includ-               Definition and deviations
ing Denmark, Finland and Italy), discharge rates fell
                                                              Discharge is defined as the release of a patient
between 1998 and 2008.
                                                            who has stayed at least one night in hospital.
     Trends in hospital discharges may reflect several      It includes deaths in hospital following in-
factors that are not easily disentangled. Demand for        patient care. Same-day separations are usually
hospitalisation may grow as populations age, since          excluded, with the exception of France and the
older population groups account for a disproportion-        Slovak Republic which include some same-day
ately high percentage of hospital discharges in all         separations.
countries. For example, in Austria and Germany, 42% of
                                                              Healthy babies born in hospitals are excluded
all hospital discharges in 2008 were for people aged 65
                                                            completely (or almost completely) from hospital
and over, more than twice their share of the population
                                                            discharge rates in several countries (e.g. Austria,
(17% and 20% respectively). However, population
                                                            Cyprus, Estonia, Finland, Greece, Ireland, Latvia,
ageing alone may be a less important factor in explain-
                                                            Luxembourg, Malta, Norway, Spain, Sweden,
ing trends in hospitalisation rates than changes in
                                                            Turkey), resulting in an under-estimation of
medical technologies and clinical practices. A signifi-
                                                            3-6% of all discharges.
cant body of research shows that the diffusion of new
medical interventions gradually extends to older              Some countries do not cover all hospitals. For
population groups, as interventions become safer and        instance, data for Denmark, Ireland and the
more effective for people at older ages (e.g. Dormont       United Kingdom are restricted to public or
and Huber, 2006). The diffusion of new medical              publicly-funded hospitals only. Data for Portugal
technologies may also involve a reduction in hospitali-     relate only to public hospitals on the mainland.
sation if it entails a shift from procedures requiring




88                                                                          HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                        3.7. HOSPITAL DISCHARGES



                            3.7.1. Hospital discharges per 1 000 population, 2008 (or nearest year available)
Per 1 000 population
  300
         267 264

  250                  239
                             232 228
                                     222
                                              208 203
                                                      202
  200                                                                   191 189
                                                                                184
                                                                                                  178 175 173
                                                                                                              172 172 169
                                                                                                                          165 165 160 159
                                                                                                                                          155
  150                                                                                                                                                   140 136
                                                                                                                                                                133
                                                                                                                                                                                   120
                                                                                                                                                                                             113 109
                                                                                                                                                                                                     106
  100                                                                                                                                                                                                             95
                                                                                                                                                                                                                       75

   50


     0
                  Fr i a 1
                Bu c e 2




                Re v i a 1



                 Fi e 1
                Hu d 1


                          a1




                                                                                                                     P y1




                                                                                                                 m n1
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                                                                                                                 K i nd 1




                                                                                                                    Tu n 1
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                                                                                                                   Cy ta 1
                                                                                                                            us 1
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1. Excludes discharges of healthy babies born in hospital (between 3-6% of all discharges).
2. Includes same-day separations.
Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                              1 2 http://dx.doi.org/10.1787/888932336939


 3.7.2. Hospital discharges for circulatory diseases                                                                    3.7.3. Hospital discharges for cancers
per 1 000 population, 2008 (or nearest year available)                                                          per 1 000 population, 2008 (or nearest year available)
         Lithuania                                                                                         42                Austria                                                                                   29
             Latvia                                                                                   38                  Germany                                                                                 24
          Bulgaria                                                                               35                        Hungary                                                                           23
         Germany                                                                                 35                           Latvia                                                                    19
            Austria                                                                              34                          Poland                                                                    19
           Estonia                                                                           33                              France                                                                    19
  Slovak Republic                                                                           32                               Greece                                                                    19
          Hungary                                                                      31                          Slovak Republic                                                                 18
         Romania                                                                       31                                 Romania                                                                  18
   Czech Republic                                                                 29                                       Slovenia                                                               18
           Finland                                                                28                                        Finland                                                           17
            Greece                                                                28                                        Estonia                                                          17
           Sweden                                                            26                                           Lithuania                                                          17
            Poland                                                       26                                         Czech Republic                                                           17
           Norway                                                       25                                                  Norway                                                           17
                 EU                                                     24                                            Luxembourg                                                        16
     Luxembourg                                                    22                                                             EU                                                    15
            France                                                21                                                       Bulgaria                                                 15
               Italy                                              21                                                        Sweden                                                 14
          Belgium                                                 21                                                      Denmark                                             13
          Slovenia                                           19                                                             Iceland                                       13
         Denmark                                             19                                                                 Italy                                     12
      Switzerland                                       17                                                                 Belgium                                       12
      Netherlands                                  16                                                                  Switzerland                                  11
           Iceland                                 15                                                                  Netherlands                                 10
          Portugal                            14                                                                           Portugal                                10
              Spain                           14                                                                               Spain                           10
  United Kingdom                              13                                                                   United Kingdom                              9
            Ireland                        12                                                                                Ireland                       9
            Turkey                       11                                                                                  Turkey                 6
              Malta                  9                                                                                       Cyprus             5
            Cyprus                  9                                                                                          Malta        4

