Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions - Proposal for a Joint Report - Health care and care for the elderly: Supporting national strategies for ensuring a high level of social protection
Date: 2003-01-03
Institutions: European Commission
Subjects: care for the elderly, elderly person, health policy, population ageing, right to health, social security

COMMISSION OF THE EUROPEAN COMMUNITIES

Brussels, 3.1.2003
COM(2002) 774 final

COMMUNICATION FROM THE COMMISSION TO THE COUNCIL, THE
EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL
COMMITTEE AND THE COMMITTEE OF THE REGIONS

Proposal for a

JOINT REPORT

Health care and care for the elderly: Supporting national strategies for ensuring a high
level of social protection

COMMUNICATION FROM THE COMMISSION TO THE COUNCIL, THE
EUROPEAN PARLIAMENT, THE EUROPEAN ECONOMIC AND SOCIAL
COMMITTEE AND THE COMMITTEE OF THE REGIONS

Proposal for a

JOINT REPORT

Health care and care for the elderly: Supporting national strategies for ensuring a high
level of social protection

1.

INTRODUCTION

Social protection systems not only provide cash benefits to replace earned income in
the event of unemployment, sickness, invalidity or retirement, or for people without
sufficient resources. They also enable people to obtain appropriate medical and long-
term  care  services,  the  costs  of  which  often  exceed  the  financial  resources  of  a
patient and his or her family. A communication issued by the Commission in 1999
on  “A  Concerted  Strategy  for  Modernising  Social  Protection”1  consequently
identified  ensuring  high  quality  and  sustainable  health  care  as  one  of  the  key
issues for closer co-operation among the Member States.

This initiative was endorsed by the Lisbon European Council of March 2000, which
stressed that social protection systems need to be reformed, inter alia in order to be
able  to  continue  to  provide  quality  health  services.  In  June  2001,  the  Gothenburg
European Council, in its consideration of what is needed to meet the challenges of an
ageing  society,  asked  the  Council,  in  conformity  with  the  open  method  of  co-
ordination,  to  prepare  an  initial  report  for  the  Spring  2002  European  Council  on
orientations in the field of health care and care for the elderly. This report was based
on  a  Commission  Communication  of  December  20012  which  examined  the
demographic, technological and financial trends that may represent challenges to our
future  ability  to  maintain  high  levels  of  social  protection  in  this  field.  The
Communication  concluded  that  health  care  and  long-term  care  systems  in  the
European Union face the challenge of ensuring at the same time the three objectives
of:

– 
– 
– 

Access for all regardless of income or wealth.
A high level of quality of care.
Financial sustainability of care systems.

These three broad goals were endorsed by the Council in an initial orientation report
on health care and care for the elderly to the Barcelona European Council which also
stressed  that  all  health  systems  in  the  EU  are  based  on  the  principles  of  solidarity,
equity  and  universality.  The  Barcelona  European  Council  invited  the  Commission
and  the  Council  to  examine  more  thoroughly  the  questions  of  access,  quality

1

2

COM(1999) 347 final
COM(2001)  723  final:  The  future  of  health  care  and  care  for  the  elderly:  guaranteeing  accessibility,
quality and financial viability.

2

                                                
and financial sustainability. For this purpose, a questionnaire was submitted to the
Member  States.  This  report  draws  the  main  conclusions  from  the  analysis  of  the
Member  States’  responses  and  proposes  future  steps.  A  more  detailed  synthesis  of
the  national  replies  to  the  questionnaire  will  be  presented  in  a  Commission  staff
working paper.

2.

COMMON CHALLENGES AND ISSUES

Our future  ability  to maintain  a high level of  social  protection  for  those  in  need  of
health and long-term care is influenced by societal and technological developments
and  will,  in  the  future,  be  particularly  driven  by  population  ageing.  These
developments were identified in the Communication of December 2001.

(1) 

New technologies and treatments

New  technologies,  treatments  and  techniques  offer  enormous  opportunities  for
improving  and  expanding  health  care.  However,  integrating  new  technologies  and
treatments into health care systems nonetheless poses an important challenge. On the
one  hand,  they  can  reduce  the  costs  of  treating  certain  diseases,  but  they  can  also
raise  expenditure  if  they  allow  the  treatment  of  conditions  not  previously  possible.
Progress in medical technologies and treatments appears to have been a major driver
of rising  costs over  the past decades.  It  is impossible  to predict  what the  aggregate
impact of technological  progress  on future health care expenditure will be.  A more
systematic  assessment  of  health  interventions,  treatments  and  technologies  could
help  improve  decision  making,  inter  alia  to  ensure  that  increased  expenditure  goes
only  to  genuine  technological  advances  and  that  opportunities  for  savings  are  not
missed.  Such  assessment  is  crucial  for  the  three  goals  of  access,  quality  and
sustainability.

(2) 

Improved well-being and patient information

The  cost  of  providing  health  and  long-term  care  tends  to  rise  as  individuals  and
society becomes richer. The reasons behind this are not very clear and are likely to
include  a  mix  of  demand  and  supply-side  factors.  One  aspect  of  this  reflects  the
positive development that people are better educated and have more direct access to
information  about  medical  treatments  and  the  quality  of  care.  As  a  result,  they
become  more  demanding  vis-à-vis  professional  care  providers  and  institutions  that
finance  access  to  care.  Under  current  approaches  to  the  provision  of  health  care,
increased consumer awareness is likely to continue to be a factor that increases costs
in the future.

It also seems clear that the future demand  for long-term care will increase due to a
combination  of  economic  and  social  factors.  The  increased  labour  market
participation  of  women;  higher  levels  of  geographical  mobility;  a  lower  ratio  of
working age people to frail elderly and changes in family structure such  as  divorce
may limit the extent to which traditional in-family care is possible.

3

(3) 

Demographic ageing

The fact that greater numbers of people are living longer is a huge achievement for
our societies and our health systems. Life expectancy has risen much in the last fifty
years, and will continue to do so also in the coming decades. However, demographic
changes will also pose new challenges for our health and long-term care systems.

As a result of low birth rates and increasing life expectancy, Europe's population has
been ageing progressively. In addition, large cohorts born in the 1950s and 60s will
reach old age in the next 10 to 15 years. Thus the number of elderly people will rise
sharply over the coming decades. One projection is that the number of people aged
65 and over in EU15 will increase from 61 millions in 2000 to some 103 millions in
2050. The number of those aged 80 and over is projected to increase from almost 14
millions  in  2000  to  some  38  millions  in  2050.  At  the  same  time  the  working  age
population is projected to decrease significantly. (See annex 1, graphs 1a, 1b and 1c).
These projections by Eurostat are based on specific assumptions, concerning e.g. the
fertility rate. There are alternative projections, using different assumptions, and thus
yielding different sizes of for instance the working age population groups.

In  terms  of  the  impact  on  health  and  long-term  care  systems,  the  main  effect  of
demographic ageing will be related to the increase in the numbers of elderly persons
demanding  care  in  the  coming  decades.  This  is  because  in  general  elderly  persons
require  more  health  care  than  prime  age  individuals  due  to  a  higher  incidence  of
severe  illness.  The  age  profiles  of  public  expenditure  on  health  and  long-term  care
show  that  spending  is  significantly  higher  for  the  older  than  for  the  younger  age
groups  (see  graphs  2a  and  2b).  Health-care  systems  will  also  have  to  adapt  to  the
different pattern of illness linked to the change in the age-profile of patients – age-
related  diseases  are  likely  to  become  more  prevalent.  For  long-term  care,  the
demands of the elderly for care, i.e. help in performing the tasks of daily living, are
often  more  related  to  disability  or  the  frailty  characteristic  of  old  age,  than  to
morbidity.

