Joint report on health care and long-term care systems & fiscal sustainability : country documents : 2019 update.
Date: 2019-07-16
Institutions: Directorate-General for Economic and Financial Affairs, Economic Policy Committee
Subjects: Portugal, care for the elderly, health care, health care system, health expenditure, health policy, report, sustainable development

ISSN 2443-8014 (online)

Joint Report 
on Health Care and   
Long-Term Care Systems 
& Fiscal Sustainability

Country Documents 
2019 Update

INSTITUTIONAL PAPER 105 | JUNE 2019

EUROPEAN ECONOMY

Economic and 
Financial Affairs
Economic Policy 
Committee

European  Economy  Institutional  Papers  are  important  reports  analysing  the  economic  situation  and 
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European Commission 
Directorate-General for Economic and Financial Affairs 

Joint Report on Health Care                                    
and Long-Term Care Systems & Fiscal Sustainability 

Prepared by the Commission Services                           
(Directorate-General for Economic and Financial Affairs),        
and the Economic Policy Committee (Ageing Working Group) 

Country Documents - 2019 Update 

EUROPEAN ECONOMY                                                                                    Institutional Paper 105 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ACKNOWLEDGEMENTS 

The Economic Policy Committee (EPC) together with the Ageing Working Group (AWG), in cooperation 
with  Commission  services  (Directorate-General  for  Economic  and  Financial  Affairs)  carried  out  an 
analysis of health care and long-term care systems in the EU.  

This is an update of the second part of the Joint Report on Health Care and Long-term Care Systems and 
Fiscal Sustainability (European Economy, Institutional Paper 037, Volume 1, October 2016). This part of 
the  report  describes  the  health  care  and  long-term  care  systems  of  all  EU  Member  States  on  a  country 
basis and presents the related policy challenges. 

The report was prepared under the supervision of Lucio Pench (Director in DG ECFIN), Wolfgang Merz 
(Chair  of  the  EPC),  Giuseppe  Carone  (Head  of  Unit,  DG  ECFIN),  Per  Eckefeldt  (Head  of  Sector,  DG 
ECFIN) and Godwin Mifsud (Chair of the AWG).  

The report was  written by Santiago Calvo Ramos (DG ECFIN), Benedetta Martinelli (DG ECFIN) and 
Boriana Goranova (DG ECFIN) with contributions from Pedro Arevalo (DG ECFIN) and the members of 
the AWG.  

It has benefited from input and comments from the Directorate General for Health and Food Safety (DG 
SANTE). 

Comments on the report would be gratefully received at the following addresses: 

Secretariat of the Economic Policy Committee 
European Commission 
Rue de la Loi 200 
B-1049 Brussels 
E-mail: EPC-Secretariat@ec.europa.eu 

DG ECFIN - Unit C2 
Directorate-General for Economic and Financial Affairs 
European Commission  
Rue de la Loi 200 
B-1049 Brussels 
E-mail: ECFIN-Secretariat-C2@ec.europa.eu 

2 

 
 
CONTENTS 

1. 

Introduction 

2.  Health care systems 

Czech Republic 

Austria 

Cyprus 

Ireland 

France 

Estonia 

Finland 

Croatia 

Belgium 

Bulgaria 

Hungary 

Denmark 

2.1. 
2.2. 
2.3. 
2.4. 
2.5. 
2.6. 
2.7. 
2.8. 
2.9. 
2.10. 
2.11.  Germany 
2.12.  Greece 
2.13. 
2.14. 
2.15. 
2.16. 
2.17. 
2.18. 
2.19.  Malta 
2.20. 
2.21. 
2.22. 
2.23. 
2.24. 
2.25. 
2.26. 
2.27. 
2.28. 

Lithuania 

Romania 

Portugal 

Slovenia 

Slovakia 

Sweden 

Poland 

Latvia 

Spain 

Italy 

Luxembourg 

The Netherlands 

United Kingdom 

3. 

Long-term care systems 

3.1. 
3.2. 
3.3. 
3.4. 
3.5. 
3.6. 
3.7. 

Austria 

Belgium 

Bulgaria 

Croatia 

Cyprus 

Czech Republic 

Denmark 

5 

8 

8 
21 
30 
39 
50 
59 
67 
74 
82 
91 
101 
111 
124 
134 
144 
155 
169 
177 
185 
194 
204 
215 
225 
235 
246 
261 
270 
279 

289 

289 
299 
307 
317 
326 
334 
339 

3 

 
345 
351 
358 
365 
371 
380 
387 
395 
402 
409 
415 
422 
429 
437 
443 
452 
459 
465 
477 
486 
494 

501 

Italy 

Latvia 

Ireland 

France 

Estonia 

Finland 

Hungary 

Lithuania 

3.8. 
3.9. 
3.10. 
3.11.  Germany 
3.12.  Greece 
3.13. 
3.14. 
3.15. 
3.16. 
3.17. 
3.18. 
3.19.  Malta 
3.20. 
3.21. 
3.22. 
3.23. 
3.24. 
3.25. 
3.26. 
3.27. 
3.28. 

Romania 

Portugal 

Slovenia 

Slovakia 

Sweden 

Poland 

Spain 

Luxembourg 

The Netherlands 

United Kingdom 

Annex 

4 

 
 
 
 
 
 
1. 

INTRODUCTION 

and 

in  most 

and  debt 
pressures 

All  EU  Member  States  face  strong  and  growing 
fiscal pressures on their health and long-term care 
systems,  driven  by  already  high  levels  of  public 
countries, 
expenditure 
demographic 
technological 
advances (1).  Further  policy  action  will  therefore 
be needed to safeguard fiscal sustainability and to 
sustain  the  contribution  of  health  care  and  long-
term  care  systems  to  improve  population  health. 
The  need  to  make  health  and  long-term  care 
systems  fiscally  sustainable  by  improving  their 
efficiency  and  effectiveness  should  go  along  with 
ensuring access to good quality services ( 2). 

to 

tool 

support 

vis-à-vis 

evidence 

available 

This  report  with  country  documents  updates 
Volume  2  of  the  2016  EC-EPC  Joint  Report  on 
Health Care and Long-term care systems & Fiscal 
Sustainability ( 3).  By highlighting system-specific 
features 
on 
international  best  practice,  the  country  documents 
the 
represent  a  versatile 
identification  of  structural  policy  options 
to 
enhance the efficiency of public spending in health 
care  and  long-term  care  in  view  of  an  ageing 
population  and 
its  related  challenges.  These 
documents  combine  a  synthetic  quantitative 
approach with a rich qualitative description of the 
system and this  makes them  a precious source for 
evidence-based  policy-making.  Data  ranges  from 
publicly available indicators produced by Eurostat 
to  indicators  from  the  Ageing  Report,  notably  the 
country-specific  projections  of  health  care  and 
long-term  care  spending.  The  country  documents 
link 
system 
inefficiencies,  as  captured  by  official  statistics, 
with 
the  projected  evolution  of  age-related 
spending  and  of  its  implications  in  terms  of  long-
term  fiscal  sustainability.    This  allows  to  gain  a 
deeper  understanding  of  the  scope  to  increase 

contextualise 

sources  of 

and 

(1)  See  European  Commission  (2019),  “Fiscal  Sustainability 
Report 2018”, European Economy, Institutional Paper 094 
and  European  Commission  (DG  ECFIN)-EPC  (AWG) 
(2018),  "The  2018  Ageing  Report  –  Economic  and 
Budgetary Projections for the 28 EU Member States (2016-
2070)", European Economy, Institutional Papers 079. 
(2)  Council  Conclusions  on  ‘Public  finances:  Conclusions  on 
spending’, 

age-related 
https://www.consilium.europa.eu/en/press/press-
releases/2018/05/25/public-finances-conclusions-on-age-
related-spending/. 

(3)  See European Commission (2016), “Joint Report on Health 
Care and Long-term-care systems & Fiscal Sustainability”, 
European 
037: 
https://ec.europa.eu/info/sites/info/files/file_import/ip037_
vol1_en_2.pdf. 

Institutional 

Economy, 

Paper 

overall 
to  achieve 

system 
capturing 
efficiency 
by 
organisation,  of 
this 
the  strategy 
outcome, as well as of the level of urgency, based 
on  current  and  projected  spending  trends.  Indeed, 
each  document  reports  the  country-specific  fiscal 
sustainability  assessment  by 
the  Commission 
Services.  The  concluding  sections  on  recent 
in 
reforms  and  on  system  challenges,  used 
combination  with 
the  sections  on  efficiency 
enhancing policy options ( 4), provide an overview 
of  possible  measures  to  tackle  system-specific 
criticalities.  

What’s new 

include  a  separate 
The  country  documents 
document for health care (HC) and long-term care 
(LTC),  detailing  the  institutional  features  of  each 
system,  the  main  descriptive  statistics  and  the 
challenges and policy options, is available for each 
Member  State.  As  in  the  2016  publication,  these 
updated country documents have been co-authored 
by  the  Commission  Services  and  the  Ageing 
the  Economic  Policy 
Working  Group  of 
Committee, representing the national authorities of 
all the countries included. 

While the structure of the documents is unchanged, 
the  descriptions  of  the  health  care  and  long-term 
care systems have been updated in order to reflect 
the most recently adopted policy measures as well 
as  those  currently  planned  by  national  authorities. 
Notably,  the  statistics  included  in  the  country 
documents  have  been  updated (5)  including  the 
new long-term expenditure projections of the 2018 
Ageing  Report  (EC  (ECFIN)  –  EPC  (AWG)) (6) 
and  the  latest  assessment  of  the  impact  of  ageing 
on  fiscal  sustainability  as  formulated  in  the  2018 
Fiscal Sustainability Report (ECFIN) (7). 

(4)  These policy options can be found in Volume 1 of the 2016 
Joint Report on Health Systems and Fiscal Sustainability. 
(5)  The  cut-off  date  for  incorporating  international  database 
updates  was  set  at  April  2018.  Later  updates  of  the  data 
were  only  taken  in  consideration  on  a  case-by-case  basis, 
where  it  was  deemed  that  omitting  the  update  would 
compromise  the  accuracy  of  the  message.  The  indicators’ 
data sources are listed in the Annex. 

(6)  https://ec.europa.eu/info/publications/economy-

finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 
(7)  https://ec.europa.eu/info/publications/economy-
finance/fiscal-sustainability-report-2018_en. 