                        0                     15                               30               45                                      0                  10                                      20               30
                                                                              Per 1 000 population                                                                                                Per 1 000 population

Source: OECD Health Data 2010; Eurostat Statistics Database.                                                    Source: OECD Health Data 2010; Eurostat Statistics Database.
           1 2 http://dx.doi.org/10.1787/888932336958                                                                      1 2 http://dx.doi.org/10.1787/888932336977




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                             89
3.8. AVERAGE LENGTH OF STAY IN HOSPITALS


     The average length of stay in hospitals is often           Focusing on average length of stay for specific
regarded as an indicator of efficiency, since a shorter    diseases or conditions can remove some of the hetero-
stay may reduce the cost per discharge and shift care      geneity arising from different mix and severity
from in-patient to less expensive post-acute settings.     of conditions treated in hospitals across countries.
However, shorter stays tend to be more service inten-      Figure 3.8.3 shows that the average length of stay for a
sive and more costly per day. Too short a length of stay   normal delivery ranges from less than two days in Tur-
could also have adverse effects on health outcomes,        key and the United Kingdom, to over five days in the Slo-
or reduce the comfort and recovery of the patient.         vak Republic, Romania, Hungary and Switzerland. The
If this leads to a rising readmission rate, costs per      length of stay for a normal delivery has become shorter
episode of illness may fall little, or even rise.          in nearly all countries over the past decade, dropping
      In all European countries, the average length of     from five days in 1995 to less than four days in 2008 on
stay in hospitals has decreased over the past decade,      average in EU countries.
falling from 8.3 days in 2000 to 7.2 days in 2008 on            Lengths of stay following acute myocardial infarc-
average (Figure 3.8.1). Several factors explain this       tion (AMI, or heart attack) also declined over the
general decline, including the use of less invasive        past fifteen years. In 2008, it was the lowest in Turkey
surgical procedures, changes in hospital payment           and some Nordic countries (Norway, Denmark and
methods, and the expansion of early discharge              Sweden). At the other end of the scale, it was highest in
programmes enabling patients to return to their home       Germany, Lithuania, Finland and Estonia (Figure 3.8.2).
to receive follow-up care. The reduction in average        In this latter group of countries, long average length
length of stay was particularly marked in Switzerland      of stays may be due to the fact that some patients
(which had the highest length of stay in 2000),            originally admitted for AMI are no longer receiving
Bulgaria and the Netherlands. In Switzerland, the pro-     acute care, but nonetheless stay in hospitals for a
gressive move from bed-day payments to DRG-based           certain period to receive post-acute care.
payments has contributed to the reduction in average
length of stay in those cantons that have modified
their payment system (OECD and WHO, 2006).
     In 2008, the average length of stay in hospitals
was the lowest in Turkey, Malta, and in several Nordic                 Definition and deviations
countries (Norway, Denmark, Iceland, Sweden). It was
the highest in Finland, followed by Switzerland and            Average length of stay (ALOS) refers to the
Germany. The high average length of stay in Finland is       average number of days that patients spend in
due to a large proportion of beds allocated for conva-       hospital. It is generally measured by dividing the
lescent patients and long-term care (see Indicator 3.6).     total number of days stayed by all in-patients
Focusing only on stays in acute care units, the average      during a year by the number of admissions or
length of stay in Finland is not greater, indeed is even     discharges. Day cases are excluded.
lower than in most other European countries.




90                                                                            HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                            3.8. AVERAGE LENGTH OF STAY IN HOSPITALS



         3.8.1. Average length of stay in hospital for all causes, 2000 and 2008 (or nearest year available)

 Days                                                                                                                        2000                                                      2008
   14
          12.6

          13.7
         12.4




                                                                                                                                                                        11.8
   12
                  10.7
                 10.5




   10
                                        9.9
                         9.8




                                                                       9.3

                                                                                   9.3
                                                          8.9
                                 8.8




                                                                                               8.7
     8
                                              8.4




                                                                                                                                                                                               8.4
                                              8.4




                                                                                                                       8.3

                                                                                                                                   8.0
                                                    7.8




                                                                                                                                               7.7
                                                                7.7

                                                                             7.7

                                                                                         7.7




                                                                                                                                                           7.6
                                                                                                              7.5
                                                                                                     7.5

                                                                                                              7.5




                                                                                                                                                                                      7.3
                                                                                                             7.3