For health care, however, the scale of this increased demand is likely to be mitigated
by improvements in the health status of elderly persons, in continuation of the trend
which has accompanied increases in life expectancy in recent decades. Some theories
suggest  that  this  is  because  severe  illness  requiring  intensive  health  interventions
only tends to affect persons at the end of their lives, and as lives are being extended,
this  need  for  intensive  health  is  also  postponed.  For  long-term  care,  there  are  also
grounds  for  optimism:  in  countries  where  data  is  available,  such  as  the  US,  it
suggests that disability rates among elderly people are declining over time, although
this  is  not  necessarily  related  to  a  lengthening  of  life  spans.  On  the  other  hand,
irrespective of increases in life expectancy, very old persons tend to  be frail and in
need of long-term care.

Ageing  will also  lead  to  a  need  for  health  and  social  services  to  adapt  to  changing
patterns of illness (rise in chronic diseases) and client structures. Systems should also
give  a  new  importance  to  the  objective  of  enabling  older  people  to  live  active,
healthy  and  independent  lives  further  into  old  age.  An  emphasis  on  preventive
strategies  including  healthier  nutrition  and  physical  and  mental  activity  is  needed,
starting with the lifestyles of the young and the middle-aged.

4

Coping with these challenges: policy responsibilities

The  organisation  and  funding  of  health  care  systems  remains  a  matter  of  national
competence and it will be a task for the  Member  States  to  adapt  their  very  diverse
systems  to  the  common  challenges  identified  above.  However,  several  other
Community policies have a bearing on national social protection systems for health
and long-term care:

– 

– 

– 

National  policies  have  to  comply  with  the  rules  of  the  Internal  Market,
including competition rules and the principles of free movement of persons, of
goods  and  of  services.  The  jurisprudence  of  the  European  Court  of  Justice3,
acknowledges  the  responsibility  of  Member  States  for  organising  their  social
protection systems, but any restrictions to the freedoms of the Internal Market
must  be  duly  justified4.  A  high-level  reflection  group  is  currently  being
established  to  examine  the  issues  arising  from  increased  patient  mobility  and
greater interaction between health systems.

In accordance with Article 152 of the Treaty on Public Health, the EU seeks
to ensure a high level of human health. The Commission communication on the
“health strategy of the European Community”5 emphasised that health services
must meet the population’s needs and  concerns, in a  context characterised  by
the challenge of ageing and the growth of new medical techniques, as well as
the  more  international  dimension  of  health  care  (contagious  diseases,
environmental health, increased mobility of persons, services and goods).

The EU also monitors the long-term  sustainability  of public finances. Since
health  care  accounts  for  a  large  proportion  of  public  spending,  this  sector  is
vital  for  the  implementation  of  the  recommendations  laid  down  in  the  Broad
Economic Policy Guidelines and the Stability and Convergence Programmes.

Thus at present, the three goals of access, quality and sustainability are considered as
aspects in the above policy areas in a rather  fragmented way  at EU level. From the
point of view of the co-operative exchange on the modernisation of social protection
it is important to look at them in an integrated way. Access to care services of poor
quality  is  not  desirable;  access  without  financial  sustainability  is  not  feasible;  and
ensuring  that  only  treatments  of  proven  quality  receive  public  funding  is  an
important way of securing financial sustainability.

3.

MEMBER STATES' POLICY RESPONSES TO THE COMMON CHALLENGES

In  response  to  the  conclusions  of  the  Barcelona  European  Council,  the  Social
Protection  Committee,  in  co-operation  with  the  Economic  Policy  Committee,
submitted a questionnaire to the Member States with a view to gathering information
on the ways in which the three objectives identified in the orientation report – access,
quality and sustainability – are addressed by Member States.

3

4

5

Judgements of 7 February 1984, Duphar and others C-238/82, ECR p 523, point 16; of 17 June 1997,
Sodemare and others C-70/95, ECR p.I-3395, point 27; and of 28  April  1998,  Kohll,  C-158/96,  ECR
p.I-1931 point 17
Cases C-157/99 (Smits/Peerbooms) and C-368/98 (Vanbraeckel)
COM(2000) 285 final

5

                                                
This section synthesises the main issues and policy approaches that can be identified
in the Member States' replies to the questionnaire. A more detailed analysis will be
presented in a separate Commission staff working paper.

3.1.

Access to health care

Mechanisms for guaranteeing access

All  Member  States  offer  universal,  or  almost  universal,  rights  to  health  care  for
persons residing in their territory. Member States fall into two broad groups in terms
of how systems are funded and in terms of how people become entitled to healthcare.
One group of systems is financed through tax revenues, with entitlement based either
on  citizenship  or  residence  criteria.  A  second  group  can  trace  their  origins  to
occupational  health  insurance  systems  for  employees  and  their  families,  where  the
primary method of financing is via social insurance contributions levied on earnings.
In practice, the difference between the two approaches has become less significant as
the  employment-based  systems  have  often  been  gradually  extended  to  cover  the
whole  population,  and  with  insurance  contributions  playing  a  reduced  role  for
funding in favour of tax revenue.

The  essentially  universal  rights  to  health  care  across  the  EU  means  that  the  vast
majority  of  the  population  is  covered;  the  extent  of  coverage  varies.  Where  the
system is based on labour market participation there can, for example, be a difference
in the way that systems treat different occupational groups, e.g. between employees
and  the  self-employed;  however,  these  differences  are  being  reduced.  More
fundamentally,  all  systems  limit  the  extent  to  which  they  cover  the  full  cost  of
treatments  or  in  their  coverage  of  different  types  of  treatment.  Thus,  the  share  of
overall health expenditure borne by households amounts to some 20 – 30 % in most
Member States.

As a result of rising health costs, Member States have tended to increase the level of
costs borne by patients,  either  directly  through  introducing  charges  or  co-payments
for services, or indirectly through reducing the range of services covered. Thus, some
countries  have  established  a  list  of  eligible  treatments  and  fixed  the  terms  of  fees
and/or  reimbursements.  Others  define  eligibility  criteria  according  to  the  "basic"
levels of health care needed, or they leave it to the patient to pay for the care required
with  subsequent  reimbursement.  In  several  countries  patients  are  charged  a  fixed
amount  for  various  health  services,  while  in  other  countries  they  must  pay  any
difference between the price of a service or product and the corresponding fixed or
variable  rate  of  reimbursement.  The  rates  of  reimbursement  may  vary  according  to
type of service (list of eligible services), or according to purchaser (e.g. income level,
annual  health  expenditure,  and  age).  Complementary  private  insurance  may  cover
such  contributions.  The  role  of  co-payments  in  the  context  of  the  sustainability  of
systems is addressed further in section 3.5.

The  fact  that  systems  demand  some  financial  participation  creates  the  risk  that
vulnerable groups may not be able to afford such charges and may thus not be able or
willing to access appropriate healthcare. The issue was discussed in the Joint Report
on  Social  Inclusion  agreed  at  Laeken  in  December  2001  and  features  again  as  a
fundamental policy concern in the replies of several Member States who tend to have
provisions  which  ensure  that  people  facing  particularly  high  health  costs  will  have

6

their total contribution capped or that people on low incomes will pay a lower share
of the treatment cost.

Thus all Member States in one form or another refer to the solidarity features of their
systems which aim both to ensure that poor health does not lead to impoverishment
and  that  low  income  does  not  diminish  people's  access  to  healthcare.  There  is  also
acknowledgement of a further dimension to health inequalities in the clear evidence
that people in vulnerable groups are likely to lead less healthy lifestyles.

Some countries target elderly people as a group at risk of not sufficiently accessing
health  care  and  preventive  care.  This  can  take  the  form  of  specific  provisions  to
ensure that healthcare does not become unaffordable or measures to ensure that older
people take up medical services in a way which reflects their need for such services.
Some countries encourage regular housecalls to older people by health professionals.
This aspect is of particular relevance for ensuring a good co-ordination of health care
and long-term care for the elderly.

The national replies say little about some other potential dimensions of inequality in
access,  such  as  regional  inequalities.  In  response  to  the  question  whether  access  to
new treatments gives rise to inequalities, they report no particular inequalities, while
acknowledging  that  managing  access  to  such  treatments  does  pose  an  important,
ongoing  and,  in  the  light  of  the  rapid  pace  of  technological  development,  ever-
increasing management challenge in the context of controlling costs.