5 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

the  aggregate  used 

An  important  update  from  the  previous  version  is 
that  current  health  care  expenditure  is  presented, 
alongside  with  the  customary  definition  from  the 
System  of  Health  Accounts,  in  an  alternative 
definition  where  expenditure  on  long-term  care  is 
excluded  as  per 
the 
projections of the Ageing Reports. This alternative 
measure  better  reflects  what  is  actually  spent  on 
health  care,  excluding  the  confounder  represented 
by the medical component when in fact associated 
with  LTC  services,  with  the  advantage  of  making 
expenditure  more  comparable  across  Member 
States often characterised by significantly different 
long-term care systems.  

in 

As  for  the  recent  policy  developments  ( 8)  (9),  in 
the updates of the sections on legislated or planned 
measures, the majority of Member States reported 
having  conducted  a  range  of  health  care  system 
reforms,  the  impact  of  which  has  not  yet  been 
captured  in  the  data  reported  in  the  statistical 
annexes.  In  the  past  two  years,  three  Member 
States,  EL,  CY  and  IE,  embarked  on  major 
healthcare reforms to introduce universal access to 
health  care.  The  majority  of  the  remaining  EU 
Member  States  have  directed  their  reform  efforts 
towards  strengthening  primary  care  (FR,  PL,  AT, 
LV, MT, EL and RO) and improving access to and 
quality  of  care,  including  by  reducing  waiting 
times (LV, MT and HU), increasing public funding 
(LV,  PL  and  CZ),  and  implementing  a  series  of 
workforce training and retention policies (LV, SK, 
CZ  and  RO).  To  address  the  expected  increase  in 
demand on health care services with the ageing of 
the  population,  LV,  IT  and  FR  enhanced  their 
disease 
promotion 
and 
programmes.  

prevention 

health 

reforms 

the  EU  was 

Another  broadly  shared  priority  in  the  recent 
health  care 
the 
in 
advancement  of  eHealth  policies  (MT,  CZ,  SK, 
DE,  AT  and  PL)  and  a  better  monitoring  of  the 
performance of health systems through developing 
Health  System  Performance  Assessment  tools  (SI 
and  LV).  Several  Member  States  have  focused 
their  reform  efforts  on  improving  the  governance 

(8)  The  cut-off  date  for  this  report  was  Q4-18,  except  for 
requests for factual corrections received by Member States 
prior to publication. 

(9)  Additional  information  can  also  be  found  in  the  State  of 
profiles 

Health 
https://publications.europa.eu/en/publication-detail/-
/publication/d16ecda5-cf37-11e7-a7df-01aa75ed71a1. 

country 

EU 

the 

in 

of  hospitals  after  settling  (fully  or  partially)  the 
accumulated  hospital  arrears  with  the  aim  to 
prevent further indebtedness  of the hospital sector 
(BG,  HR,  HU  and  PT).  Promising  policy  actions 
with  regards 
terms  of 
efficiency  gains  are  the  introduction  /  refinement 
of  central  procurement  of  medicinal  goods  (EL, 
SK)  and  better  governance  of  planning  capacities 
for  investment  decisions  in  the  health  care  sector 
(PL, SK). 

their  potential 

in 

to 

In  general,  recent  reform  activities  in  long-term 
care  in  the  EU  were  less  pronounced  in  number 
and  scope.  The  overarching  reform  topics  in  the 
past  two  years  were  the  deinstitutionalisation  of 
care  (EL,  LV,  LT,  BG  and  PL)  and 
the 
development of national strategies and action plans 
on dementia (DK, AT, DE, IE, MT, EL and UK). 
Improving access to home care services was at the 
core of LTC reforms in DE,  IE, SE, CY and MT. 
Additionally,  policies  targeting  the  training  of  the 
workforce  (SI,  DE)  and  increasing  wages  in  the 
sector  (FR,  LU)  aim  at  improving  access  to  and 
quality  of  LTC  services.  Starting  from  a  low 
spending  and  coverage  for  this  kind  of  services, 
BG and PL have developed national strategies and 
implementation  plans  on  LTC,  while  SK  have 
broadened the benefits basket to be covered by the 
health insurance scheme. 

to 

for 

the 

looking  at 

its  potential 

The trends emerging from the policy updates point 
at  common  approaches  within  the  areas  of  health 
care  and  long-term  care,  which  appear  more 
clearly  when 
two  systems 
separately, and highlight the overarching challenge 
of  care-integration.  To  tackle  this  and  other 
challenges  at  the  forefront  of  the  EU-level  policy 
debate,  the  availability  of  tools  such  as  the  Joint 
Report  country  documents  adds  significant  value 
thanks 
cross-country 
comparisons.  Comparability is made easier thanks 
to  the  separation  between  health  care  and  long-
term  care,  and  is  further  expanded  in  this  edition 
thanks to the addition of the Ageing Report health 
care aggregate, as mentioned above. Not only does 
this  feature  allow  national  policy  makers  to 
benchmark  their  systems and to learn  from policy 
experiences and outcomes in other Member States, 
but it also substantiates the EU-level assessment of 
these  systems,  providing  grounds  to  advise  the 
lines of policy action deemed necessary in order to 
achieve,  or  preserve,  compliance  with  EU 
standards  and  ensure  future  fiscal  sustainability. 

6 

 
                                                           
implicit 

Thus,  national  level  policy-making  benefits  from 
an 
the 
cross-fertilisation 
additional  layer  of  EU  level  policy  guidance, 
for  national 
which  maximises 
initiatives  to  generate  positive  spill-overs  into 
other EU systems. 

the  potential 

through 

1. Introduction 

7 

 
2.  HEALTH CARE SYSTEMS 

2.1. 

AUSTRIA 

General  country  statistics:  GDP,  GDP  per 
capita; population 

Austrian  GDP  per  capita  has  been  among  the 
highest  in  the  European  Union  over  the  last 
decades  and  in  2015  amounted  to  34,234  PPS, 
compared  to  the  EU  average  of  29,610  PPS.  In 
terms  of  population,  the  Austrian  population  was 
around 8.6 million in 2015, slowly increasing over 
the last decade (8.2 million in 2005). It is projected 
to  further  increase  by  1.5  million  from  2016  to 
2070, reaching 10.2 million. 

Total and public expenditure on health as % of 
GDP 

Total expenditure on health is one of the highest in 
the EU: 11.1% of GDP in 2015, slightly increasing 
over the last decade (10.2% in 2005). This is above 
in  2015.  Public 
the  EU  average  of  10.2% 
expenditure  on  health  amounted  to  8.1%  of  GDP 
in  2015,  putting  Austria  in  line  with  the  EU 
average  of  8.0%.  When  measured  in  per  capita 
terms,  in  2015  Austria  is  above  the  EU  average 
both  in  terms  of  total  (4,031  PPS  vs.  the  EU 
average of 3,305) and public spending (2,965 PPS 
vs.  2,609  PPS).  Looking  at  health  care  without 
long-term  care (10)  reveals  a  similar  picture  with 
spending  at  the  EU  average  (6.9%  vs  6.8%  in 
2015). 

Expenditure projections and fiscal sustainability  

As  a  result  of  ageing,  health  care  expenditure  is 
projected to increase by 1.3 pps of GDP, which is 
higher  than  the  EU  average  of  0.9  pps  over  the 
same period. When taking into account the impact 
of  non-demographic  drivers  on  future  spending 
growth 
risk  scenario"),  health  care 
expenditure  is  expected  to  increase  by  2.1  pps  of 
GDP by 2070, higher than the average EU level of 
1.6 (11). 

("AWG 

Over  the  long  run,  medium  sustainability  risks 
appear  for  Austria.  These  are  primarily  related  to 
the  strong  projected  impact  of  age-related  public 

(10)  To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 
(11)  The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

8 

spending 
care) (12). 

(mainly  healthcare  and 

long-term 

Health status  

The  last  decade  saw  a  steady  increase  in  life 
expectancy,  which  grew  by  3.3  years  since  2000 
overall.    Between  2005  and  2015,  it  grew  by  2.2 
years for men and by 1.5 for women. The Austrian 
population  lives  slightly  longer  than  the  average 
EU citizens: in 2015, life expectancy was 0.7 years 
above  the  EU  average  (13).  Broken  down  by 
gender,  life  expectancy  at  birth  of  both  women 
(83.7 years) and men (78.8 years) was higher than 
the  EU  averages  of  83.3  and  77.9  years  in 
2015 (14).  

life  years, 

Healthy 
although  with  minor 
fluctuations, have remained quite stable during the 
past  decade (15)  and  in  2015  amounted  to  58.1 
years  for  women  (compared  to  63.3  years  in  the 
EU)  and  57.9  years  for  men  (compared  to  62.6 
years in the EU). Infant mortality of 3.1‰ was in 
2015  still  slightly  below  the  EU  average  of 
3.6‰ (16). As in most other European countries, in 
Austria  non-communicable  diseases  remain  the 
leading causes of morbidity and mortality. The two 
main  causes  of  death  in  Austria  are  circulatory 
diseases (such as stroke and myocardial infarction) 
and  malignant  neoplasms  (cancer),  accounting  for 
about  two  thirds  of  all  deaths (17).  A  reduction  in 
the  most  common  causes  of  death  was  achieved 
since  2010,  though  less  marked  for  malignant 
neoplasms  and  especially 
lung  cancer. 
Cardiovascular  diseases  still  rank  first  for  both 
men  and  women  (38%  and  47%  of  the  total 
respectively). Cancer currently ranks as the second 

for 

(12)  European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(13)  Bachner F, Bobek J, Habimana K, Ladurner J, Lepuschütz 
L, Ostermann H, Rainer L, Schmidt A E, Zuba M, Quentin 
W,  Winkelmann  J.  (2018)  Austria:  Health  system  review. 
Health Systems in Transition, 2018; 20(3): 1 – 256. 

(14)  Data  on  life  expectancy  and healthy  life  years  is  from  the 

Eurostat database. 

(15)  A  break  in  series  exists  between  2003  and  2004,  so  the 
strong 

in  2004  has 

likely 

a 

marked  decrease 
methodological component. 

(16)  Data on infant mortality is from the OECD database. 
(17)  Bachner F, Bobek J, Habimana K, Ladurner J, Lepuschütz 
L, Ostermann H, Rainer L, Schmidt A E, Zuba M, Quentin 
W,  Winkelmann  J.  (2018)  Austria:  Health  system  review. 
Health Systems in Transition, 2018; 20(3): 1 – 256. 

 
                                                           
 
                                                           
cause of death (29% for men and 24% and women 
respectively). Of particular significance within the 
group  of  malignant  growths  are  smoking-related 
cancers,  with  lung  cancer  causing  the  5%  of  total 
deaths 
in  2014.  Breast  cancer  also  plays  a 
significant  role  for  women,  and  it  caused  2%  of 
overall deaths in 2014 (18). 

also 

(21%).  Alcohol  consumption 

increased 
the  mortality 

In  terms  of  lifestyle-related  risk  factors,  Austria 
can be classified as follows. While the percentage 
of  obese  adults,  14%  in  2014,  is  below  the  EU 
average,  this  is  on  an  increasing  path  (12.4%  in 
amongst 
2006).  Obesity 
adolescents.  Consistently, 
rates 
related  to  diabetes  have  increased  substantially 
since  2000,  from  17.1  to  28.9  per  100  000 
population.  The  percentage  of  regular  smokers 
(24%  in  2014)  lies  above  the  EU  average  for  the 
same  year 
is 
growing,  with  12.3  litres  per  capita  in  2014  (11.9 
litres per capita in 2011) and the value for Austria 
was,  according  to  the  latest  figures,  the  third 
highest  in  the  EU  in  that  year  (around  10  litres). 
Traditionally,  the  provisions  of  social  insurance 
law  were  strongly  oriented  towards  a  curative 
approach, but a series of legislative initiatives have 
been set up in the last decade, in order to enhance 
the 
and 
prevention (19).  It  is  estimated  that  28%  of  the 
overall  burden  of  disease  in  Austria  in  2015 (20) 
could be attributed to behavioural risk factors (21). 
Underlying  data  -  and  the  projections  hereafter  - 
suggest  that  the  authorities  could  continue  their 
efforts to improve population life-styles. 

promotion 

approach 

health 

to 

System characteristics  

The  Austrian  health  care  system  has  a  complex 
structure  based  on  the  federalist  structure  of  the 
Austrian state. The regulatory responsibility for the 
health care sector lies with the federal government, 
with  the  exception  of  the  system  of  hospitals. 
Concerning the latter, the Federal Republic enacts 
only  basic  laws,  while  their  implementation  and 
enforcement  is  under  the  responsibility  of  the 

(18)  State of Health in the EU - Austria. Country Health Profile 

2017. 