                                                                                                                             7.2




                                                                                                                                                                                                                                           7.1
                                                                                                                                                                  7.0
                                                                                                                                         7.0

                                                                                                                                                     7.0
     6




                                                                                                                                                                 6.8

                                                                                                                                                                 6.8

                                                                                                                                                                                   6.8


                                                                                                                                                                                6.4

                                                                                                                                                                                6.4
                                                                                                                                                                                6.4




                                                                                                                                                                                                                    6.3




                                                                                                                                                                                                                                                                  6.2
                                                                                                                                                                               6.2

                                                                                                                                                                               6.2




                                                                                                                                                                                                                   6.1
                                                                                                                                                                                                     6.1




                                                                                                                                                                                                                                                                                                  6.0
                                                                                                                                                                                                                 6.0




                                                                                                                                                                                                                                                                                      6.0
                                                                                                                                                                                                                 5.9

                                                                                                                                                                                                               5.7

                                                                                                                                                                                                               5.7

                                                                                                                                                                                                               5.6

                                                                                                                                                                                                                                                 5.6

                                                                                                                                                                                                                                                            5.4

                                                                                                                                                                                                                                                                        5.2
     4




                                                                                                                                                                                                                                                                                4.9

                                                                                                                                                                                                                                                                                            4.8

                                                                                                                                                                                                                                                                                                        4.3
     0
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Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                                                                  1 2 http://dx.doi.org/10.1787/888932336996


     3.8.2. Average length of stay following acute                                                                                                                                  3.8.3. Average length of stay
           myocardial infarction (AMI), 2008                                                                                                                                          for normal delivery, 2008
              (or nearest year available)                                                                                                                                            (or nearest year available)
         Germany                                                                                                                   10.9                           Slovak Republic                                                                                                             5.5
         Lithuania                                                                                                             10.8                                      Romania                                                                                                        5.3
           Finland                                                                                                    10.2                                                Hungary                                                                                                     5.2
           Estonia                                                                                                    10.1                                            Switzerland                                                                                                     5.2
            Greece                                                                                                10.0                                                      Cyprus                                                                                                5.0
             Latvia                                                                                               10.0                                             Czech Republic                                                                                             4.8
            Ireland                                                                                        9.0                                                              France                                                                                 4.4
  United Kingdom                                                                                       8.8                                                                  Poland                                                                                 4.4
         Romania                                                                                     8.6                                                                  Belgium                                                                                 4.3
              Spain                                                                            8.3                                                                        Bulgaria                                                                                4.3
          Portugal                                                                             8.2                                                                          Austria                                                                          4.2
      Switzerland                                                                          8.1                                                                       Luxembourg                                                                             4.1
                 EU                                                                      7.9                                                                                Greece                                                                         4.0
               Italy                                                                     7.9                                                                              Slovenia                                                                     3.9
          Belgium                                                                    7.8                                                                                     Latvia                                                                    3.9
          Slovenia                                                                   7.8                                                                                 Lithuania                                                                 3.8
            Cyprus                                                                   7.8                                                                                         EU                                                              3.7
            Austria                                                                7.6                                                                                         Italy                                                       3.5
              Malta                                                                7.6                                                                                     Finland                                                     3.4
           Iceland                                                     7.0                                                                                               Germany                                                      3.3
          Hungary                                                     6.9                                                                                                  Norway                                                    3.2
   Czech Republic                                                     6.8                                                                                                Denmark                                             2.8
     Luxembourg                                                  6.7                                                                                                      Portugal                                          2.7
      Netherlands                                                6.7                                                                                                          Spain                                        2.6
            Poland                                         6.4                                                                                                                Malta                                        2.6
            France                                        6.2                                                                                                              Sweden                                    2.3
  Slovak Republic                              5.6                                                                                                                          Ireland                              2.1
           Sweden                      4.8                                                                                                                            Netherlands                                2.1
         Denmark                     4.7                                                                                                                                   Iceland                             2.0
           Norway              4.3                                                                                                                                United Kingdom                           1.8
            Turkey             4.2                                                                                                                                          Turkey             1.4

                       4                        6                                   8                            10                    12                                               1                  2                     3                     4                      5                 6
                                                                                                                                     Days                                                                                                                                                    Days

Source: OECD Health Data 2010; Eurostat Statistics Database.                                                                                                     Source: OECD Health Data 2010; Eurostat Statistics Database.
           1 2 http://dx.doi.org/10.1787/888932337015                                                                                                                       1 2 http://dx.doi.org/10.1787/888932337034




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                                                                        91
3.9. CARDIAC PROCEDURES (CORONARY ANGIOPLASTY)