Systems for monitoring and evaluation

Several  Member  States  have  established  or  proposed  various  indicators  to  monitor
access. Such indicators may be based on measures of supply, e.g. number of nights
spent  in  hospital;  numbers  of  particular  interventions;  rehabilitation  by  population
categories. These  are  aimed at  measuring efficiency, delivery or  performance  gaps.
There  are  waiting  lists  for  various  treatments  in  many  countries,  but  their  extent
differs considerably depending on the system. Countries with insurance-based health
care seem to have fewer problems with waiting lists.

Challenges

The  demographic  and  epidemiological  trends  represent  major  challenges  to  the
existing  health  care  systems.  Systems  need  to  be  continuously  adapted  in  order  to
respond to the envisaged demand for care  and to take account of technological and
medical progress. Other important challenges are:

– 

– 

– 

– 

review  the  range  of  new  treatments  and  medicines  provided  or
reimbursed;

shorten waiting times for non-acute hospital care;

establish more  and new types of  health care  services which  cater to  the
particular  patterns  of  illness  linked  to  ageing,  and  which  could  help  to
maintain the independence of the elderly;

develop  preventive  strategies  aimed  at  enabling  older  people  to  live
active, healthy and independent lives further into old age;

7

– 

ensure  the  availability  of  sufficient  and  appropriately  trained  medical
staff.

Planned policy changes

Member States outline the following priorities:

– 

– 

– 

– 

Improve  access  for  certain  categories  of  the  population  (self  employed,
elderly, people on low income);

Improve the speed of access (reduce waiting times);

Address  distribution  of  appropriate  health  care  services  across  the
country (urban/rural areas, prosperous/poor regions).

Improve  the  recruitment  and  training  of  qualified  staff  (physicians,
nurses  and  other  staff)  in  view  of  the  ageing  of  existing  staff,  difficult
working conditions and emerging staff shortages.

In  relation  to  the  particular  health  needs  of  older  people  the  following  issues  are
cited:

– 

– 

The  need  to  provide  alternative  geriatric  or  post-acute  facilities  for
rehabilitation outside hospitals in order to free up space in hospitals and
to enable active and independent living for the elderly as far as possible.

The  establishment  or  re-activation  of  local  health  centres  in  order  to
facilitate  access  to  care  and,  through  a  multidisciplinary  approach,  to
appropriate treatment.

In general, Member States  acknowledge that the ageing of the population will pose
new  problems  and  challenges  if  they  are  to  maintain  the  type  of  general  and
comprehensive  forms  of  access  to  healthcare  to  which  citizens  have  become
accustomed.  Nevertheless,  several  Member  States  express  a  determination  that  this
very basic objective of systems should be maintained, even in the face of increasing
costs,  while  others  refer  to  the  fact  that  they  are  proposing  further  refinements  and
improvements to their access mechanisms. Thus Member States are likely in future
to  have  to  place  a  greater  emphasis  on  policies  to  increase  cost-efficiency  and
effectiveness as discussed in section 3.5.

3.2.

Access to long term care

Unlike  health  care,  the  need  for  long-term  care  is  only  now  being  recognised  as  a
major  social  risk  that  needs  to  be  covered  by  social  protection  systems.  Long-term
care consists  of  assistance to persons who are unable  to live autonomously and  are
therefore  dependent  on  the  help  of  others  in  their  everyday  lives.  Their  needs  for
assistance can range from facilitating mobility, shopping, preparing meals and other
household tasks to washing  and  feeding  in  the  most  extreme  cases.  Providing  such
long-term  care  does  not  necessarily  require  medical  skills.  This  type  of  care  is
therefore often left to relatives, usually spouses and descendants who continue to be
the main providers of long-term care.

8

For reasons presented in section 2(2)  above,  relatives  can  no  longer  be expected to
provide care to the same extent as they used to. An increasing number of frail elderly
people therefore depend on professional carers who may deliver their care services in
the  dependent  person's  home  or  in  specialised  institutions.  The  cost  of  long-term
care, just like medical care, very often exceeds the current  income  of  the  person in
need of care and may rapidly consume any wealth of this person. Thus the need for
long-term care is a major social risk and there is clearly a need for social protection
mechanisms.

Such social protection mechanisms take very different forms in the Member States.
In  some  countries,  families  remain  responsible  for  providing  care  or  financing  it.
Public  support,  in  the  form  of  social  assistance,  through  social  services  or  a
placement  in  a  care  institution  will  only  be  available  if  there  is  no  such  family
support. After the death of the dependent person the cost of publicly supported care
may be recouped from the estate of the deceased person. This is the most basic form
of  social  protection,  which  requires  families  to  bear  most  of  the  risk  of  long-term
care  and  only  intervenes  if  families  are  no  longer  able  to  provide  care.  In  other
countries,  no  legal  obligations  for  descendants  vis-à-vis  their  elderly  parents  exist,
but the risk may still be borne mainly by individuals who have to pay for their care
needs from their income and wealth.

More and more countries are moving towards a broader sharing of risks. This can be
achieved  through  the  direct  provision  of  care  services  at  home  or  in  institutions  or
through insurance mechanisms. Such public provision is usually the responsibility of
local  authorities,  often  in  partnership  with  non-profit  organisations.  The  alternative
approach to risk sharing is an insurance system. In some cases, long-term care needs
are  covered  by  statutory  health  insurance  schemes;  some  countries  recently
introduced  long-term  care  insurance  as  a  new  branch  of  their  social  protection
system.  The  financing  of  direct  provision  of  care  services  is  typically  through
taxation,  whereas  insurance-based  systems  tend  to  be  financed  through  social
insurance  contributions.  However,  at  least  one  country  uses  inheritance  taxes  as  a
source of funding; this appears justified insofar as mutualising the cost of long-term
care  also  avoids  descendants  having  to  forego  a  significant  proportion  of  their
inheritance.

Long-term  care  can  be  provided  in  different  ways.  Apart  from  family  support,
professional care can be delivered at home, in day-care centres, in special long-term
care institutions or in hospitals. Social protection mechanisms will affect the way of
providing  care.  If  more  support  is  available  for  long-term  care  institutions  than  for
care at home, then it is likely that more people will live in institutions.

Some Member States have tried to make their social protection mechanisms neutral
with regard to the way in which care is provided. This requires in particular offering
support for informal carers. People in need of care can be given the choice between
benefits in kind or a cash grant that can be used for family carers. Informal care may
insurance
also  be  encouraged 
entitlements for care givers, training, a right to leave from one's employment to care
for a relative, the provision of substitute carers during rest periods for the care giver
and the provision of day-care centres so  that carers can be relieved. The  rights  and
duties  of  informal  carers  may  even  be  defined  in  contracts.  Support  for  informal
carers has the advantage of being cost-effective (the allowances paid to informal care
givers are typically lower than the cost of professional carers) and of allowing care to

tax  advantages,  pension  and  social 

through 

9

be provided by a trusted and familiar care giver. Moreover, the dependent person can
stay at home.

All  countries  have  an  infrastructure  for  professional  long-term  care,  but  the
importance  of  such  institutions  varies  depending  on  the  role  of  families,  on  social
protection  mechanisms  and  on  the  supply  of  care  services  and  facilities.  A  lack  of
facilities  and  services  can  lead  to  dependent  persons  having  to  remain  longer  in
hospitals or in the care of relatives.

Challenges

Social protection mechanisms to guarantee access to long-term care are fairly new in
many  Member  States  and  have  yet  to  be  developed  beyond  social  assistance
mechanisms  in  others.  As  demand  for  long-term  care  increases,  there  may  be
shortages of professional staff.

Staff shortages may also explain to some extent the lack of capacity in institutional
long-term  care,  which  leads  to  elderly  people  occupying  beds  for  acute  care  in
hospitals  for  longer  than  necessary.  Institutional  care  is  particularly  important  for
people suffering from Alzheimer's disease and other forms of dementia who require
intensive care and continuous supervision.