(19)  See for instance the Health Promotion Act of 1998, which 
established  the  Healthy  Austria  Fund,  and  the  adoption  in 
2005 of the "New Preventive Check-up". 

(20)  Measured  in  terms  of  Disability  Adjusted  Life  Years 

(DALYs). 
(21)  HiT (2018). 

Health care systems 

2.1. Austria 

Social 

(“Bundesländer”). 

insurance 
states 
providers  are  supposed 
to  be  self-governing 
bodies,  which  implies  that  they  have  important 
concerning 
regulatory 
outpatient health services ( 22). 

especially 

functions, 

System  financing:  taxed-based  or  insurance-
based 

The Austrian health system is financed from a mix 
of  sources.  In  2015,  73.6%  of  expenditure  was 
public, while 26.4% came from private sources. As 
for public spending, about 60% comes from health 
insurance  contributions,  while  about  40% 
is 
financed  from  taxes,  mainly  general  tax  revenue; 
these proportions have remained rather stable. 

Revenue  collection  mechanism  (tax/social 
security contributions/premium) 

Mandatory health insurance is based on mandatory 
contributions  paid  by  all  employed  people.  The 
contributions  amount  to  a  maximum  of  7.65%  of 
the  contribution  basis  (generally  wage),  and  they 
are  mostly  equally  divided  into  two  parts  paid  by 
respectively (23).  A 
employer  and  employee, 
statutory  'maximum  contribution  basis'  puts  a 
ceiling on the wages used for the calculation of the 
contributions.  In  2018  this  ceiling  amounted  to 
€5,130.  The  contributions  are  collected  and 
administered  directly  by  the  health  insurance 
funds. 

Social  security  funds  are  the  main  source  of 
financing  in  the  health  system,  accounting  for 
more  than  50%  of  current  health  expenditure ( 24). 
The  financing  of  acute  hospital  care  is  partially 
to 
budgeted  and 
performance-related  criteria  within  the  framework 
of  yearly  budget.  The  states,  which  are  owners  of 
the  hospitals,  not  only  cover  investment  and 
maintenance  costs,  but  also  contribute  to  the 

is  carried  out  according 

der 

(22)  See also Austria - ASISP Annual Report 2009. 
(23)  Hauptverband 

Sozialversicherungsträger 

(Main 
Association of Austrian Social Security Institutions) (2018) 
Beitragsrechtliche  Werte  in  der  Sozialversicherung  2018. 
Stichtag:  1.  Jänner  2018  Zahlen  -  Daten  -  Fakten  --> 
Aktuelle Werte, Vienna: HVB. 

(24)  http://www.euro.who.int/__data/assets/pdf_file/ 

0017/233414/HiT-Austria.pdf,  HiT  Austria  (2013).  In  the 
quantification  of  this  share  as  50%,  expenditure  on  long-
term care is excluded from total current health expenditure.

9 

 
                                                           
                                                           
 
 
 
 
 
European Commission 

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current expenditure of the hospitals. Hospital debts 
are also covered at federal level by the states. 

and 

targets 

includes 

Since 2013 Austria imposes a constraint on public 
spending on health via the budget process (25). The 
reform 
the 
financial 
introduction of a budget cap on public expenditure 
on health (expenditure containment path). Over the 
period  until  2016,  the  increase  in  public  health 
long-term  care)  was 
expenditure 
(excluding 
gradually  aligned  with 
the  expected  average 
nominal  growth  of  gross  domestic  product  (plus 
3.6%  per  year) (26).  In  total  it  had  been  agreed  to 
contain expenditures by €3.43 billion until 2016 by 
the  regional  governments  (€2.058  billion)  and  the 
social 
(€1.372  billion). 
institutions 
Actual  containment  exceeded  this  value  in  the 
period  2013-2016,  also  due  to  somewhat  non 
ambitious  targets,  considering  that  in  2011  an 
expenditure growth of 3.3% was recorded and that 
the  expected  growth  for  2012  was  estimated  at 
3.4% (27). 

insurance 

organisation: 

Administrative 
of 
government, levels and types of social security 
settings 
involved,  other 
institutions 

involved,  Ministries 

levels 

As  mentioned  earlier,  the  Austrian  health  system 
has  a  complex  structure  based  on  the  federalist 
structure of the Austrian state, with a multitude of 
relevant  decision  makers (28).  Nevertheless,  the 
level  of  expenditure  in  administering  such  a 
complex 
the  EU 
remains 
average (29).  Public  (0.2%)  and 
total  (0.4%) 

system 

about 

(25)  Austria  scored  0  out  of  6  in  the  2010  OECD  scoreboard 

due to the soft budget constraint. 

(2018)  Monitoringbericht 

(26)  Bachner,  F.,  Bobek,  J.,  Lepuschütz,  L.,  Rainer,  L.,  Zuba, 
I/2018,  Vienna: 
at: 

M. 
GÖG/BMASGK. 
https://www.bmgf.gv.at/cms/home/attachments/9/1/9/CH1
443/CMS1405074131923/monitoringbericht2018_nachbzk
1.pdf. 

Available 

(27)  Austrian  Court  of  Auditors 

(2016a).  Bericht  des 
Rechnungshofes.  Instrumente  zur  finanziellen  Steuerung 
der  Krankenversicherung.  Vienna:  Austrian  Court  of 
Auditors. 

(28)  Irrespective  of  the  reforms  of  2005  (The  2005  Health 
Reform),  which  were  aimed  at  improving  integrated 
planning by the introduction of a Federal Health Agency, a 
Federal  Health  Commission  and  a  Structural  Healthcare 
Plan  at  the  national  level  and  of  State  Health  Funds  and 
Health Platforms at the state level (Austria, ASISP Annual 
Report 2009). 

(29)  Of course, we have to take into account the important share 
of the health expenditure as a % of GDP, and the GDP per 
capita itself. 

10 

expenditure  on  health  administration  and  health 
insurance (HC7) (30) as a percentage of GDP is at 
the same level as the EU average (0.3% and 0.4% 
respectively  in  2015),  and  so  are  public  and  total 
expenditure  on  health  administration  and  health 
insurance  as  a  percentage  of  current  health 
expenditure  2.8%  vs.  3.4  for  the  EU  and  3.8%  vs 
3.8% for the EU in 2015 (31). 

Health  care  insurance  is  provided  by  a  number  of 
health  insurance  funds.  They  are  decentralised 
institutions.  The  Central 
self-administrated 
of  Social-Insurance 
Institutions 
Association 
coordinates 
the  specific 
the  management  of 
institutions.  Insured  individuals  do  not  have  free 
choice of health insurance fund. They are assigned 
a  given  fund  according  to  the  location  of  their 
employer  or  occupational  group 
(e.g.  self-
employed,  farmers,  civil  servants,  specific  funds 
for  miners,  railway  employees,  etc.)  they  belong 
to.  Given  that  the  coverage  of  individual  funds  is 
clearly specified, and the funds cannot choose their 
members  according  to  risk  selection  or  any  other 
criterion,  there  is  no  competition  between  them. 
However,  individual  institutions  have  a  large 
degree 
their 
administrative procedures. 

establishing 

freedom 

of 

in 

Coverage (population) 

insurance 

for  people 

About 99 % of the Austrian population are covered 
by  the  social  health  insurance,  organised  as  a 
in  gainful 
compulsory 
employment.  The  insurance  contribution  covers 
also dependent members of the family (their share 
amounts  to  about  one  third  of  the  total  number 
covered  by  the  statutory  health  insurance),  while 
the persons  without insurance  may have access to 
the  health  care  system  via  means-tested  social 
insurance. 

(30)  Corresponding  to  SHA  classification  HC7  “Governance 

and health system and financing administration”. 

(31)  After  a  data  update  by  Eurostat,  AT  stands  at  2.2%  for 
public  expenditure  on  governance  and  health  system  and 
financing  administration  (HC7)  as  a  share  of  current 
expenditure  on  health  and  at  4.1%  total  expenditure  on 
health administration and health insurance as a percentage 
of  current  health  expenditure.  However  this  data  is  not 
comparable with the figures displayed in this document nor 
with the EU averages. 

 
                                                           
                                                           
Health care systems 

2.1. Austria 

Treatment options, covered health services 

The  benefits  guaranteed  by  the  social  health 
insurance  system  include  both  in-kind  and  cash 
benefits  and  do  not  depend  on  the  level  of 
contributions.  Further,  all  health  insurance  funds 
are  supposed  to  provide  all  necessary  services. 
Still,  the  bundle  of  "necessary  services"  is  not 
explicitly defined by law, which may lead to some 
variations between the funds. 

Role  of  private  insurance  and  out  of  pocket 
co-payments 

Since an individual person apart from members of 
selected  self-governed  professions  has  no  right  to 
opt  out  from  statutory  insurance,  private  health 
insurance serves predominantly as a supplement to 
the  former  and  covers  additional  costs  for 
treatment  in  private  hospitals  or  serves  as  an 
insurance for daily benefits. 

in 

patients 

standard 

Hospitalised 
class 
accommodation  pay  a  fee  of  around  €11  per  day 
for  a  maximum  of  28  days  per  year.  This  fee  is 
collected  directly  by  hospitals.  Here  again, 
individuals who already pay a deductible as well as 
those  in  need  of  social  protection  are  exempted 
from  this  regulation.  Furthermore,  since  2017 
patients  up  to  the  age  of  18  years  are  also 
exempted.    The  co-payment  for  dependants  of 
those  insured  is  slightly  higher  (between  €12  and 
19/day depending on the hospital) (32). 

from 

private 

insurance 

Private  expenditure  (e.g.  patient  co-financing  and 
voluntary 
(5.1% 
health 
combined)  (33)  represented  around  26.4%  of  the 
total  health  expenditure  in  2015,  and  the  share 
increased 
the  2005  value  of  23.3% 
throughout  the  decade.  The  figure  for  2015  is 
slightly  above  the  EU  average  of  21.6%  for  the 
same  year.  Out-of-pocket  spending  accounts  for 
17.9%  of  total  current  health  spending  (slightly 
above  the  EU  average  of  15.9%  in  2015)  and, 
though  slightly  fluctuating  during  the  past  decade 
remained  broadly  stable  since  2005  
it  has 
(17.8%) (34).  Over  the  same  period,  the  share  of 

(32)  Source: HIT 2018 and sozialversicherung.at. 
(33)  Note 

that  Non-profit 

institutions  serving  households 
(NPISH) and company schemes (1.8%) are included in the 
share of 26.4%. 