     Heart diseases are a leading cause of hospitalisa-      ischemic heart diseases; ii) differences in the capacity
tion and death in OECD countries (see Indicator 1.4).        to deliver and pay for these procedures; iii) differences
Coronary angioplasty is a revascularisation procedure        in clinical treatment guidelines and practices; and
that has revolutionised the treatment of ischemic            iv) coding and reporting practices.
heart diseases over the past twenty years. It involves            The large variations in the number of revascular-
the threading of a catheter with a balloon attached to       isation procedures across countries do not seem to be
the tip through the arterial system, usually started         closely related to the incidence of ischemic heart
in the femoral artery in the leg, into the diseased          disease (IHD), as measured by IHD mortality (see
coronary artery. The balloon is inflated to distend the      Figure 1.4.1). IHD mortality in Germany is lower than
coronary artery at the point of obstruction. The place-      the average across EU countries, but Germany has the
ment of a stent to keep the artery open accompanies          highest rate of revascularisation procedures. On the
the majority of angioplasties. Drug-eluting stents (a        other hand, IHD mortality in Finland is above the EU
stent that gradually releases drugs) are increasingly        average, while revascularisation rates are below
being used to stem the growth of scar-like tissue            average.
surrounding the stent.
                                                                  Coronary angioplasty is an expensive interven-
     There is considerable variation across European         tion, although it is much less costly than a coronary
countries in the us e of c oronary ang ioplasty              bypass because it is less intrusive. In 2007, the average
(Figure 3.9.1). Germany and Belgium have the highest         estimated price of an angioplasty was about EUR 6 000
rates of angioplasty in 2008, followed by Italy and          in France, EUR 8 000 in Sweden and EUR 8 600 in Italy.
Norway. In Belgium, the high rate of coronary                Nonetheless, the estimated price of an angioplasty in
angioplasty can only be partly attributed to patient         Italy remains 30% lower than in the United States
mobility. In 2006, only 2.5% of people who received an       (Koechlin et al., 2010).
angioplasty on an in-patient basis in Belgium were
non-residents (European Commission, 2008a).
The rate of use of angioplasty is the lowest in the
Netherlands and Switzerland, although these
two countries report only the main procedure (not                        Definition and deviations
all procedures), resulting in a significant under-               The data relate to in-patient procedures,
estimation (see box on definition).                            normally counting all procedures. However,
     The use of angioplasty has increased rapidly              classification systems and registration practices
since 1990 in most OECD countries, overtaking                  vary across countries, and the same procedure
coronary bypass surgery as the preferred method of             can be recorded differently (e.g. an angioplasty
revascularisation around the mid-1990s – about the             with the placement of a stent can be counted as
same time that the first published trials of the efficacy      one or two procedures). Some countries report
of coronary stenting began to appear (Moïse, 2003). In         only the main procedure (or the number of
most European countries, angioplasty now accounts              patients receiving one or more procedures),
for at least 70% of all revascularisations (Figure 3.9.2).     resulting in a significant under-estimation of
Although angioplasty has replaced in many cases                the total number. This is the case for the
bypass surgery, it is not a perfect substitute since           Netherlands and Switzerland. In Ireland, the
bypass surgery is still the preferred method for               data only include activities in publicly-funded
treating patients with multiple-vessel obstructions,           hospitals (it is estimated that over 10% of all
diabetes and other conditions (Taggart, 2009).                 hospital activity in Ireland is undertaken in
     A number of reasons can explain cross-country             private hospitals). For all countries, the data do
variations in the number of revascularisation proce-           not include coronary angioplasties performed
dures in general and angioplasty in particular, includ-        on an ambulatory basis.
ing: i) differences in the incidence and prevalence of




92                                                                              HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                              3.9. CARDIAC PROCEDURES (CORONARY ANGIOPLASTY)



                                             3.9.1. Coronary angioplasty per 100 000 population
                 2008 (or nearest year available)                                                                       Change 1998-2008 (or nearest year available)
                                                          140                       Netherlands                                            9.8

                                                          141                       Switzerland               n.a.

                                                          141                        Portugal                                                                    15.8

                                                         142                          Finland                                                           12.9

                                                         143                       Luxembourg                                  5.6

                                                         147                          Estonia                 n.a.

                                                    166                              Denmark                                                     10.9

                                                   169                                   Greece               n.a.

                                                   170                               Hungary                  n.a.

                                                   173                               Sweden                                                                        16.5

                                                  178                                    Ireland                                             10.6

                                                  185                                Slovenia                 n.a.

                                                 189                                     France                              4.8

                                            212                                          Poland                                                                                     24.4

                                           224                                             EU                                                       12.2

                                       232                                               Austria              n.a.

                                       235                                               Spain                                                          13.3

                                       236                                            Iceland                          3.6

                                      248                                         Czech Republic              n.a.

                                287                                                   Norway                                                              13.7