Another  challenge  is  the  need  to  co-ordinate  different  care  providers.  Dependent
people  usually  need  a  range  of  medical  and  non-medical  support,  which  requires  a
good co-operation between families, professional carers and medical staff. It may be
useful  to  define  a  co-ordinator  that  could  also  have  overall  responsibility  for
managing the costs of different types of care.

Planned policy changes

For  several  Member  States  the  main  priority  is  to  implement  the  major  policy
changes  that  have  been  introduced  recently.  Others  plan  new  measures,  notably  to
provide better support for care at home. Some countries are planning new structures
aimed  at  providing  integrated  and  continuous  care.  This  involves  addressing  the
complex needs for health care and social support of people who lost their autonomy
or from chronic diseases.

3.3.

Quality - Health care

Ensuring quality in the organisation and delivery of health care and long-term care is
identified as a key policy concern of all Member States.

It seems useful to distinguish between different contexts in which quality criteria are
introduced. First, there are structural quality criteria, which refer to the way a service
is staffed and equipped, and to the cases it treats. Process quality criteria apply to the
operation  of  the  service  and  how  specific  interventions  are  performed.  Finally,
outcome  criteria  seek  to  measure  service  quality  by  looking  at  the  outcome  of
specific interventions – for example at long-term survival rates or complications.

In almost all Member States, structural quality criteria have been developed for the
in-patient  sector,  e.g.  for  hospitals.  These  cover,  for  example,  staff  (staffing  levels,
training and experience), equipment, number of cases, building standards, etc. These
standards  are  usually  binding  and  are  set  by  public  bodies  or  the  social  insurance

10

providers. In the out-patient sector, however, setting structural standards seems to be
more  difficult.  Generally,  they  cover  only  basic  requirements,  e.g.  formal  training
requirements for medical staff.

The  situation  for  process  quality  criteria  is  more  diverse.  While  many  health
professionals  would  regard  following  standards  and  guidelines  set  by  medical
associations and other formal bodies as standard practice, the development of formal
guidelines  for  treatments  and  procedures  as  a  matter  of  policy  is  lagging  behind.
However,  Member  States  are  putting  considerable  effort  into  this  area  and  are
making important progress, mostly as regards in-patient care.

In this area, the degree of formality with which standards are applied differs widely.
Often, central governments, such as in Denmark or Sweden, set a legal framework or
issue recommendations  to  be used to  develop  more  specific  guidelines  at  local  and
regional  level,  by  health  and  social  insurance  institutions,  medical  associations  or
other bodies.

Some  guidelines  and  standards  are  introduced  on  a  voluntary  basis,  through  pilot
projects, general recommendations, or using financial incentives. In general, national
health systems, such  as in  the  UK,  can  introduce  more  binding  standards  using  the
central  regulatory  instruments  at  their  disposal  and  can  apply  sanctions  to  ensure
compliance. It is clear that the application of quality standards in clinical practice is
the crucial element of a quality policy in health care. This has been pursued in many
Member  States.  Monitoring  of  process  quality  in  Member  States  in  a  comparable
way would require the output of the health care system to be systematically described
by  medical  procedures  performed  and  diseases  treated,  and  it  would  require  these
disease-procedure combinations to be linked to respective quality assessment efforts.
Efforts in this direction are not yet very advanced currently.

A  systematic  approach  to  evaluating  health  outcomes  as  part  of  the  quality  agenda
can only be found in some Member States. While health outcomes may in principle
be a good way to measure the quality of interventions, there are a number of practical
difficulties  involved.  They  include  scant  or  unreliable  data,  and  the  political
difficulties  of  involving  the  government  in  an  area  that  is  regarded  as  a  core
competence of medical professions. For example, only a few countries, such as the
UK, are running ranking systems of hospitals by quality of service rendered.

The  growing  interest  in  quality  issues  has  lead  Member  States  to  create  specific
institutions  or  bodies  in  charge  of  promoting  quality  work,  running  assessments,
developing  guidelines  or  accreditation  systems.  Central  bodies  now  exist  in  almost
all Member States.

Often,  the  central  government  can  create  only  framework  legislation,  which  must
then  be  implemented  at  regional  or  local  level.  One  noteworthy  trend  in  Member
States’ responses is the focus on the role of patients.  In nearly all countries, efforts
have  been  made  to  introduce  measures  to  safeguard  the  rights  of  patients,  in
particular  in  the  hospital  sector.  Empowering  patients  to  take  informed  decisions,
providing  adequate  information  and  transparency  about  health  services,  treatment
options  and  access  to  medical  records  are  important  aspects  in  this  context.  For
example, there are now specific patients’ rights laws in Austria, Finland, Denmark.

11

Finally, it is essential to understand how access and quality considerations are linked.
Deficiencies  and  inequalities  in  access  to  health  services  are  also  an  important
quality issue, and it is crucial to take access and equity considerations into account
when  developing  quality  standards.  Addressing  these  challenges  requires  actions
across different policy areas.

3.4.

Quality - Long term care

Most  Member  States  have  national  quality  standards  for  the  care  of  the  elderly.
However,  there  are  differences  in  terms  of  whether  these  are  legally  binding,  or
merely  recommendations.  Moreover,  it  can  be  deduced  from  a  number  of  the
responses  to  the  questionnaire  that,  compared  to  health  care,  the  long-term  care
sector operates in a very decentralised way, and regional and local authorities have a
large  degree  of  discretion  in  the  standards  they  apply.  It  is  interesting  to  note,
however,  that  the  UK  has  taken  back  this  responsibility  to  the  national  level  by
establishing an independent national body, the National Care Standards Commission
(NCSC) to regulate social care and independent health care services. The aim of this
new  arrangement  is  to  increase  the  quality  of  services  and  improve  the  level  of
protection  for  vulnerable  groups  while  safeguarding  and  maintaining  good  quality
homes for the elderly.

There seem to be difficulties related to decentralisation in several Member States; for
example,  programmes  are  poorly  targeted,  with  uneven  monitoring  and  lack  of
quality enhancing initiatives.

For  institutional  care,  most  Member  States  have  set  structural  quality  criteria,  for
instance on staff qualifications and building standards. In Belgium and Germany, for
example,  respecting  these  standards  is  a  condition  for  reimbursement  by  the  social
insurance system.

Some  countries,  such  as  France,  have  also  developed  process  quality  criteria  for
institutions. This quality approach to residential care includes specific quality targets
and the establishment of a “facility strategy” with reference to specifications that set
objectives for the main quality criteria.

Other countries, such as Italy, refer to the lack of standardised systems to guarantee
minimum levels of care as a basic challenge for the system of long-term care.

Most  Member  States  indicated  in  their  responses  that  there  is  a  lack  of  standard
setting  in  relation  to  home  care.  Some  quality  standards  pilot  schemes  were
conducted  in  Belgium,  while  in  Denmark,  a  system  of  local  quality  assurance  has
been introduced.  France has established  a “Home  Service  Standard”  which  aims  to
ensure quality services. It is also about to establish an external organisation to ensure
compliance with these standards. In terms of training of informal caregivers, Austria
has  legislation  regarding  training  of  care  providers  to  the  elderly,  include  home-
helpers.

At  the  same  time,  demand  for  home  care  has  increased  due  to  demographic
developments  and  as  the  issue  has  increasingly  been  covered  by  social  security
systems. As mentioned earlier, in Greece, care for the elderly is considered a family
matter. However, as family structures are changing, Greece is giving attention to the
development of Home Care Programs.

12

Most Member States state that recipients’ rights are covered in the quality criteria or
the protection of patients rights, while in some case there are specific acts aiming at
the promotion of users/clients rights.

A number of Member States, including Finland, the UK and Sweden, have identified
staff  shortages,  high  turnover  and  increasing  work  pressure  as  particular  areas  of
concern  in  this  sector.  Several  countries  state  that  the  demographic  changes
occurring  in  the  older  population  demand  an  increase  in  trained  and  educated
personnel in the field as well as new approaches to increase the attractiveness of the
profession.