(34)  Note  that  since  2008,  prescription  charges  are  limited  to 

2% of annual net income. 

the 

public  expenditure  out  of 
total  health 
expenditure  has  decreased  going  from  76.7%  to 
73.6%, but the share of public spending out of total 
in  2015)  has 
government  spending 
remained 
last 
the 
decade (14.2% in 2005). 

constant 

(14.4% 

quite 

over 

Types of providers, referral systems and patient 
choice 

Patients  who  are  insured  in  the  mandatory  social 
health  insurance  system,  as  well  as  their  family 
members,  are  provided  with  electronic  health 
insurance  cards  (E-Cards)  being  certificates  of 
entitlement to health services. For each accounting 
period, which is usually 1 or 3 months – depending 
on  the  insurance  fund  -  a  patient  can  choose  one 
general  practitioner  (GP)  and  one  specialist,  for 
any specialty (35), by means of his/her personal E-
Card,  which  has  replaced 
the  former  health 
vouchers.  For  the  issue  of  an  E-Card,  a  lump 
sum (36) deductible is paid. He/she can also switch 
the  contract  physician  with  the  agreement  of  the 
health insurance fund (37). 

A large share of primary care is provided by self-
employed  physicians  who  predominantly  work  in 
individual  practices.  Patients  have  also  direct 
access  to  outpatient  clinics  which  are  run  by  both 
the social health insurance schemes and by private 
individuals.  Outpatient  care  is  mostly  based  on 
contractual 
individual 
relationships  between 
private  providers  and  insurance  funds,  but  a  large 
share  of  patients  also  opt 
for  outpatient 
departments of publicly run hospitals. 

Hence,  private  practices  are  run  by  self-employed 
physicians,  about  half  of  which  are  general 
practitioners  and  half  specialists.  The  number  and 
regional  distribution  of  self-employed  physicians 
is specified in the "location plan" drawn up by the 
health  insurance  funds  and  the  Medical  Chamber 
in  order  to  avoid  imbalances  in  the  provision  of 
care. However, there are large differences between 
rural and urban areas. 

Only  around  51%  of  physicians 
(including 
dentists)  in  private  practice  have  a  contract  with 

(35)  For up to 3 specialists by period. 
(36)  €10.85 in 2016. 
(37)  According to the OECD, the level of choice of provider in 

Austria had a score of 2.7 out of 6 in 2010. 

11 

 
                                                           
                                                           
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one  or  more  health  insurance  fund  in  December 
2015 (38).  They  exercise 
to  some  extent  a 
gatekeeper  function  as  they  can  control  patients' 
flows  by  referrals.  This  is  the  case  when  several 
physicians  are  consulted  in  one  accounting  period 
or  when  hospital  treatment  is  required.  The  other 
49% private physicians who do not hold a contract 
with a health insurance fund do not require E-card 
intervention  and  mostly  apply  much  higher  fees, 
whereas  their  services  are  reimbursed  for  four 
fifths  of  the  fee  which  the  health  insurance  funds 
would pay for a "contracted physician". 

out in health planning (41). As such, inpatient care 
is predominantly provided by the public entities. A 
minor  share  is  also  organised  by  the  private  non-
profit-making providers, who operate according to 
the  public  law  and  by  private  profit-making 
hospitals ( 42). Hospitals which are subject to public 
law are obliged to admit and provide services to all 
patients,  but  are  entitled  to  receive  state  subsidies 
for  their  day-to-day  operations.  On  the  contrary, 
private for-profit providers have the right to refuse 
patients, but must finance their operations on their 
own. 

The  number  of  practising  physicians  per  100,000 
inhabitants (510 in 2015) is above the EU average 
(344  in  2015)  and  showing  a  consistent  increase 
since 2005 (432). The number of GPs per 100,000 
inhabitants  (77  in  2015)  is  in  line  with  the  EU 
average  (78  for  the  same  year),  and  has  remained 
stable  during  the  past  decade  (76  in  2005).  This 
figure,  paired  with  the  high  number  of  practicing 
physicians,  suggests  that  the  Austrian  health  care 
system  is  currently  hospital  centred.  The  number 
of  practicing  nurses  per  100,000  inhabitants  (805 
in  2015)  is  slightly  below  the  EU  average  (833) 
having  increased  throughout  the  decade,  from  a 
level  of  718  in  2005 (39).  Still,  there  have  been 
concerns about inequalities in the supply structure 
between  the  states  and  also  between  urban  and 
rural  areas.  In  addition,  staff  issues  may  be 
reinforced  by  the  fact  that  in  2015  as  many  as 
58% (40) of all physicians were more than 45 years 
old  in  2012  and  many  will  retire  in  less  than  10 
years.  These 
a 
comprehensive  human  resources  strategy  may  be 
necessary in order to ensure that the skill mix stays 
in  favour  of  a  primary  care  oriented  provision, 
without excessive recourse to it, and face regional 
disparities and staff ageing. 

elements 

suggest 

that 

to 

the 

law, 

is,  according 

Hospital  care 
the 
responsibility  of  the  states.  The  Federal  Hospitals 
Act (KAKuG) stipulates  that  each state is obliged 
to  ensure  the  availability  of  inpatient  care  for 
people  who  require  it.  The  states  establish  the 
structure of inpatient acute care in quantitative and 
qualitative terms according to the specifications set 

(38)  Excluding dentists the corresponding share was 45%. 
(39)  Data  for  density  of  health  personnel  is  taken  from  the 
OECD  database.  As  this  figure  includes  only  nurses 
employed 
the  actual  number  may  be 
underestimated. 

in  hospitals, 

(40)  Source: Austrian Medical Chamber. 

12 

The  management  structure  of  the  hospital  sector 
changed  considerably  over  the  first  half  of  the 
decade  of  2000s,  as  public  hospitals  have  been 
assigned operating companies which act according 
to  the  private  law.  A  similar  change  has  taken 
place  in  the  case  of  private  non-profit  making 
companies. 

Empirical  data  suggest  overutilisation  of  hospital 
care in Austria. The number of available acute care 
beds  (566  per  100,000  inhabitants  in  2015), 
although  somewhat  lower  than  a  decade  before 
(643 per 100,000 in 2005) is more than 40% higher 
than the respective amount in the EU (402). At the 
same  time,  the  inpatient  average  length  of  stay  of 
8.5  days  is  above  the  EU  average  for  2015  (7.6), 
and  the  number  of  inpatient  discharges  per  100 
inhabitants  (26)  is  one  of  the  highest  in  the  EU, 
more than 60% higher than the EU average of (16). 
Consistently, the number of day-case discharges is 
lower  than  average  (7,031  in  Austria  vs.  7,635  in 
the  EU  in  2015).  Sectoral  fragmentation,  which 
also  creates  the  bias  towards  hospital  care,  is  a 
long standing weakness of the Austrian health care 
system.  Therefore,  it  seems  essential  to  improve 
the cost efficiency of the hospital care, by reducing 
the number of beds and replacing acute care stays 
with day-case treatments or outpatient treatment.  

The physicians who operate their private outpatient 
practice  are  reimbursed  by  the  insurance  funds 
according to a mixed fee system, which combines 
lump-sum payment for basic services with fee-for-
service  for  more  complex  treatments.  The  level 
and  structure  of  payment  is  established  in  regular 

(41)  HIT 2013. 
(42)  72.5%  of  acute  care beds  are  in  publicly  owned  hospitals, 
18.8% in not-for-profit privately owned hospitals and 8.7% 
in for-profit ones. 

 
                                                           
                                                           
Health care systems 

2.1. Austria 

negotiations  between  health  insurance  funds  and 
the  Medical  Chamber  and  varies  heavily  across 
funds  and  specialties.  In  practice,  specialists  who 
execute more complicated or technical tasks (in the 
areas such as radiology or laboratory analysis) are 
paid  almost  exclusively  according  to  a  fee-for-
service scheme, while general practitioners receive 
proportionately  more  often  flat  rate  payments  per 
basic  case,  which  are  accompanied  by  basic 
practice allowances and fees for home visits. 

psychiatric  day  care,  etc.),  while  special  rules 
apply for stays which are longer or shorter than the 
predefined  bounds.  Financing  in  the  fund  control 
area  can  be  modified  by  the  individual  states, 
which  gives  them  an  opportunity  to  take  into 
account  different  structural  criteria  (e.g.  hospital 
type,  staff,  equipment,  state  of  hospital  buildings, 
utilisation of capacities, quality of accommodation, 
etc.)  when  distributing  financial  resources  among 
the hospitals. 

The  level  of  the  flat  rate  fees  for  basic  services 
varies  according  to  specialty  and  state.  In  some 
states,  in  order  to  distribute  the  general  budget 
more equally among the physicians, it is calculated 
on a decreasing scale, depending on the number of 
E-Card  certificates  invoiced  per  provider  and  per 
accounting period. 

About  50%  ( 43)  of  specialists  work  exclusively  in 
hospitals  and  are  paid  salaries,  which  vary  across 
states. They can also treat private patients in public 
hospitals  and  earn  additional  incomes  from  these 
practices. 

Hospitals  are  paid  differently  depending  on  the 
type  of  expenditure.  Investment  and  capital  costs 
are borne by the owners and operating companies. 
The  ongoing  operating  costs  are  estimated 
prospectively  based  on  the  modified,  activity-
oriented  diagnosis-related  groups  (DRGs).  The 
units  of  calculation  are  points,  whose  value  is 
established retrospectively at the level of the state 
by  dividing  the  fixed  budget  by  the  number  of 
points performed during  the accounting period. In 
the DRG system two types of payments exist: the 
nationally  uniform  DRG  core  area  and  the  DRG 
fund control area, which can vary according to the 
state. Health insurance funds also participate in the 
funding  of  hospitals  by  transferring  a  fixed  share 
of  their  resources  (about  35%)  to  the  states’ 
hospital funds. 

In the core area, procedure- and diagnosis-oriented 
case groups form the basis for awarding points for 
an inpatient stay.  A nationally  uniform number of 
points is allocated for stays in a number of selected 
specialised  units  (intensive  care,  geriatric  care, 

(43)  Bachner F, Bobek J, Habimana K, Ladurner J, Lepuschütz 
L, Ostermann H, Rainer L, Schmidt A E, Zuba M, Quentin 
W,  Winkelmann  J.  (2018)  Austria:  Health  system  review. 
Health Systems in Transition, 2018; 20(3): 1 – 256. 

. 

The  activity-related  hospital 
financing  DRG 
system was introduced in 1997. The main effect of 
this  measure  was  a  shortening  of  the  average 
length  of  stay,  but  also  increased  hospitalisations 
and a shift towards high scoring diagnoses (44). 

In  2017  it  was  agreed  to  introduce  the  diagnosis-
related  groups  reimbursement  system  also  for 
ambulatory  departments  in  hospitals.  This  has  the 
aim to promote a shift of excess capacity from the 
inpatient to the outpatient sector and a consequent 
reduction in acute care beds. 