                     384                                                                  Italy                                                          13.4

               427                                                                   Belgium                                         8.7

 568                                                                                 Germany                  n.a.

600                 400                           200                         0                           0                          10                                 20                   30
Per 100 000 population                                                                                                                                           Average annual growth rate (%)

Note: Some of the variations across countries are due to different classification systems and recording practices.
Source: OECD Health Data 2010.
                                                                                                                     1 2 http://dx.doi.org/10.1787/888932337053


           3.9.2. Coronary angioplasty as a percentage of total revascularisation procedures, 1998-2008
                            Belgium                             France                                                               Denmark                                 Finland
                            Italy                               Netherlands                                                          Norway                                  Sweden
% of total revascularisation procedures                                                           % of total revascularisation procedures
   90                                                                                                90


   80                                                                                                80


   70                                                                                                70


   60                                                                                                60


   50                                                                                                50


   40                                                                                                40


   30                                                                                                30
        1998         2000           2002               2004       2006            2008                    1998               2000            2002                2004        2006          2008

Note: Revascularisation procedures include coronary bypass and angioplasty.
Source: OECD Health Data 2010.
                                                                                                                     1 2 http://dx.doi.org/10.1787/888932337072




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                  93
3.10. CATARACT SURGERIES


     In the past 20 years, the number of surgical pro-      thetists (Castoro et al., 2007), together with limitations
cedures carried out on a day care basis has steadily        in data coverage. In France, the share of cataract
grown in European countries. Advances in medical            surgeries carried out on a same-day basis has
technologies, particularly the diffusion of less inva-      increased rapidly over the past decade, from 23%
sive surgical interventions, and better anaesthetics        in 1998 to 70% in 2007, but it still remains below that
have made this development possible. These innova-          of many other European countries.
tions have improved effectiveness and patient safety.            In Sweden, there is evidence that cataract surger-
They also help to reduce the unit cost of interventions     ies are now being performed on patients suffering
by shortening the length of stay. However, the overall      from less severe vision problems compared to five or
impact on cost depends on the extent to which any           ten years ago. This raises the question of how the
greater use of these procedures may be offset by a          needs of these patients should be prioritised relative
reduction in unit cost, taking into account the cost of     to other patient populations (Swedish Association of
post-acute care and community health services.              Local Authorities and Regions and National Board of
    Cataract surgery provides a good example of a           Health and Welfare, 2008).
high volume surgery which is now carried out
predominantly on a day care basis in most European
countries. It has become the most frequent surgical
procedure in many European countries.                                   Definition and deviations
     The number of cataract surgeries per capita ranges
                                                                Cataract surgeries consist of removing the lens
from a low of about 200 surgeries per 100 000 population
                                                              of the eye because of the presence of cataracts
in Cyprus to a high of 1 848 per 100 000 population in
                                                              which are partially or completely clouding the
Belgium (Figure 3.10.1). Both demand factors (including
                                                              lens, and replacing it with an artificial lens. The
an older population structure) and supply factors (such
                                                              surgery may be carried out as day cases or as
as the capacity to perform the intervention in hospital
                                                              in-patient cases (involving an overnight stay in
and outside hospital) provide explanations for these
                                                              hospital). Same-day interventions may either be
cross-country variations. However, the comparability of
                                                              performed in a hospital or in a clinic. However,
data is also limited by registration procedures, parti-
                                                              the data for many countries (e.g. Ireland,
cularly the lack of registration of day surgeries carried
                                                              Hungary, Poland) only include interventions
outside hospitals in some countries, which explain the
                                                              carried out in hospitals. Caution is therefore
low rates in Ireland, Poland and Denmark. The very high
                                                              required in making cross-country comparisons
rate in countries such as Belgium may be explained
                                                              of available data, given the incomplete coverage
partly by the registration of more than one procedure
                                                              of day surgeries in several countries.
per surgery.
                                                                Denmark only includes cataract surgeries
     Cataract surgeries are now predominantly
                                                              carried out in public hospitals, excluding proce-
performed on a day care basis in many European
                                                              dures carried out in the ambulatory sector and
countries. Day surgery accounts for 90% or more of all
                                                              in private hospitals. In Ireland too, the data
cataract surgeries in about half of the countries for
                                                              cover only procedures in public hospitals (it is
which data are available, including in the Nordic
                                                              estimated that over 10% of all hospital activity
countries, the Netherlands, the United Kingdom and
                                                              in Ireland is undertaken in private hospitals).
Spain (Figure 3.10.2). However, the diffusion of day
                                                              The data for Spain only partially include the
surgery is still relatively low in some countries,
                                                              activities in private hospitals.
such as Cyprus, Lithuania, Poland and Hungary. In
Luxembourg, only 35% of all cataract surgeries were              Classification systems and registration prac-
carried out as day cases in 2007, a modest increase           tices for cataract surgeries vary across countries,
compared with the rate in the late 1990s. The small           for instance whether they are counted as one
share of day surgeries in these countries may be              intervention involving at least two steps (removal
explained by more advantageous reimbursement for              or the lens and replacement with an artificial
in-patient stays, national regulations, and obstacles to      lens) or as two separate interventions.
changing individual practices of surgeons and anaes-