Measures  also  have  to  be  taken  in  order  to  reduce  work-related  fatigue  among
personnel  in  institutional  care.  Sweden,  which  is  facing  difficulties  in  recruiting
health care personnel, is looking at salary increases, an increase in staff density, “on-
the-job-training”  programs  and  work  environment  improvements  for  staff  in  long
term care.

Some  Member  States  note  that  there  is  a  lack  of  adequate  quality  indicators  and
controls and see the development of these as immediate challenges. To address some
of the issues, Belgium will launch  a new policy for  older  people in  2003 including
tools for needs assessments of care for older people, which will also operate as a tool
for  monitoring  and  evaluating  care  results.  Denmark  intends  to  develop  a  general
model for better practices, follow-up procedures and entrenching quality standards in
local authorities.

3.5.

Financial sustainability - Health care

The structures of financing of health care systems in the EU

The  way  in  which  health  care  systems  are  financed  in  the  EU  varies  considerably
between Member States, broadly in line with the various different models employed
for structuring health care systems. In general, health care systems in the EU tend to
be  mixed  systems,  comprising  public  financing  (which  is  predominant)  with  some
element of private financing. Most systems, although not all, include a (mandatory)
sickness  insurance,  and  almost  all  are  in  some  part  financed  directly  by  general
taxation.  Often  resources  to  finance  health  care  systems  are  raised  at  the  regional
level. All systems have some element of user charges for patients which contribute to
the financing of public health  care  - the  primary role of these, however,  is  often to
attempt to control demand for health care goods and services.

Common challenges for the financial sustainability of public health care systems

In  terms  of  ensuring  the  financial  sustainability  of  public  health  care  systems,
Member States outlined a number of challenges faced by their systems. Despite the
differences  among  health  care  systems  across  the  EU,  a  number  of  common
challenges can be identified.

With  regard  to  long-term  challenges  for  the  financial  sustainability  of  health  care
systems,  Member  States  highlighted  the  key  developments  in  society,  already
described in section 2:

13

– 

– 

There  are  important  pressures  in  the  health  system,  both  from  health
professionals as well as from patients, for the increased diffusion of new and
expensive medical technology.

The  long-term  tendencies  of  populations  to  consume  more  as  they  become
wealthier over time as being a source of increased costs in health systems.

– 

The demographic changes linked to ageing populations.

In  the  responses  to  the  questionnaires,  Member  States  noted  the  following  urgent
short-term challenges for financial management of public health care systems:

– 

– 

– 

The  need  to  reduce  the  over-consumption  of  health  care  goods  and  services
beyond that which is effective in improving health outcomes.

In  some  Member  States  there  is  a  pressing  need  to  deal  with  immediate  cost
overruns,  which  are  jeopardising  the  financial  balance  of  sickness  insurance
funds and/or making the overall management of public finances rather difficult.

In  other  Member  States,  the  pressure  is  rather  different,  and  is  more  directed
towards  the  need  to  increase  the  volume  of  services,  inter  alia  by  reducing
waiting  times,  but  without  jeopardising  the  financial  management  of  the
system.

In the face of these short and long-term trends for the financial sustainability of their
health systems, many Member States point to challenges they face in readapting their
health systems. For example they list the following challenges:

– 

– 

Finding means of using resources more effectively.

Involving  doctors  and  health  professionals  more  actively  in  managing
resources.

Recent trends in health care expenditure

While  many  of  the  responses  of  Member  States  to  the  EPC/SPC  questionnaire
discussed  recent  developments  in  health  expenditure,  the  responses  did  not
systematically  provide  quantitative  indications  of  the  trends  in  overall  levels  of
expenditure  for  health  care  expenditure.  Moreover,  where  expenditure  numbers  are
provided they are not necessarily consistent or comparable across Member States. As
a  result,  this  information  cannot  readily  be  used  to  compare  expenditure  for  health
care systems across the EU. Instead in Annex 1, Table 4, the latest information from
the OECD health database is provided for illustrative purposes.

The  responses  to  the  questionnaire  do  allow  for  some  qualitative  comparison  to  be
made  –  subject  to  the  limitations  resulting  from  insufficient  consistency  and
comparability mentioned above. From this information it seems that Member States
differ  in  terms  of  the  recent  trends  in  health  expenditure,  and  in  their  policy
responses:

– 

In  a  number  of  Member  States  rapid  expenditure  growth  is  causing  concern,
with public expenditure often growing faster than GDP and health sectors thus
expanding  as  a  share  of  GDP.  This  includes  countries  such  as  Belgium,

14

Germany, France, Italy, Luxembourg and Portugal. Often cost overruns in the
health  sector  are  a  cause  of  concern  for  the  wider  management  of  public
finances.  In  some  Member  States,  these  cost  overruns  persist  despite  the
existence of numerous cost control mechanisms. It should be noted, however,
that  rapid  expenditure  growth  in  countries  such  as  Portugal  and  Italy  is  in  a
context of relatively low levels of overall public expenditure on health care.

– 

– 

In some other Member States, expenditure growth has also been rapid, but this
has been the result of explicit policy measures to target more resources to the
health  sector  with  a  view  to  improving  the  quality  of  care.  This  group  of
countries includes Denmark, Ireland and the UK.

In  a  third  group,  the  questionnaire  responses  indicate  that  expenditure  levels
are  relatively  stable,  and  thus  cost  containment  is  not  a  pressing  challenge  –
this  is  the  case  in  Spain,  where  the  focus  of  policies  is  rather  to  improve  the
management and the efficiency of the National Health System.

In terms of the key  components of rapid expenditure growth, many Member States
highlighted rapid growth in expenditure on pharmaceuticals.

Long-term financial sustainability of public health care

Again,  not  all  Member  States  provided  quantitative  information  about  the  likely
evolution  of  health  expenditures  over  the  long-term.  Where  quantitative  estimates
were provided, often Member States provided  a summary of the projections carried
out under the remit of the EPC in 20016. Some countries also provided information
based on other long-term projections - this included Belgium, Spain and Finland. In
most cases, other national projections gave estimates of long-term increases in health
expenditure  above  the  estimates  of  the  EPC.  This  is  not  surprising,  as  the  EPC
estimates aimed  to  measure  only  the  impact  of  demographic  changes  under  neutral
assumptions  for  other  cost  drivers.  However,  it  can  be  expected  that  these  other
factors,  including  notably  the  diffusion  of  new  and  expensive  medical  technology,
would lead to additional upward pressure on overall levels of expenditure. The EPC
projections  are  summarised  in  Annex  1,  Table  3.  Such  long-term  projections  must
however be read with caution, as noted in the EPC report.

The  EPC  projections,  together  with  the  other  national  projections  cited  above,
suggest that future increases in expenditure on health care and long-term care could
be significant, thus implying an important additional burden for the public finances
over  the  long-term.  The  EPC  projections  for  public  health  care  expenditure  reveal
that  the  impact  of  demographic  changes  over  the  fifty  year  period  would  be  in  the
range of 0.7  to  2.3  percentage  points  of  GDP  over  the  fifty  year  projection  period.
Some  Member  States  (e.g.  Germany  and  Ireland)  are  expected  to  see  increases  in
expenditure  of  around  or  above  2  percentage  points  of  GDP  over  the  projection
period.  (Austria  has  revised  their  projections  in  2002.  The  revised  projections  are
shown in a note after Table 3.)

6

Report by the Economic Policy Committee on budgetary challenges posed by ageing populations: the
impact on public spending on pensions, health and long-term care for the elderly and possible indicators
of the long-term sustainability of public finances.
http://europa.eu.int/comm/economy_finance/epc/epc_ageing_en.htm

15

                                                
In  summary  therefore,  over  the  long-term,  significant  additional  expenditure
pressures can be expected in health sectors. Some Member States note that there will
be a need for  explicit policy measures to  prepare  for  the  financial  consequences  of
ageing  populations,  particularly  given  expected  increases  in  other  age-related
expenditures, such as pensions, over the long-term.