The market for pharmaceutical products 

Public  expenditure  on  pharmaceuticals  (45)  is  just 
below  the  EU  average  when  measured  as  %  of 
GDP (0.9% vs. 1.0% in 2015), and it is also lower 
when  calculated  as  percentage  of  public  current 
health expenditure (11.3% vs. 12.7% in 2015). 

for 

Austria  applies  external  price  referencing  when 
establishing  maximum  price 
reimbursed 
pharmaceuticals.  The  price  of  drugs,  taking  into 
account  ex-factory  and  wholesale  price  level,  is 
included  in  the  Reimbursement  Code  -  or  "EKO" 
(“Erstattungskodex”),  in  place  since  2005  -  and 
cannot  be  higher  than  the  EU  average  price,  as 
established by the Pricing Committee. 

All  reimbursable  pharmaceuticals  are  explicitly 
listed  in  a  list  annexed  to  the  Austrian  Social 
Insurance Law. The cost-sharing mechanism takes 
the form of a flat rate fee paid for each prescription 

(44)  As a result, the OECD score for remuneration incentives to 

raise the volume of care in Austria is 3 out of 6. 

(45)  Expenditure  on  pharmaceuticals  used  here  corresponds  to 
category  HC.5.1  (pharmaceuticals  and  other  medical  non- 
durables)  in  the  OECD  System  of  Health  Accounts.  Note 
that this SHA-based estimate only records pharmaceuticals 
in  ambulatory  care  (pharmacies),  not  in  hospitals.  Data  is 
taken from Eurostat. 

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Health  Technology  Assessments.  Preselected 
medical devices undergo HTA assessment through 
the  annual  evaluation  of  their  uptake  into  the 
Austrian  DRG  system.  For  pharmaceuticals,  up 
until  now,  there  has  been  no  uniform  and  formal 
HTA process in place. However, in  the outpatient 
sector  pharmaceuticals  are  evaluated  in  an  HTA 
related  process  to  establish  a  positive  list  of  the 
pharmaceuticals  that  are  covered  by  the  public 
health insurance scheme.  

eHealth, Electronic Health Record 

In  2012  the  Austrian  parliament  passed  a  law  to 
strengthen  eHealth  in  the  Austrian  health  care 
system  by 
the  Electronic  Health 
Record  (ELGA).  Its  implementation  is  making 
significant progress together  with its e-medication 
and e-report applications.  

introducing 

The  Electronic  Health  Record  (ELGA)  is  an 
information  system  that  offers  personalised  health 
data  to  the  individual  citizens  and  to  their  health 
service  providers  (hospitals,  pharmacies,  general 
practitioners,  specialists,  etc.).  Doctors  can  access 
individual  medical  exams,  prescriptions  and  other 
relevant  health  information  independently  from 
location  and 
their 
in  order 
decisions and diagnoses. 

to  support 

time 

ELGA  aims  to  raise  quality  of  care  and  thus 
patient safety. It also helps to reduce organisational 
barriers,  avoid  duplication  of  medical  exams  by 
improving 
the 
information  flow  between  health  care  providers' 
crosslinking interfaces. 

coordination 

ensuring 

and 

Patients are generally free to opt out of ELGA, but 
also have the right to ban only certain information 
within  the  portal  or  even  a  single  health  care 
provider  from  usage.  Patients  will  also  be  able  to 
check who is accessing their individual record. 

is 

limited 

to  ELGA 

Access 
to  health  care 
providers.  Private  companies,  health  insurers  or 
employers  are  strictly  banned  from  accessing  the 
health  records.  The  functionalities  of  ELGA  will 
be implemented stepwise. 

a 

ceiling  on  prescription 

by  all  patients,  apart  from  socially  disadvantaged 
people  (in  particular  elderly  pensioners  with  an 
income below a certain threshold and persons with 
communicable  diseases)  who  are  exempted. 
Moreover, 
fees 
(Rezeptgebührenobergrenze)  was  introduced  in 
2008. Patients have to pay the flat rate prescription 
fee  until  it  exceeds  the  threshold  of  2%  of  their 
annual  net  income.  Patients  pay  out-of-pocket  for 
over-the-counter 
non-reimbursable 
and 
pharmaceuticals, but in some precisely determined 
circumstances, 
individual 
reimbursement, which requires an ex-ante approval 
of the head physician.  

they  can  apply  for 

through 

is  ensured 

Rational  prescribing 
the 
Economic  Prescription  Guidelines  published  by 
the  Main  Association  of  Social  Security 
Institutions  (MASSI)  in  2004.  These  guidelines 
encourage  doctors 
the  most 
several 
economical  pharmaceutical  out  of 
therapeutically  similar  alternatives ( 46).  Regional 
health  funds  also  monitor  the  prescribing  patterns 
of GPs and specialists who are under contract with 
them,  and  provide  them  with  information  leaflets 
and newsletters (47). 

to  prescribe 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

A  national Health Technology  Assessment (HTA) 
strategy  was  published 
in  2010,  establishing 
common goals of the major decision-makers in the 
health-care  sector  and  creating  a  framework  for 
expanding  the  use  of  HTA.  The  importance  of  an 
evaluation of health technologies as an instrument 
to support or to control their dissemination and use 
or to help define policies is increasingly referred to 
by  the  public  health  insurances  and  hospitals. 
Several  academic  institutions  (48)  are  carrying  out 

Pharma 

(46)  Vogler,  S.,  Schmickl,  B.,  Zimmermann,  N.,  Short  PPRI  / 
PHIS 
2013.  Vienna: 
Profile  Austria 
Pharmaceutical  Pricing  and  Reimbursement  Information 
(PPRI) 
/  Pharmaceutical  Health  Information  System 
(PHIS). 
http://whocc.goeg.at/Literaturliste/Dokumente/CountryInfo
rmationReports/Short_PPRI_PHIS_Pharma_Profile_Austri
a_2013_final.pdf. 

(47)  Vogler,  S.;  Zimmermann,  N.,  (2013),  'How  do  regional 
sickness  funds  encourage  more  rational  use  of  medicines, 
including  the  increase  of  generic  uptake?  A  case  study 
from  Austria',  Generics  and  Biosimilars  Initiative  Journal 
(GaBI Journal) 2/2:65-75. 

(48)  Currently:  LBI-HTA,  GÖG,  Donau-Uni  Krems,  Med-Uni 

Graz, UMIT. 

14 

 
                                                           
Health care systems 

2.1. Austria 

Health  and  health-system 
reporting mechanisms 

information  and 

In the past few years, great efforts have been made 
to  build  and  expand  information  systems  in  the 
health  care  system  with  the  principal  aim  of 
increasing 
transparency.  A  series  of  national 
guidelines  on  the  systematic  documentation  of 
services  and  costs,  particularly  in  inpatient  care, 
were recently issued or refined. 

organisation  of  the  system,  on  providers  and 
services, on the “best point of service” for patients 
according  to  their  needs,  and  on  the  quality  of 
treatments. Equal attention is paid to measures that 
contribute to the improvement of health literacy of 
the  population  and  of  communication  skills  of 
health  care  providers.  Transparency 
is  also 
improved  by  the  obligation  to  publish  major 
reform documents and evaluation reports. 

Health  promotion  and  disease  prevention 
policies 

As  introduced,  some  socio-economic  risk  factors 
could translate into an important burden of disease 
and  financial  costs.  This  is  why  the  authorities 
have  emphasised  somewhat  health  promotion  and 
disease  prevention  measures  in  very  recent  years. 
Currently,  public  and 
total  expenditure  on 
prevention and public health services as a share of 
GDP  (0.2%  and  0.2%  in  2015)  are  close,  though 
slightly below, the EU average (0.3% and 0.3% in 
the  same  year).  The  figures  are  below  average 
when  measured,  as  a  %  of  total  current  health 
expenditure, with 2.1% vs. 3.1% for total and 2.1% 
vs. 3.2% for public expenditure in 2015 (49). 

Transparency and corruption 

Since  2008,  anti-corruption  legislation  has  aimed 
to  increase  transparency  in  the  formation  of 
waiting lists and to minimise the incentive to make 
and  solicit  informal  payments  but  were  relaxed 
slightly  again  in  2009 (50).  Doctors  have  to  abide 
by  the  medical  association’s  code  of  conduct  (51), 
which  regulates  in  this  context  the  cooperation 
industry 
between  doctors  and  pharmaceutical 
regarding attendance at conferences, acceptation of 
gifts  or  professional  samples.  Patients  have  the 
possibility  of  complaint;  there  are  ombudspersons 
and patients advocates in charge. 

Improving  transparency  within  the  health  care 
system is also a major target of the health reforms 
includes 
launched 
the 
improvement  of 

information  systems  on 

2013.  The 

target 

in 

(49)  Data  on  expenditure  on  prevention  and  public  health 

services was taken from OECD. 

(50)  HiT 2018. 
(51)  http://www.aerztekammer.at/. 
documents/10431/19066/%C3%84rztlicher+Verhaltenskodex+

konsolidierte+Fassung/4ce3afe0-57d0-4cc4-923a-
0dab81fe045f?version=1.0&t=1387379387000. 

Recently 
reforms  

legislated  and/or  planned  policy 

to  address 

In  order 
the  major  challenge 
(fragmentation)  of  the  Austrian  health  system  the 
Federal Ministry of Health started a reform process 
in  December  2010  by  drawing  the  roadmap  for  a 
health reform in the next years. The key element of 
the  reform 
is  a  cooperative  “governance  by 
objectives”  approach  for  achieving  targets  which 
the 
will  guarantee  better  coordination  within 
system. 

The first period of the health care reform (“target-
based health governance”) covered the years 2013 
to  2016.  At  the  end  of  the  year  2016  the  federal 
government,  the  regional  governments  and  the 
social 
the 
continuation  of  the  health  reform  for  the  years 
2017 to 2021. 

institutions  agreed  on 

insurance 

First period of the health reform (2013 to 2016)  

With  the  reform  of  the  Austrian  Internal  Stability 
Pact,  agreement  was  reached  to  limit  health 
expenditure  growth.  In  the  context  of  the  health 
system  reform  plan  (2013-2016)  the  different 
layers of government agreed to limit public health 
expenditure  growth  from  2016  onwards  so  that  it 
remains  in  line  with  expected  average  nominal 
GDP growth. 

Major  elements  of  the  health  reform  are:  1)  the 
creation  of  institutional  capacity  for  the  effective 
realisation  of  the  “governance  by  objectives” 
approach,  2)  enhanced  primary  health  care 
capacity,  3)  standardisation  of  care  processes,  4) 
monitoring  of  health 
the 
definition of accounting standards to better enable 
adherence to the budget cap. 

indicators  and  5) 

The reform also included financial targets and the 
introduction of a budget cap on public expenditure 

15 

 
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

on health (expenditure containment path). The aim 
was to gradually align the increase in public health 
expenditure  (excluding  long-term  care)  with  the 
expected  average  nominal  growth  of  gross 
domestic  product  (plus  3.6  %  per  year)  over  the 
period  until  2016.  According  to  the  financial 
monitoring  reports,  the  states  and  the  social 
financial 
insurance 
targets in the first reform period, though the targets 
were criticised for their lack of ambition ( 52).  

institutions 

reached 

their 

Already  in  the  first  reform  period  (2013-2016),  a 
contract  between  the  federal  government,  social 
insurance  institutions  and  the  states  had  been 
signed  to  formalise  both  health  and  financial 
targets.  It  is  divided  into  four  key  areas  (1)  the 
structure  of  provision,  (2)  the  process  of  care,  (3) 
outcome  and  health  targets  and  (4)  financial 
targets.  