94                                                                             HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                                                                                                     3.10. CATARACT SURGERIES



    3.10.1. Number of cataract surgeries, in-patient and day cases, per 100 000 population, 1998 and 2008
                                           (or nearest year available)
                                                    Day cases in 2008                                                    In-patient cases in 2008                                                        In-patient and day cases in 1998
Per 100 000 population
2 000
                1 848




 1 500

                            1 205
                                        1 141

 1 000                                              944
                                                              896        864
                                                                                        807        790        786        777            773     765
                                                                                                                                                              676             674        651
                                                                                                                                                                                                 563              475
  500                                                                                                                                                                                                                      450        421           410              393
                                                                                                                                                                                                                                                                                  351
          2.3




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Note: Some of the variations across countries are due to different classification systems and recording practices.
Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                                                              1 2 http://dx.doi.org/10.1787/888932337091


     3.10.2. Share of cataract surgeries carried out as day cases, 1998 and 2008 (or nearest year available)
                                                                                                                         1998                                                        2008
% of total cataract surgeries
 100
                                                                                         95


                                                                                                      95


                                                                                                                 94


                                                                                                                              93
                       99


                                  99




                                                    96
                                             98


                                                    97


                                                                   97


                                                                              97

                                                                                    87




                                                                                                                                         84


                                                                                                                                                     84
                                                              84




                                                                                                                                                                    80
                                                                                                            79




   80
                                                                         71




                                                                                                                                                                                71


                                                                                                                                                                                           70
                             67




                                                                                                                                                                                                        66
                                        65




                                                                                                                         65




                                                                                                                                                                                                                     63




   60



   40
                                                                                                                                                                                                                                35


                                                                                                                                                                                                                                             34
                                                                                                                                                                                                                           28
                                                                                                                                                                                      23
                                                                                                                                                                           21




                                                                                                                                                                                                                                                           20
                                                                                                                                                18




   20
                                                                                                                                                                                                                                                                        11


                                                                                                                                                                                                                                                                                     7
                                                                                                                                                                                                 n.a.
                n.a.




                                                                                               n.a.




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                                                                                                                                                                                                                                                    n.a.


                                                                                                                                                                                                                                                                 n.a.


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Source: OECD Health Data 2010; Eurostat Statistics Database.
                                                                                                                                                                              1 2 http://dx.doi.org/10.1787/888932337110




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                                                                                                   95
3.11. HIP AND KNEE REPLACEMENT