Cost control mechanisms

In  general,  the  questionnaire  responses  provided  a  large  amount  of  qualitative
information on cost control measures in Member States. However, the responses did
not always indicate which measures were effective. A broad overview of the types of
measures  taken  in  different  Member  States  is  included  below,  based  on  a
categorisation used by the OECD.7

(1)  Measures to shift costs to consumers

Almost all Member States have some type of user charge for health care goods and
services - while charges can include a contribution towards the costs of hospital stays
or  visits  to  practitioners,  most  often  they  concern  contributions  to  the  purchase  of
medicines prescribed in primary care. Cost shifting measures have two aims: firstly
to  directly  shift  the  burden  of  financing  away  from  the  public  finances  to  private
sources - this motivation for example appears to have been dominant in increases in
user  charges  throughout  the  1990s  in  Finland.  Secondly,  they  are  intended  to  help
control the demand by consumers for services and thus indirectly bring down public
(as  well  as  total)  expenditure.  However,  user  charges  will  not  play  a  role  in
controlling  consumer  demand  if  they  are  reimbursed  by  supplementary  health
insurance.

(2) 

Price and volume controls on both supply and demand

In some Member States, national agreements exist to fix prices between providers of
health  goods  and  services  (e.g.  producers  or  organisations  representing  health  care
professionals)  and  health  care  funders.  Such  agreements  exist  for  example  in
Belgium and Spain. In particular, in almost all  Member  States,  specific  agreements
exist  covering  pharmaceuticals  products.  Agreements  often  set  prices  for
pharmaceutical products, require the use of generic rather than branded products, and
in  some  cases  even  include  maximum  spending  levels  on  these  products  at  the
aggregate level (e.g. in Spain).

In some countries, there are direct barriers to access to some health care services. For
example,  in  the  UK,  the  Netherlands,  Finland  and  Denmark,  access  to  certain
specialist  health  practitioners  requires  a  referral  from  a  general  practitioner.
Experience has shown that this mechanism is effective in controlling health costs.

7

OECD  (1994),  Economics  Department  Working  Paper  No.  149,  H.  Oxley  &  M.  MacFarlan,  “Health
Care Reform: Controlling Spending and Increasing Efficiency”

16

                                                
(3) 

Reforms to encourage the efficient use of resources

In some cases, health care funders impose direct top-down controls on expenditure -
these  include  fixed  budgets  for  regional  health  boards  or  for  hospitals  -  this  is  the
case in Greece, Italy and Portugal for example. Increasingly health systems in the EU
are  using  contracts  between  health  care  purchasers  (either  funders  or  third  party
purchasers such as insurance companies) and service providers in order to ensure the
more efficient use of financial resources. In some cases, these contracts require any
cost  overruns  to  be  taken  out  of  the  following  year’s  budget  -  this  is  the  case  for
hospitals in Belgium and health boards in Ireland. The approach appears to be rather
effective  in  encouraging  efficiency.  In  other  countries,  the  allocation  of  financial
resources  is  increasingly  related  to  performance  measures,  or  to  the  case-mix  of
hospitals. These measures also seem to be rather effective in encouraging efficiency
improvements  -  this  has  been  the  case  in  Austria  where  the  introduction  of  such
contracts has led to a marked decline in the average length of hospital stays.

In other countries,  for  example in Spain and Portugal,  services  in  the  public  health
system  will  increasingly  be  provided  by  private  suppliers.  Spain  is  among  the
Member  States  that  have  introduced  market  mechanisms  to  the  greatest  extent  into
the health sector.

3.6.

Financial sustainability - Long-term care

The structure of financing of long-term care in the EU

The situation in terms of the financing of long-term care systems in the EU is even
more  difficult  to  categorise  than  that  of  health  systems.  The  reason  for  this  is  that
long-term  care  is  often  divided  between  various  different  public  structures  and
budgets,  most  often  between  the  health  budget  and  the  budget  for  social  services.
Moreover,  long-term  care  provided  in  the  health  system  is  often  difficult  to
distinguish from more traditional health interventions. Finally, long-term care social
services  are  often  provided  at  a  very  local  level  -  for  this  reason  it  is  sometimes
difficult  to  discern  national  trends.  In  some  Member  States  there  are  insurance
systems for dependency, and in others such an insurance system is being developed.

Challenges

The  most  common  challenge  for  the  financing  of  long-term  care  highlighted  by
Member  States  in  the  questionnaire  responses  has  been  ageing.  Firstly,  ageing  will
lead to a much greater number of elderly and very elderly persons. Secondly, long-
term care is an extremely labour-intensive sector. It is noted in some Member States
that the sector is likely to suffer from acute labour shortages (also related to ageing),
which  in  itself  will  also  drive  up  wage  costs.  The  German  report  notes  that  the
pressure on long-term care systems from ageing will in large part be fuelled by the
sharply  increased  incidence  of  chronic  conditions  such  as  dementia,  which  do  not
necessarily demand much in terms of traditional health care interventions but imply a
heavy burden in terms of care.

In  addition  to  ageing,  the  Danish  and  the  German  reports  note  that  if  past  trends
continue,  there  may  be  increased  demand  for  formal  care  services  as  a  result  of
reduced provision of informal care due to changes in society.

17

Portugal and Italy cite a number of challenges that they face in the drawing together
of  a  coherent  system  of  care  for  elderly  persons.  One  of  the  key  challenges  is  to
provide  integrated  solutions  for  patients  covering  the  full  range  of  care  services
required, including health care. Another is to develop the provision of care services
in the home of the elderly person, which are both more in line with the wishes of the
elderly person and are more cost effective.

Recent expenditure trends

Information in the national reports is somewhat patchy on this issue, partly reflecting
the difficulty in quantifying the costs of long-term care services, which are financed
by  numerous  different  budgets.  Among  the  Member  States  that  do  provide  some
quantitative information, it is difficult to see clear cross-country trends. In Denmark,
the  resources  devoted  to  the  sector  have  been  growing  in  real  terms,  although  at  a
rate  below  that  of  real  GDP  growth.  These  cost  increases  have  been  promoted  by
both  increases  in  the  number  of  the  elderly  as  well  as  increases  in  costs  per  head.
Cost increases have also been notable in Spain, where increasing resources are being
devoted  to  long-term  care  by  the  Autonomous  Communities,  and  in  Luxembourg
where the dependency insurance is still in its infancy.

Long-term expenditure projections

Again,  the  information  provided  on  the  long-term  outlook  for  long-term  care
expenditure  is  very  patchy.  Of  those  Member  States  that  do  provide  some
information on the outlook, the projections are essentially based on those carried out
with the EPC. For further information see Annex 1, Table 3.

Cost control mechanisms

In  some  Member  States  an  integrated  policy  for  long-term  care  is  still  being
developed.  As such,  there  is  not  yet  a  need  for  explicit measures  to  control  costs  -
this is the case in Belgium, for example.

In France and Portugal, financial allocations are made on the basis of national plans
and objectives. For France the objectives are integrated with those set for health care
as  a  whole.  These  allocations  and  objectives  are  set  with  a  view  to  limiting
expenditures  a  priori,  but  the  reports  do  not  state  whether  they  are  effective  in
controlling costs. In Germany, cost control is to some extent the responsibility of the
sickness insurance fund.

In  some  countries,  the  services  to  be  provided  are  defined  upfront  –  thus  to  some
extent limiting the scope for increases in expenditure. In Austria they are defined in
law, and in Denmark and Luxembourg these are dependent on an individualised care
plan based on needs. In Ireland there are attempts to provide care in the home, which
costs less and is usually in line with the wishes of the elderly person.

In France, cost control is also carried out by means of some user charges, which are
dependent  on  the  financial  means  (including  the  recently  introduced  independence
social allowance) of the elderly persons.

18

4.

CONCLUSIONS

The replies from Member States confirm the usefulness of the three broad objectives
of access, quality and sustainability as a basis for looking at policies for health care
and  long-term  care  for  the  elderly.  All  Member  States  are  trying  to  find  the  best
balance between these three  goals: how to raise enough funding to secure  adequate
care for all, with high quality; how to provide services more cost-effectively?