In order to raise institutional capacity the “Federal 
Target-Based  Governance  Commission”  was 
established in 2013 as a new cooperative decision-
“Federal  Target-Based 
making  body.  The 
for 
Governance  Commission” 
steering  and  controlling  the  Austrian  health  care 
system. At the state level, nine “Provincial Target-
Based Governance Commissions” were established 
in order to ensure “governance by objectives”.  

responsible 

is 

Second period of the health reform (2017 to 2021) 

In the course of the reform of the Austrian Internal 
Stability  Pact  an  agreement  was  reached  on  the 
legal  basis  for  the  health  care  reform  from  2017 
onwards.  

for 

second  period  are 
the 
The  priorities 
strengthening  of  the  primary  health  care  sector, 
fostering of day clinic service provision, increased 
health  promotion  and  prevention,  joint  provision 
further 
and  procurement  of  pharmaceuticals, 
strengthening of the public health care system (e.g. 
focusing  on  the  extension  of  in-kind  benefits), 
measurement  of  outcome  quality,  improvements 
for  health  professionals  (e.g.  skill  mix)  and  e-
health.  

(52)  Austrian  Court  of  Auditors 

(2016a).  Bericht  des 
Rechnungshofes.  Instrumente  zur  finanziellen  Steuerung 
der  Krankenversicherung.  Vienna:  Austrian  Court  of 
Auditors. 

16 

Stakeholders  also  reached  an  agreement  on  the 
continuation  of  target-based  financial  governance 
mechanisms  with  the  aim  of  reducing  annual 
growth  of  public  health  expenditure  (excluding 
long-term  care)  stepwise  from  3.6  percentage 
points  to  3.2  percentage  points  in  2021,  based  on 
GDP growth. 

governance 

target-based 

In  April  2017  the  federal  government,  the  states 
and the social insurance institutions agreed on the 
federal 
contract 
(“Zielsteuerungsvertrag”)  for  the  years  2017  to 
2021,  where  the  agreed  measures  and  financial 
targets  are  operationalised.    The  fragmentation  of 
financing  responsibilities  between  inpatient  and 
ambulatory  sector  contributes  to  inefficiencies, 
especially  in  the  hospital  sector.  While  many 
reform  waves  have  attempted  to  improve  the 
coordination and cooperation in the health system, 
promoting 
and 
financing  by  putting  the  Federal  Target-Based 
Commission  in  charge  of  implementing  the  new 
governance,  fragmentation  in  the  organisational 
and financial structure is still a challenge. 

joint  planning,  governance 

that 

is  promising 

It 
the  states’  healthcare 
expenditure,  having  for  many  years  exhibited  a 
rate  of  growth  above  that  of  other  levels  of 
government  and  above  nominal  GDP  growth,  has 
been  much  better  controlled  in  recent  years. 
However,  the  target  to  converge  to  3.2%  in  2021 
could  make  compliance  more  challenging  in  this 
second phase.  

the  previous 

Following general elections in October 2017, new 
coalition government decided to merge the Federal 
Ministry  of  Health  with  the  Federal  Ministry  of 
Labour,  Social  Affairs  and  Consumer  Protection, 
forming  the  new  Federal  Ministry  of  Labour, 
Social  Affairs,  Health  and  Consumer  Protection 
(BMASGK).  While  there  are  substantial  overlaps 
reform  agenda,  such  as 
with 
strengthening  primary  health  care,  reallocation  of 
resources  and  focus  on  public  health,  the  new 
programme  also  envisages  an  overhaul  of  the 
social  security  system,  with  mergers  of  existing 
social security funds bringing the number from 21 
down to 5. This reform aims  to improve the cost-
efficiency, 
the 
system ( 53).  A  recent  comprehensive  study  of  the 

transparency  and  equity  of 

(53)  Country Report Austria 2018 {COM(2018) 120 final}. 

 
                                                           
                                                           
in  procurement  could 

Austrian  system  (54)  concludes  that  an  effective 
risk  adjustment  mechanism  and  reducing  the 
fragmentation 
increase 
efficiency. While expected benefits are assumed to 
materialise  in  the  medium/long  term,  costs  from 
mergers  will  necessarily  materialise  in  the  short 
term.  The  new 
to  be 
implemented in the course of 2019. 

is  expected 

reform 

Challenges 

A  range  of  reforms  have  been  implemented  in 
recent years – or are still in the process of gradual 
implementation  –  implying  substantial  structural 
changes,  with  a  focus  on  more  integrated  nation-
wide planning, assuring and improving the quality 
fiscal 
of 
sustainability  of  the  health  care  system.  As  the 
analysis above has shown, the main challenges for 
the  Austrian  health  system  currently  are  as 
follows:  

the  health  system,  and  ensuring 

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the 
the  rising  expenditure  pressures  over 
coming decades, which is a risk to the medium 
and long-term sustainability of public finances. 

•  To  explore  if  current  cost-sharing  could  be 
adjusted 
to  discourage  overuse/  encourage 
better  use  of  more  effective  and  cost-effective 
services  –  e.g.  use  of  primary  care  rather  than 
specialist  care,  and  notably  more  health 
promotion  and  disease  prevention  activities 
(e.g. vaccination). 

and 
by 

•  To  correct  the  misalignment  between  revenue 
currently 
spending, 
generation 
characterised 
of 
high 
a 
decentralisation,  to  improve  coordination  at 
sub-federal level and increase efficiency in the 
reduce 
provision 
unnecessary costs. 

health 

level 

care 

and 

of 

•  To  continue 

human 
spatial/regional 

resources 

to  develop  a  comprehensive 
tackles 
inequalities 

disparities 

strategy 

that 

– 

(54)  LSE  Consulting  (2017).  Efficiency  review  of  Austria’s 
social  insurance  and  healthcare  system.  Volume  1  – 
International  Comparisons  and  Policy  Options.  London: 
London  School  of  Economics  and  Political  Science  (LSE 
Health). 

Health care systems 

2.1. Austria 

between the states and between urban and rural 
areas  –  and  that  ensures  sufficient  numbers  of 
staff  in  general  and  in  the  future  in  view  of 
population ageing. 

•  To 

the 

tackle 

degree 

excessive 

of 
hospitalisation, one of the  major drivers of the 
high spending, deriving from the fragmentation 
of competencies between different government 
levels,  where  states  and  local  governments  are 
both  involved  in  providing  hospital  services, 
while  out-patient  care  is  provided  by  social 
security  services,  and  the  consequent  weak 
incentives  to  shift  care  from  hospitals  to 
outpatient settings. 

•  To control more effectively the use of specialist 
and  hospital  care,  by  strengthening  primary 
health  care  as  a  gatekeeper  and  fostering  the 
coordination  of 
care  between  primary, 
secondary  and  hospital  care.  To  this  end,  to 
strengthen/improve  the  referral  system  and 
ensure  reimbursement  of  health  care  providers 
delivers  the  incentives  to  pursue  efficiency 
goals. 

•  To 

the 

improve 

cost-efficiency  within 
hospitals,  ensuring  that  care  is  provided  in  the 
most  clinically  appropriate  and  cost-effective 
way, 
the 
proportion  of  elective  care  provided  on  a  day 
case  basis,  day-of-surgery  admission  and 
containing unnecessary hospitalisation. 

for  example  by 

  maximising 

•  To  monitor  and  adapt,  as  necessary, 

the 
functioning  and  competences  of  the  “Federal 
Target-Based  Governance  Commission”  and 
the  “Federal  Health  Commission”  with  a  view 
to  give  room  to  further  improve,  cost  control, 
quality management and efficiency. To monitor 
how  the  work  of  these  governing  bodies  is 
aligned with fiscal targets established for health 
care  spending,  as  well  as  with  national  public 
health goals. 

•  To improve data collection, especially in some 
crucial  areas  such  as  resources  and  care 
utilisation;  to  improve  the  patient  information 
system. 

17 

 
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  To  foster  the  wide  use  of  Health  Technology 
and 

Assessment 
communication technologies in health care. 

information 

and 

•  To  further  enhance  health  promotion  and 
disease prevention activities, promoting healthy 
life styles and disease screening given the most 
recent pattern of risk factors (smoking, alcohol, 
cardiovascular diseases). 

•  To further strengthen the health literacy of the 
population  by  improving  health  information 
systems and monitoring of health literacy. 

18 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.1.1:  Statistical Annex – Austria 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

1
9

EU- latest national data

2005

254

32.5

1.5

:

2005

10.2

9.4

0.8

2006

268

33.4

2.9

1.4

2006

10.1

9.6

0.5

2007

284

34.0

3.4

3.7

2007

10.1

9.6

0.4

2008

294

33.6

1.1

2.9

2008

10.3

9.6

0.7

2009

288

31.4

-4.0

1.0

2009

10.8

9.5

1.3

2010

296

32.2

1.6

1.6

2010

10.8

9.5

1.3

2011

310

32.9

2.6

0.8

2011

10.6

9.9

0.7

2012

319

33.8

0.2

2.9

2012

10.9

10.1

0.8

2013

324

33.3

-0.6

-0.3

2013

10.9

10.2

0.7

2014

333

33.4

0.0

1.0

2014

11.0

10.3

0.8

2015

344

34.2

0.1

0.2

2015

11.1

10.3

0.7

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,873

2,966

3,145

3,299

3,393

3,479

3,572

3,754

3,806

3,928

4,031

2,745

2,895

7.8

7.5

7.7

7.5

7.8

7.5

8.0

7.7

8.5

8.1

8.4

8.1

7.9

7.5

8.1

7.7

8.0

7.7

8.1

7.8

8.1

7.8

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,204

2,277

2,421

2,571

2,661

2,714

2,650

2,774

2,800

2,889

2,965

2,153

2,263

2,324

2,609

0.33

76.7

14.2

98.0

17.8

0.28

76.8

14.6

98.5

17.4

0.31

77.0

14.8

98.7

17.3

0.31

77.9

14.5

98.8

16.9

0.35

78.4

14.0

98.8

17.0

0.36

78.0

14.3

98.8

17.2

0.35

74.2

14.6

99.9

17.8

0.37

73.9

14.5

99.9

17.8

0.36

73.6

14.8

99.9

18.2

0.36

73.6

14.0

99.9

18.1

0.33

73.6

14.4

99.9

17.9

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

8.2

82.2

76.6

60.1

58.2

54

4.2

8.3

82.8

77.1

61.0

58.7

52

3.6

8.3

83.1

77.4

61.4

58.7

48

3.7

8.3

83.3

77.7

59.9

58.5

47

3.7

8.3

83.2

77.6

60.8

59.5

45

3.8

8.4

83.5

77.8

60.8

59.4

43

3.9

8.4

83.8

78.3

60.1

59.5

114

3.6

8.4

83.6

78.4

62.5

60.2

112

3.2

8.5

83.8

78.6

60.2

59.7

112

3.1

8.5

84.0

79.1

57.8

57.6

109

3.0

8.6

83.7

78.8

58.1

57.9

109

3.1

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

3.5

0.0

2.5

1.3

0.4

0.2

0.4

3.0

0.0

1.7

0.9

0.2

0.2

0.3

3.4

0.0

2.4

1.3

0.4

0.2

0.4

3.0

0.0

1.7

0.9

0.2

0.2

0.2

3.4

0.0

2.4

1.3

0.4

0.2

0.4

3.0

0.0

1.7

0.9

0.2

0.2

0.2

3.5

0.0

2.4

1.4

0.4

0.2

0.4

3.1

0.0

1.7

0.9

0.2

0.2

0.3

3.7

0.0

2.6

1.3

0.5

0.2

0.4

3.2

0.0

1.8

0.9

0.2

0.2

0.3

3.7

0.1

2.6

1.3

0.4

0.2

0.4

3.2

0.1

1.8

0.9

0.2

0.2

0.3

3.4

0.1

2.5

1.2

0.4

0.2

0.4

3.0

0.1

1.7

0.8

0.2

0.2

0.2

3.5

0.1

2.5

1.2

0.4

0.2

0.4

3.0

0.1

1.8

0.8

0.2

0.2

0.2

3.4

0.1

2.5

1.2

0.5

0.2

0.4

3.0

0.1

1.8

0.8

0.2

0.2

0.2

3.5

0.1

2.6

1.3

0.5

0.2

0.4

3.0

0.1

1.8

0.9

0.2

0.2

0.2

3.4

0.1

2.6

1.3

0.5

0.2

0.4

3.0

0.1

1.9

0.9

0.2

0.2

0.2

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

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Table 2.1.2:  Statistical Annex - continued – Austria 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