     Significant advancements in surgical treatment        growing number of people over 60 and 65 years with a
have provided effective options to reduce the pain and     greater risk of suffering from osteoarthritis (even if
disability associated with certain musculoskeletal         the age and sex specific rate does not increase); and
conditions. Joint replacement surgery (hip and knee        2) the growing prevalence of obesity, which is the
replacement) is considered the most effective inter-       main risk factor for osteoarthritis beyond age and sex
vention for severe osteoarthritis, reducing pain and       (European Commission, 2008b).
disability and restoring some patients to near normal           The number of hip and knee replacement has
function.                                                  increased rapidly over the past ten years in most
     Ostheoarthritis is one of the ten most disabling      European countries (Figures 3.11.3 and 3.11.4). On
diseases in developed countries. Worldwide estimates       average, the number of hip replacement increased
are that 9.6% of men and 18.0% of women aged over          by one-third between 1998 and 2008. The growth
60 years have symptomatic osteoarthritis, including        rate was even higher for knee replacement, which
moderate and severe forms (WHO, 2010a). Age is the         more than doubled during this ten-year period. For
strongest predictor of the development and progres-        example, in the United Kingdom, hip replacement rate
sion of osteoarthritis. It is more common in women,        increased by 40% since 2000, while knee replacement
increasing after the age of 50 especially in the hand      increased by 112%.
and knee. Other risk factors include obesity, physical          A hip or knee replacement is an expensive inter-
inactivity, smoking, excess alcohol and injuries           vention, although the cost varies across countries.
(European Commission, 2008b). While joint replace-         In 2007, the average estimated price of a knee replace-
ment surgery is mainly carried out among people            ment in France was EUR 10 600, about 20-25% more
aged 60 and over, it can also be performed among           than in Finland, Germany, Portugal and Sweden.
people at younger ages.                                    Nonetheless, the estimated price of a knee replace-
      There is considerable variation across countries     ment in France remained 15-20% lower than in the
in the rate of hip and knee replacement (Figures 3.11.1    United States (Koechlin et al., 2010).
and 3.11.2). Germany, Austria, Belgium, Norway and
Switzerland have the highest rates of hip replace-
ment. These countries are also amongst those that
have the highest rates of knee replacement. A number                   Definition and deviations
of reasons can explain these cross-country variations
                                                               Hip replacement is a surgical procedure in
in the rate of hip and knee replacement, including:
                                                             which the hip joint is replaced by a prosthetic
i) differences in the prevalence of osteoarthritis
                                                             implant. It is generally conducted to relieve
problems; ii) differences in the capacity to deliver and
                                                             arthritis pain or treat severe physical joint
pay for these expensive procedures; iii) differences in
                                                             damage following hip fracture.
clinical treatment guidelines and practices; and
iv) international mobility of patients across borders          Knee replacement is a surgical procedure to
(e.g. in Belgium, about 2% of knee replacement are           replace the weight-bearing surfaces of the knee
performed on people who are not residing in the              joint to relieve the pain and disability of osteo-
country; European Commission, 2008a).                        arthritis. It may be performed for other knee
                                                             diseases such as rheumatoid arthritis.
     There are too few comparable studies on the
prevalence of osteoarthritis in Europe to draw any             Classification systems and registration
conclusions on cross-country variations. Nor is there        practices vary across countries, which may
any evidence as to whether the age- and sex-specific         affect the comparability of the data. In Ireland,
incidence of osteoarthritis has changed in recent            the data only include activities in publicly-
decades. However, the number of people suffering             funded hospitals (it is estimated that over 10% of
from osteoarthritis has increased, and is expected to        all hospital activity in Ireland is undertaken in
continue to increase in the coming years, for two            private hospitals).
reasons: 1) population ageing, which is resulting in a




96                                                                           HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                                       3.11. HIP AND KNEE REPLACEMENT



               3.11.1. Hip replacement surgery,                                                                        3.11.2. Knee replacement surgery,
                 per 100 000 population, 2008                                                                             per 100 000 population, 2008
                  (or nearest year available)                                                                              (or nearest year available)
         Germany                                                                                   289              Germany                                                                     206
           Austria                                                                           243
                                                                                                                      Austria                                                             187
          Belgium                                                                        240
                                                                                                                      Finland                                                             184
          Norway                                                                       231
                                                                                                                  Switzerland                                                         179
      Switzerland                                                                      226
            France                                                                 220                               Belgium                                                        168

     Luxembourg                                                                    217                            Luxembourg                                                   155
          Sweden                                                                 207                        United Kingdom                                                    146
      Netherlands                                                                205
                                                                                                                  Netherlands                                          119
  United Kingdom                                                            195
                                                                                                                      Iceland                                          119
           Finland                                                          195
         Slovenia                                                          189                                        France                                          114

         Denmark                                                     174                                             Sweden                                          110

           Iceland                                               165                                                        EU                                       107
              Italy                                            154
                                                                                                                       Spain                                      106
                EU                                             153
                                                                                                                    Denmark                                       106
           Greece                                          140
                                                                                                                           Italy                                97
           Ireland                                       126
            Latvia                                 107                                                               Slovenia                              79

             Spain                            96                                                                       Latvia                         61
         Hungary                              96                                                                     Portugal                     54
           Estonia                           91
                                                                                                                     Hungary                     47
         Portugal                        85
                                                                                                                      Cyprus                     46
         Romania                 46
           Poland               39                                                                                    Ireland                    45

           Cyprus          15                                                                                        Romania           5

                      0                  100                           200             300                                         0                        100                       200             300
                                                                     Per 100 000 population                                                                                         Per 100 000 population

Source: OECD Health Data 2010; Eurostat Statistics Database.                                              Source: OECD Health Data 2010; Eurostat Statistics Database.
           1 2 http://dx.doi.org/10.1787/888932337129                                                                1 2 http://dx.doi.org/10.1787/888932337148


        3.11.3. Trend in hip replacement surgery,                                                                 3.11.4. Trend in knee replacement surgery,
         1998 to 2008 (or nearest year available),                                                                  1998 to 2008 (or nearest year available),
                    selected countries                                                                                        selected countries
                          Belgium                        Portugal                            Spain                                     Ireland                        Italy                      Netherlands
                          United Kingdom                               EU (14 countries)                                               Switzerland                                        EU (12 countries)
Per 100 000 population                                                                                    Per 100 000 population
  250                                                                                                       200