The Member States' replies show that seeking this balance poses a major  challenge
for the overall management of systems. Thus, many national replies refer to the need
to  ensure  good  decision  making  at  the  interface  between  their  health  care  and  the
emerging long-term care sectors and a better co-ordination of health care provisions
and  long-term  care  services  for  the  elderly.  Achieving  the  best  balance  also  raises
governance  issues;  there  needs  to  be  a  balance  between  the  focus  on  quality,
standards and cost control which are often centrally driven on the one hand, and local
management and delivery, on the other.

While  it  was  not  an  explicit  objective  of  the  questionnaire,  some  Member  States'
replies point to the large employment challenges and opportunities in the care sector.
The challenges include: how to retain staff under sometimes rather difficult working
conditions;  how  to  recruit  and  train  new  staff  as  demand  increases  over  the  next
decades; and how to develop the quality of work, by providing skill development and
career  progression,  in  the  sector.  There  will  clearly  be  opportunities  to  increase
employment. The health and social services sector is already a large employer with
9,7 % of total employment in the European Union in 2001.8

In relation to access, Member States express their determination to maintain general
and  comprehensive  access  as  a  cornerstone  of  their  systems,  even  in  the  face  of
increasing  costs,  with  several  proposing  to  further  refine  and  improve  their  access
mechanisms.

In the  area of quality, the  replies reveal that there is scope for  greater  co-operation
between  Member  States  in  the  area  of  quality  of  service  delivery  regarding  both
health and long-term care. This is particularly true in the perspective of greater cross-
border mobility of patients and enlargement. The Community’s action programme in
the field of public health, which will come into  force in  January 2003,  will  help in
developing tools for quality assessment.

Regarding financial sustainability, Member States point to the challenge of ensuring
that resources and in particular new technologies can be deployed in the interest of
efficiency  and  cost  effectiveness  and  of  ensuring  that  health  professionals  and
patients integrate cost considerations into their decisions.

Recommended next steps

The Commission invites the Council, on the basis  of this Communication,  to adopt
the joint report requested by the Barcelona European Council and to submit it to the
Spring 2003 European Council.

8

Employment in Europe 2002, page 32. http://europa.eu.int/comm/dgs/employment_social/key_en.htm

19

                                                
A process of mutual learning and co-operative exchange should be continued on the
basis  of  the  issues  identified  in  the  joint  report.  The  Commission  will  present  in
autumn 2003 further proposals for pursuing this co-operation. That Communication
should also cover the specific aspects of these issues related to the enlargement of the
European Union.

Co-operation between Member States could concentrate on exchanging experiences
and best practice with regard to each of the three broad objectives. There should be a
particular focus on  improving the information  base and on  indicators  as a basis for
such co-operation, drawing on the existing close co-operation between Eurostat and
the  OECD  in  this  area.  It  would  also  be  useful  to  pay  particular  attention  to
employment issues.

20

ANNEX 1

ANNEX 1: TABLES AND GRAPHS

Graph 1a:

Men

Population Pyramid in 2000 - EU15

EUROSTAT - Population projections - Baseline scenario (1999)

90+

90+

85-89

85-89

80-84

80-84

75-79

70-74

65-69

60-64

55-59

75-79

70-74

65-69

60-64

55-59

Women

20

15

10

Graph 1b:

Men

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

5

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

0

million

5

10

15

20

Population Pyramid in 2050 - EU15

EUROSTAT - Population projections - Baseline scenario (1999)

90+

90+

85-89

85-89

Women

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

80-84

75-79

70-74

65-69

60-64

55-59

50-54

45-49

40-44

35-39

30-34

25-29

20-24

15-19

10-14

5-9

0-4

2

15

10

5

0

million

5

10

15

20

Source: EUROSTAT

21

Graph 1c:

Projected size the EU working-age and elderly population (millions)

2 5 0

2 2 5

2 0 0

1 7 5

1 5 0

1 2 5

1 0 0

7 5

5 0

E m p lo y m e n t

W o rk in g  a g e

E ld e rly

2 0 0 0

2 0 0 5

2 0 1 0

2 0 1 5

2 0 2 0

2 0 2 5

2 0 3 0

2 0 3 5

2 0 4 0

2 0 4 5

2 0 5 0

Note: Working age population refers to persons aged 15 to 64.

Elderly population refers to persons aged 65 and above

Source: Economic Policy Committee (2001) “Budgetary challenges posed by ageing populations”, Eurostat and
projections of the EPC working group on ageing populations.

Graph 2a: Age profiles for public expenditure on health care

a
t
i
p
a
c

r
e
p
P
D
G

f
o
e
r
a
h
s

a

s
a
d
e
s
s
e
r
p
x
e
d
a
e
h
r
e
p
e
r
u
t
i
d
n
e
p
x
e

e
g
a
r
e
v
A

20

15

)

%

(

10

United Kingdom

Spain

France

Austria

5

0

United Kingdom

France

Germany

Austria

Belgium

Finland

Spain

Sweden
Netherlands

Italy

Denmark

0-4

5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95+

Age groups

Notes:
(1) The age-related profiles expressed as a share of GDP per capita, were those used for running the projections of health care expenditure. The
base year used for the projections varies slightly across Member States and so the profiles in the graph above refer to different years for different
Member  States:  1997  for  France,  1998  for  Belgium,  Denmark,  Spain  and  the  United  Kingdom;  1999  for  Italy;  and  2000  for  Germany,  Finland,
Netherlands, Austria, and Sweden. (Profiles for Portugal are not presented here as a different age classification is used.)
(2)The  expenditure  profiles  here  relate  to  public  expenditure  on  health  care  only.  Notably,  they  exclude  private  expenditures  and  public
expenditure on long-term care. See definition of expenditures for projections in Annex 4.
(3) Where the age-profile is flat at the tail-end of the age-distribution, this is generally because a breakdown across age-groups was not available
at the highest ages in those Member States.

Source: Economic Policy Committee (2001) “Budgetary challenges posed by ageing populations”

22

 
 
 
 
 
 
 
 
 
 
 
Graph 2b: Age profiles for public expenditure on long-term care

)

%

(
a
t
i
p
a
c

r
e
p

P
D
G

f
o
e
r
a
h
s
a
s
a
d
e
s
s
e
r
p
x
e
d
a
e
h
r
e
p
e
r
u
t
i
d
n
e
p
x
e
e
g
a
r
e
v
A

100

90

80

70

60

50

40

30

20

10

0

Denmark

Sweden

Netherlands

Finland

Belgium

Austria

Italy

0-4

5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95+

Age groups

Notes:
(1) The age-related profiles expressed as a share of GDP per capita, were those used for running the projections of long-term care expenditure.
The base year used varies across Member States, and hence the profiles in the graph above refer to different years for different Member States:
1998 for Belgium, Denmark; 1999 for Italy; and 2000 for Austria, Finland, Netherlands, and Sweden.
(2)The expenditure profiles here relate to public expenditure on long-term care only. Notably, they exclude private expenditures.
(3) Where the age-profile is flat at the high-end of the age-distribution, this is generally because a breakdown across age-groups was not available
at the highest ages in those Member States.

Source: Economic Policy Committee (2001) “Budgetary challenges posed by ageing populations”

23

 
 
 
 
 
 
 
 
 
 
 
 
Table 3: Total public expenditure on health care and long-term care

Expressed as a share of GDP. Central demographic variant.