36.8%

0.4%

26.2%

14.1%

4.4%

2.1%

4.4%

40.0%

0.4%

22.9%

11.9%

2.7%

2.3%

3.5%

2005

1.62

0.9

3.0

0.2

:

:

12.4

2005

432

718

76

690

2005

6.7

27

2006

35.7%

0.4%

25.1%

13.8%

4.3%

2.0%

4.1%

40.0%

0.5%

22.8%

11.8%

2.7%

2.3%

3.1%

2006

1.68

0.9

3.0

0.2

12.4

23.2

12.4

2006

445

727

77

617

2006

6.7

28

2007

35.0%

0.4%

25.3%

13.9%

4.3%

2.0%

4.0%

39.7%

0.5%

22.9%

12.2%

2.5%

2.3%

3.2%

2007

1.77

0.9

3.0

0.2

:

:

12.5

2007

453

738

77

608

2007

6.8

28

2008

36.3%

0.5%

25.4%

14.4%

4.3%

2.0%

4.3%

39.8%

0.6%

22.4%

12.2%

2.6%

2.1%

3.3%

2008

1.80

:

3.0

0.2

12.8

22.9

12.0

2008

460

752

77

559

2008

6.9

28

2009

38.6%

0.5%

27.7%

14.0%

4.7%

2.0%

4.5%

39.9%

0.6%

22.6%

11.1%

2.6%

2.0%

3.2%

2009

1.84

:

2.9

0.2

:

:

11.3

2009

468

761

77

553

2009

6.9

28

2010

38.5%

0.5%

27.3%

13.8%

4.6%

2.0%

4.4%

40.1%

0.6%

22.3%

10.9%

2.6%

2.0%

3.1%

2010

1.86

:

3.0

0.2

:

:

12.1

2010

478

767

78

546

2010

6.9

28

2011

34.4%

0.5%

24.7%

12.5%

4.3%

2.0%

3.5%

39.3%

0.7%

23.0%

11.2%

2.5%

2.0%

2.8%

2011

1.86

:

2.9

0.2

:

:

12.0

2011

482

775

78

535

2011

6.9

27

2012

34.5%

0.7%

24.5%

12.1%

4.3%

2.0%

3.6%

39.4%

0.9%

23.0%

10.9%

2.6%

2.0%

2.9%

2012

1.91

:

3.0

0.2

:

:

12.3

2012

490

783

78

528

2012

6.8

27

2013

33.7%

0.8%

24.9%

12.2%

4.4%

2.1%

3.7%

38.7%

1.0%

23.4%

10.8%

2.6%

2.0%

2.9%

2013

1.92

:

3.0

0.2

:

:

11.8

2013

499

787

77

523

2013

6.8

27

2014

33.5%

0.9%

25.0%

12.3%

4.5%

2.1%

3.7%

38.4%

1.0%

23.6%

11.1%

2.6%

2.1%

2.8%

2014

1.97

:

2.9

0.2

14.3

24.3

12.3

2015

33.2%

0.9%

25.1%

12.4%

4.5%

2.1%

3.8%

38.2%

1.2%

23.7%

11.3%

2.6%

2.1%

2.8%

2015

2.07

:

2.9

0.2

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2014

2015

2009

2011

2013

2015

505

800

77

524

2014

6.8

26

510

805

77

518

2015

6.6

26

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

4,487

4,834

5,113

5,457

5,501

5,690

6,018

6,348

6,595

6,911

7,031

6,362

6,584

86.0

7.0

14.0

2016

7.0

7.0

2016

8.7

87.0

6.9

14.8

2020

7.0

7.1

2020

9.0

77.7

7.9

:

2025

7.2

7.3

2025

9.4

78.5

7.9

16.2

2030

7.3

7.6

2030

9.7

77.9

7.8

16.5

2035

7.5

7.9

2035

9.9

77.0

7.9

17.1

2040

7.7

8.2

2040

10.1

76.3

7.8

18.0

2045

7.9

8.4

2045

10.2

75.2

7.9

19.0

2050

8.0

8.6

2050

10.2

75.4

8.1

19.9

2055

8.1

8.8

2055

10.2

75.0

8.2

20.8

2060

8.2

8.9

2060

10.2

74.3

8.5

21.3

2065

8.2

9.0

2065

10.2

77.1

8.0

28.0

2070

8.3

9.1

2070

10.2

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Austria

1.3

2.1

EU

0.9

1.6

Change 2016-2070, in %

Austria

17.0

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.2. BELGIUM 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

With €410 billion (2015), the Belgian share in the 
EU  economy  is  some  2.8%.  GDP  per  capita  in 
2015 was, with 32,169 PPS, above the EU average 
of  29,610  PPS  for  the  same  year.  The  population 
has  increased  during  the  past  decade,  from  10.4 
million in 2005 to 11.2 in 2015. Over the decades 
to  come,  the  Belgian  population  is  projected  to 
continue 
increase  significantly,  from  11.3 
million  in  2016  to  13.9  million  in  2070.  This 
projected  increase  in  population  is  much  higher 
than that of the EU (23.0 % vs 2.0%). 

to 

Total and public expenditure on health as % of 
GDP 

(total)  expenditure,  having 

Total  expenditure  on  health,  as  a  percentage  of 
GDP,  has  steadily  increased  during  the  past 
decade,  from  9.7%  in  2005  to  10.5%  of  GDP  in 
2015.  Total  expenditure  in  PPS  is  with  3,503 
higher than the EU average (3,305 PPS per capita). 
Public 
increased 
somewhat steadily over the past decade, is  broadly 
in  line  with  the  EU  average  (8.1%  vs  8.0%  in 
2015),  whereas,  in  per  capita  terms,  it  stands 
slightly above the average with 2,715 vs 2,609 PPS 
for  the  EU.  Looking  at  health  care  without  long-
term care (55) reveals a level of spending below the 
EU average (5.9% vs 6.8% in 2015). 

Expenditure projections and fiscal sustainability 

As a consequence of population ageing, health care 
expenditure  is  projected  to  increase  by  0.4  pps  of 
GDP,  below  the  average  growth  of  0.9  pps 
projected  for  the  EU,  according  to  the  "AWG 
reference scenario" (56). When taking into account 
the  impact  of  non-demographic  drivers  on  future 
spending  growth  ("AWG  risk  scenario"),  health 
care expenditure is expected to increase by 0.9 pps 
of  GDP  from  now  until  2070,  still  lower  than  the 
average (EU level: 1.6).  

(55)  To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 
(56)  The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

There  are  high  medium-term  fiscal  sustainability 
risks,  with  the  indicator  S1  at  4.3  pps  of  GDP, 
primarily  related  to  the  high  level  of  government 
the  projected  ageing  costs,  which 
debt  and 
contribute  1.2  percentage  points  of  GDP  overall. 
Over  the  long-term,  fiscal  sustainability  risks  are 
high  as  well,  with 
indicator  S2  at  4.3 
the 
percentage points of GDP driven by the projected 
ageing costs, contributing 3.5 percentage points of 
GDP,  primarily  related  to  pensions  and  long-term 
care expenditure (57). 

Health status  

With  83.4  and  78.7  years  for  women  and  men 
respectively,  life  expectancy  at  birth  in  2015  in 
Belgium  was  slightly above the EU average (83.3 
and 77.9 respectively). The years spent healthy are 
also  slightly  above  average,  with  64.0  for  women 
and  64.4  (vs  the  EU  average  of  63.3  and  62.6, 
respectively).  Infant  mortality,  which  represents 
the  ratio  of  the  number  of  child  deaths  under  one 
year  of  age  per  1000  live  births,  has  declined  to 
3.3.  This  declining  trend  is  noted  throughout  the 
whole  of  the  EU,  which  averages  around  3.6  in 
2015. 

System characteristics 

financing, 

System 
collection 
mechanism,  coverage  and  role  of  private 
insurance and out of pocket co-payments 

revenue 

The responsibility for the regulation and financing 
of  the  compulsory  health  insurance  lies  with  the 
federal government. It also creates the programmes 
and  normative  framework  for  the  hospitals.  In 
addition  it  governs  the  rules  for  recognition  of 
providers  and  organises 
registration  of 
pharmaceuticals and their price and determines the 
rules  for  financing  of  healthcare  infrastructure 
(such  as  costly  medical  equipment).  At  federal 
level,  decisions  are  also  made  regarding  which 
products and services can be benefitted from under 
the system.  

the 

The compulsory health insurance is combined with 
a  mostly  private  system  of  health  care  delivery, 
based on independent medical practice, free choice 

(57)  European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf.  

21 

 
                                                           
 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

of  physician  and  predominantly  fee-for-service 
payment. 

health  insurance  coverage  in  the  general  scheme 
and the scheme for the self-employed, as the latter 
now includes the coverage of minor risks. 

general 

taxation, 

Financing  for  the  healthcare  insurance  is  obtained 
through employee and employer contributions and 
through a contribution  from the state budget from 
the 
complemented  with 
alternative  financing  by  earmarked  taxes  derived 
from  VAT  income.  The  budget  for  the  system  is 
fixed  and  is  adjusted  to  inflation  and,  on  top  of 
that,  according  to  a  legally  inscribed  real  growth 
norm.  Between  2004  and  2012,  the  health  care 
budget  was  allowed  to  grow  by  4.5%  per  year 
(since  2004),  after  adjustment 
inflation. 
However,  the  actual  expenditures  were  growing 
slower on average, which, together with the aim of 
to  a 
controlling  public  expenditure,  has 
downward revision of the growth norm in the wake 
of the financial crisis. The norm  was set to 2% in 
2012 and 3% in 2013 and 2014. After the change 
in  government  in  2014  and  the  austerity  policy  it 
set out to pursue, the growth norm was set to 1.5% 
from 2015 onward.  

led 

for 

statute 

(preferential 

Citizens  contribute  financially  to  the  healthcare 
system  according  to  their  employment  situation, 
their 
reimbursement  or 
not) (58),  the  type  of  service  they  request  and  on 
the basis of the amount of  user charges they  have 
already  paid  during  that  year.  Users  of  healthcare 
services will participate in health-care financing by 
paying  a  certain  fixed  amount  of  the  cost  of  a 
service,  with  the  third-party  payer  covering  the 
balance  of 
In  2001,  Belgium 
introduced  a  system  of  maximum  billing.  The 
system  has  been  designed  as  a  structural  measure 
to find a compromise between social protection of 
the weakest groups in society on the one hand and 
individual responsibility on the other hand. Thanks 
to this scheme, each household (both with high and 
low  incomes)  has,  according  to  the  family's  net 
taxable income, an annual out-of-pocket ceiling for 
all necessary health care expenses. The ceiling has 
a minimum and a maximum height. 

the  amount. 