  200                                                                                                       150




  150                                                                                                       100




  100                                                                                                        50




   50                                                                                                         0
        1998          2000            2002                2004              2006                   2008             1998           2000               2002                  2004            2006         2008

Source: OECD Health Data 2010; Eurostat Statistics Database.                                              Source: OECD Health Data 2010; Eurostat Statistics Database.
           1 2 http://dx.doi.org/10.1787/888932337167                                                                1 2 http://dx.doi.org/10.1787/888932337186




HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010                                                                                                                                                                97
3.12. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER


     Cervical cancer is largely preventable. Screening        cancer mortality rates reflect the effect of care in past
by regular pelvic exam and pap smears can identify            years and changes in incidence. Mortality rates
premalignant lesions, which can be effectively treated        for cervical cancer are higher in eastern European
before the occurrence of the cancer. Regular screening        countries (Figure 3.12.3). Between 1998 and 2008 the
also increases the probability of diagnosing early            rates declined for most European countries, with
stages of the cancer and improving survival. Conse-           larger improvements for Iceland, Denmark, Slovenia,
quently, the Council of the European Union and the            the Czech Republic and Norway.
European Commission promote population based
cancer screening programmes among member states
(European Union, 2003; European Commission, 2008c)
and European countries have instituted screening
programmes with specific periodicity and target
                                                                         Definitions and deviations
groups. In addition, promising cancer preventing                  Screening rates for cervical cancer reflect the
vaccines have been developed based on the discovery             proportion of women who are eligible for a
that cervical cancer is caused by sexual transmission           screening test and actually receive the test. As
of certain forms of the Human Papilloma Virus. The              policies regarding screening periodicity differ
efficacy and safety of those vaccines is now well               across countries, the rates are based on each
established, but debates about cost-effectiveness               country’s specific policy. An important consider-
and the implications of vaccination programmes for              ation is that some countries ascertain screening
teenagers for a sexually transmitted disease continue           based on surveys and other based on encounter
in a number of countries (Huang, 2008).                         data, which may influence the results. If a
     Screening rates vary widely across countries with          country has an organised screening programme,
Austria, Norway, the United Kingdom and Sweden                  but women receive care outside the programme,
achieving coverage of around 80% of the target popula-          rates may be underreported. Survey-based
tion (Figure 3.12.1). Some countries with very low              results may also underestimate the rates due to
screening rates, like Turkey and Latvia, did not have           recall bias.
uniform national screening programme as of 2008;                  Relative cancer survival rates reflect the
the low rates reflect local programmes or opportu-              proportion of patients with a certain type of
nistic screening. Screening rates in several countries          cancer who are still alive after a specified time
declined slightly between 2000 and 2008.                        period (commonly five years) compared to those
     Relative survival rates are commonly used to track         still alive in absence of the disease. Relative
progress in treating cancer over time as they reflect           survival rates capture the excess mortality that
both how early the cancer was detected and the                  can be attributed to the diagnosis. For example,
effectiveness of the treatment provided. Survival rates         a relative survival rate of 80% does not mean
have been used to compare European countries in the             that 80% of the cancer patients are still alive
EUROCARE study, in comparisons between European                 after five years, but that 80% of the patients that
countries and the United States (Gatta et al., 2000), and       were expected to be alive after five years, given
in national reporting activities in many countries.             their age at diagnosis, are in fact still alive. All
Nearly all countries recorded five-year relative survival       the survival rates presented here have been age-
rates above 60% for the period 2002-07. The rates               standardised using the International Cancer
rang ed from 71% in Iceland to 50% in Poland                    Survival Standard (ICSS) population. The
(Figure 3.12.2). Over the periods 1997-2002 and 2002-07,        survival rates are not adjusted for tumor stage at
the five-year relative rates improved in most countries,        diagnosis, hampering assessment of the relative
although in all instances the increase is not statistically     impact of early detection and better treatment.
significant.                                                      The definition of cancer mortality rates is
    Mortality rates alone are not sufficient to draw            provided under Indicator 1.5.
timely inferences about quality of care, but current




98                                                                               HEALTH AT A GLANCE: EUROPE 2010 © OECD 2010
                                                                                                                                   3.12. SCREENING, SURVIVAL AND MORTALITY FOR CERVICAL CANCER



             3.12.1. Cervical cancer screening,                                                                                                              3.12.2. Cervical cancer five-year relative
        percentage of women screened aged 20-69,                                                                                                               survival rate, 1997-2002 and 2002-07
               2000 to 2008 (or nearest year)                                                                                                                            (or nearest period)
                                                       2000                      2004                              2008                                                                             1997-2002                        2002-07

          Austria 2                                                                                                  81.5
                                                                                                                                                                               71.0