TOTAL HEALTH AND 
LONG-TERM CARE

Expenditure 
as a share of 
GDP in 2000

Increase in 
expenditure in 
per cent of GDP 
between 2000 
and 2050

per 
capita

per 
worker

6.1%
8.0%

+2.1
+2.7

+2.4
+3.5

6.9%
6.6%
5.5%
7.2%
5.8%

6.2%
8.8%

6.3%

+1.7

+1.9
+3.2
+2.8

+2.8
+3.0

+1.8

+2.5
+2.5
+2.1
+3.8
+3.1

+3.9
+3.3

+2.5

HEALTH CARE

LONG-TERM CARE

Increase in 
expenditure in 
per cent of GDP 
between 2000 
and 2050

per 
capita

per 
worker

+1.3
+0.7
+1.4
+1.7
+1.7
+1.2

+1.5
+1.0
+1.7
+0.8
+1.2
+1.0

+1.0

+1.5
+1.1
+2.1
+1.6
+1.5
+1.9
+2.3
+1.7
+1.3
+2.0
+1.3
+1.8
+1.2

+1.4

Expenditure 
as a share of 
GDP in 2000

Increase in 
expenditure in 
per cent of GDP 
between 2000 
and 2050

per 
capita

per 
worker

0.8%
3.0%

+0.8
+2.1

+0.8
+2.5

0.7%
0.7%
0.6%
2.5%
0.7%

1.6%
2.8%

1.7%

+0.5

+0.4
+2.2
+1.0

+1.7
+2.0

+0.8

+0.6
+0.2
+0.4
+2.5
+1.1

+2.1
+2.1

+1.0

Expenditure 
as a share of 
GDP in 2000

5.3%
5.1%
5.7%
4.8%
5.0%
6.2%
5.9%
4.9%
4.7%
5.1%
5.4%
4.6%
6.0%

4.6%

B
DK
D (1)
EL (1)
E (1)
F 
IRL (2)
I 
NL
A 
P (1)
FIN
S

UK 

EU (weighted 
average) (3)

6.6%

+2.2

+2.7

5.3%

+1.3

+1.7

1.3%

+0.9

+1.0

Notes:

(1) Results for public expenditure on long-term care are not yet available for a number of Member States.

(2) Results for Ireland are expressed as a share of GNP.

(3) Weights are calculated according to the Member States for which results are available. Therefore for health care
it is a weight for the EU-14, and for long-term care, and total expenditure on health and long-term care, the average
is for 10 Member States.

Source: Economic Policy Committee (2001) “Budgetary challenges posed by ageing populations”

Note 13/11/2002: New projection, based on new demographic forecasts, by the Austrian Statistical Office in 2002.

Austria (2002)

5,6%

+2.4

+2.5

4.9%

+1.5

+1.6

0,7%

+0.9

+0.9

24

Table 4 a: Total expenditure on health care as a share of GDP (%)

Table

Total expenditure on health - % GDP
1980 1985 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Austria
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Luxembourg
Netherlands
Portugal
Spain
Sweden
United Kingdom

Czech Republic
Hungary
Poland
Slovak Republic
Turkey

7.6
6.4
9.1
6.4

8.8
6.6
8.4

5.9
7.5
5.6
5.4
9.1
5.6

6.6
7.2
8.7
7.2

9.3

7.6

5.9
7.3
6
5.4
8.7
5.9

7.1
7.4
8.5
7.9
8.6
8.7
7.5
6.6
8
6.1
8
6.2
6.6
8.5
6

5

5.3

7.1
7.7
8.4
9
8.9

7.8
7
8.3
6
8.2
6.8
6.8
8.4
6.5

5.2
7.1
6.6

7.5
7.9
8.5
9.1
9.1
9.9
7.2
7.6
8.4
6.2
8.4
7
7.2
8.6
6.9

5.4
7.7
6.6

7.9
7.9
8.5
7.8
9.4

8
8.5
8.2
7.3
9.4

8
8.5
8.4
6.9
9.3

8.7
8.8
8.3
7.7
9.6

8.1
8.7
8.5
6.9
9.4

8.6
8.7
8.2
7.5
9.6

8
7.9
8.7
8.1
8.3
8.8
6.6
8.3
9.5
9.5
9.9 10.2 10.6 10.9 10.7 10.6 10.7 10.6
8.3
8.1
6.7
7.5
8.1
8.1
6.4
8.5
7.3
7.5
8.6
6.9

8.7
6.8
7.7
5.8
8.1
8.3
7.6
7.9
6.8

8.7
6.9
7.7
5.9
8.2
8.6
7.6
8.1
6.8

8.9
7
7.5
6.4
8.3
8.5
7.7
8.4
7

8.9
7.2
7.4
6.4
8.4
8.3
7.7
8.1
7

8.9
7.5
7.8
6.1
8.4
7.3
7.4
8.2
7

8.7
6.8
7.8
6
8.2
8.4
7.7

8.1
8.2
7.7

7.1

7.3

8.4

8.1

7.2
7.7
6.4

7.3
8.3
6

7.3
7.5
6

7.1
7.2
6.4

7.1
7
6.1
6.1
4.2

7.1
6.9
6.4
5.9
4.8

7.2
6.8
6.2
5.8

7.2
6.8

5.9

13 12.9
9.1
8.9

13
9.2

13
9.1

9.3

3.3

2.2

3.6

3.8

3.8

3.7

3.6

3.4

3.9

8.7
United States
Canada
7.1
Copyright OECD HEALTH DATA 2002 4th ed.

10 11.9 12.6
9.7
9
8.2

13 13.3 13.2 13.3 13.2
8.9
9.5
10

9.1

9.8

Table 4 b: Public expenditure on health care as a share of GDP (%)

Public expenditure on health - % GDP 
1980 1985 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

Austria
Belgium
Denmark
Finland
France
Germany
Greece
Ireland
Italy
Luxembourg
Netherlands
Portugal
Spain
Sweden
United Kingdom

Czech Republic
Hungary
Poland
Slovak Republic
Turkey

5.2

5

5.2

5.2

5.5

5.9

5.9

8
5

6.9
3.7
6.8

5.5
5.2
3.6
4.3
8.4
5

7.4
5.6

7.2

5.8

5.3
5.2
3.3
4.4
7.9
5

7
6.4
6.6
6.7
4.7
4.8
6.4
5.7
5.4
4.1
5.2
7.6
5

4.8

4.8

7
7.3
6.7

4.7
5.2
6.6
5.6
5.7
4.3
5.3
7.4
5.4

5.1
6.4
5

7
7.3
7
7.7
4.2
5.5
6.5
5.8
6.1
4.2
5.6
7.5
5.8

5.2
6.8
5.1

7.2
6.3
7.3
7.6
4.7
5.5
6.2
5.9
6.3
4.6
5.8
7.4
5.9

6.8
6.7
4.7

7
5.9
7.2
7.8
4.7
5.5
5.9
5.6
6.1
4.6
5.6
7
5.9

6.9
7.2
4.3

6.1
6
6.8
5.7
7.3
8.1
4.8
5.3
5.3
5.9
6
5.1
5.5
6.9
5.8

6.8
6.3
4.4

6.1
6.4
6.8
5.8
7.3
8.4
4.9
5.1
5.4
5.9
5.5
5.5
5.5
7.1
5.8

6.5
5.9
4.7

0.9

1.1

2.2

2.4

2.5

2.5

2.5

2.4

2.7

3.6
United States
Canada
5.4
Copyright OECD HEALTH DATA 2002 4th ed.

4.7
6.7

4
6.2

5.2
7.2

5.5
7.4

5.7
7.2

5.9
6.8

6
6.5

6
6.3

5.6
6
6.8
5.6
7.2
8.1
4.8
5.3
5.6
5.4
5.5
5.5
5.4
6.8
5.4

6.5
5.6
4.4
5.6
3

5.9
6.2

5.7
6
6.9
5.3
7.1
7.9
4.7
5.2
5.6
5.4
5.5
5.6
5.4
6.6
5.5

6.5
5.5
4.2
5.4
3.5

5.8
6.5

6.9

6.1

5.6
6.2
7
5.2
7.1
8
4.7
5.2
5.7
5.6
5.4
5.9
5.4

5.6
6.2
6.8
5
7.2
8
4.6
5.1
5.9

5.5
5.8
5.4

5.7

5.9

6.5
5.3
4.4
5.2

6.6
5.1
4.2
5.3

5.7
6.5

5.8
6.5

6.8

Source: OECD Health Data 2002, © OECD, Aug. 2002

25