Almost  the  whole  population  (>  99%)  is  covered 
for  a  very  broad  benefits  package.  Since  January 
2008,  there  is  no  longer  any  difference  between 

(58)  To qualify for preferential reimbursement the patient has to 
belong  to  a  socioeconomically  vulnerable  group  and  have 
an income below a certain limit. In addition, patients with 
certain  medical  conditions  or  chronic  diseases  are 
exempted from cost-sharing. 

22 

insurance 

A  large  majority  of  the  population  hold  voluntary 
health 
(both  complementary  and 
supplementary), covering for example single room 
accommodation  for  hospitalised  patients.  These 
insurances are being provided by both the sickness 
funds  and  private  for  profit  insurance  companies. 
Private  health  insurance  is  relatively  limited  in 
importance, as it represented around 4.8% of total 
(current)  health  expenditure  in  2015 (59),  and 
covered  mostly  inpatient  expenditure,  even  when 
larger  coverage  (ambulatory  care  and  dental  care) 
also exist.  

Private  expenditure  (patient  co-financing  and 
voluntary insurance) in Belgium is higher than the 
EU-average  (around  22.5%  of  total  expenditure). 
This  share  used  to  be  higher,  28.4%  in  2005,  but 
the share of public expenditure out of the total has 
increased  from  2005  to  2015  from  71.6%  to 
77.5%, closer to the EU average of 78.4%. Out-of-
pocket  expenditure  alone,  however,  displays  at 
17.6% in 2015, a wider gap with respect to EU. 

Administrative organisation 

The  compulsory  health  insurance  is  executed 
through 
six  private,  not-for-profit  national 
associations  of  sickness  funds  and  one  public 
sickness  fund.  It  is  their  major  responsibility  to 
reimburse  health  service  benefits.  The  sickness 
funds  are  members  of  the  National  Institute  for 
Health  and  Disability  Insurance  (NIHDI-RIZIV-
INAMI).  Since  1995  a  trend  has  started  to  make 
financially 
Belgian 
accountable  for  their  expenses  made.  They  act 
collectively  in  their  negotiations  with  health  care 
providers. 

funds  more 

sickness 

public 

expenditure 

The 
healthcare 
administration and health insurance in Belgium in 
2015  is,  with  0.3%  of  GDP,  in  line  with  the  EU 
average for the same year (0.3% of GDP). 

on 

(59)  http://ec.europa.eu/eurostat/web/health/health-

care/data/database (SHA). 

 
                                                           
                                                           
Treatment options, covered health services 

The  services  that  are  covered  by  compulsory 
health  insurance,  which  is  characterised  as  a  fee-
for-service  system,  are  described  in  the  nationally 
established 
than  8000 
services), the so called ‘nomenclature’.  

schedule 

(more 

fee 

Types of providers, referral systems and patient 
choice   

National  planning  sets  various 
targets  and 
accreditation  norms  that  institutions  must  follow. 
Access  to  professions  is  regulated  by  law.  The 
Belgian  health  system  is  mainly  based  on  the 
principles  of  equal  access  and  freedom  of  choice. 
All  residents  have  to  register  to  a  Bismarckian-
type  of  public  compulsory  health 
insurance 
(sickness funds) which offers a very broad benefits 
package  (a  positive  list  of  goods  and  services  is 
defined at the central level). 

their  services 

Belgium  has  a  well-developed  system  of  primary 
care. The service is provided through independent 
general  practitioners  (GPs,  or  "family  doctors"). 
in  group 
Some  GPs  provide 
practices.  There  are  relatively  many  GPs  in 
Belgium,  compared  to  other  EU  Member  States 
(113  vs  78  in  the  EU  respectively  per  100  000 
inhabitants  in  2015).  The  Belgian  government 
aims  at  a  strengthening  of  the  role  of  the  GP,  for 
example  in  the  treatment  of  chronic  diseases.  The 
current apparent over capacity could facilitate that 
shift.  

outpatient 

Specialist 
provided 
predominantly  in  hospital  outpatient  departments 
and at times in private group practices.  

care 

is 

Day  care  and  inpatient  treatment  is  provided  in 
hospitals. Two thirds of the hospital acute beds are 
owned by private not-for-profit hospitals. The rest 
of the hospitals are publicly owned. The number of 
acute  care  beds  per  100  000  inhabitants  (518  in 
2015),  while  showing  a  reduction,  is  still  well 
above the EU average (402). Overall there are not 
so  many  physicians  per  inhabitant  in  Belgium 
compared to the EU average (302 compared to 344 
per  100  000  inhabitants) (60).  The  amount  of 

(60)  Note  that  the  actual  figures  may  be  underestimated  as 
Belgium  limits  the  count  to  physicians  with  a  minimum 
amount  of  activity,  whereas  other  countries  count  all 

Health care systems 

2.2. Belgium 

practising  nurses  per  100  000  inhabitants  on  the 
other  hand  is  higher  than  in  the  average  EU  level 
(1,083 in Belgium and 833 in the EU in 2015). 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Two systems of payment are implemented, the first 
one  is  a  reimbursement  system  (for  outpatient/ 
ambulatory  care)  and  the  second  one  is  a  third-
party payer system where the patient pays only the 
co-insurance or the co-payment (for inpatient care 
third-party  payer 
and  pharmaceuticals).  The 
system  is  gradually  being  further  enlarged  and 
implemented also in ambulatory care. 

is 

fee 

Most  health  care  professionals  are  self-employed 
and  are  paid  on  a  fee-for-service  basis,  with  the 
patient  partly  reimbursed  (generally  at  a  rate  of 
75%)  afterwards.  Indeed,  less  than  1%  of  the 
physicians  working  in  hospitals  are  employees. 
Nurses  are  mainly  salaried  in  comparison.  To 
avoid competition between services from hospitals 
or from office-based specialists, the same national 
imposed.  However,  when 
negotiated 
working  in  hospitals,  the  specialists  allow  the 
institutions  to  retain  a  proportion  of  the  fees  as 
compensation  for  the  space,  equipment,  staff  and 
additional  services.  The  government  sets  the  fees 
for GPs and specialists every two years following a 
bargaining  process  with  representatives  of  the 
concerned parties. Only non-contracted physicians 
can set their fees freely even if the contracted can, 
in  some  specific  cases  like  activity  outside  core 
time  for  example,  charge  higher  fees.  The  same 
principle applies to dentists,  pharmacists and self-
employed nurses. In Belgium the remuneration gap 
is  particularly  large  between  GPs  and  specialists 
with  GPs  earning  three  times  less  than  specialists 
even  if  some  efforts  have  been  made  recently  to 
decrease  this  gap.  A  possibility  has  been  created 
for  GPs  to  receive  compensation/pay  for  the 
management of chronic diseases.  

Inpatient  care  is  covered  by  the  third-party  payer 
system.  The  patient  pays  a  co-payment  while  the 
bulk  of  the  cost  is  directly  paid  by  the  sickness 
fund  to  the  hospitals.  For  the  hospitals'  running 
costs,  a  national  budget ( 61)  is  set  annually  and 

physicians  who  have  had  at  least  one  patient  contact  per 
year. 

(61)  This  budget  only  covers  about  50%  of  the  hospitals’ 
operational  costs.  The  other  half  is  financed  by  fee-for-

23 

 
                                                           
                                                                                   
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

paid to the hospitals via the sickness funds with an 
aim  to  make  the  hospitals  accountable  for  their 
operations by means of financial rewards or fines. 
Hospitals  are  paid  on  a  combination  of (62): 
“common services” (about 25%) based on surface 
area, number of cases, number of patient days etc., 
“clinical  services”  (about  47%)  based  on  volume 
and  type  of  activity,  intensity  of  nursing  services 
and other activity indicators, and “legally required 
services”  (general  surgeon,  hospital  hygiene, 
registry  keeping,  quality  policy  and  monitoring, 
hospital pharmacy) (about 14%) and other smaller 
items. Hospital activity is in line with the average, 
with  hospital  inpatient  discharges  at  16  per  100 
inhabitants in 2014 (EU average 16 in 2015 and in 
2013).  Belgium  is  characterised  by  substantially 
higher  than  average  (more  than  double)  numbers 
of day case discharges (15,922 in 2014 vs. 7,635 in 
2015  and  7,143  in  2013).  Day  case  surgery  has 
increased  significantly  in  the  last  decade  (from 
39.5  in  2005)  and  the  percentage  of  surgical 
procedures  conducted  as  day  cases 
in  2014 
(50.1%) is well above the EU average for 2013 and 
2015 (30.9% and 32.3%). From 1982, the "number 
of  days"  for  an  inpatient  stay  is  subject  to 
restrictions  (pathology  weighted)  to  discourage 
hospitals  to  extend  stays  for  financial  reasons. 
Despite  that  kind  of  control  procedure,  Belgium 
had for long time a hospital average length of stay 
above  the  EU  average,  but  this  has  decreased 
through  the  past  decade,  bringing  Belgium  in  line 
with  the  average.  The  average  is  currently  7.6 
(2014)  vs  7.6  days  in  the  EU  in  2015  and  7.7  in 
2013. 

One of the key advantages of the Belgian system is 
that  the  precise  price  setting  (flat  rate)  avoids 
unexpected  fees  for  the  patient.  However,  in 
hospitals,  the  patient's  out-of-pocket  contribution 
per  day  of  hospitalisation  may  vary  if  there  are 
additional  costs 
room,  non-
reimbursable  products  or  non-publicly  contracted 
physicians.  Recent  legislation  however,  obliges 
hospitals 
the 
treatment to the patient at the admission. 

to  provide  a  cost  estimate  of 

for  a 

single 

service  payments  by  the  NIHDI  and  patient  out-of-pocket 
(or  private  insurance)  payments  (mainly  physicians’  fees 
and drugs). 

(62)  CM  2013,  De  organisatie  en  financiering  van  de 
ziekenhuizen.  CM  Informatie  nr.  253  (info  fiche)  [also 
available in French]. 

24 

The market for pharmaceutical products 

are 

exclusively 

Pharmaceuticals 
distributed 
through  community  pharmacies  and  hospital 
pharmacies  and  their  establishment  is  strictly 
regulated since 1973. 

Total  expenditure  in  Belgium  on  pharmaceuticals 
as a percentage of GDP has over the last few years 
quite closely  matched the EU average,  which  was 
still the case in 2015 with 1.0 % of GDP, both for 
Belgium and the EU. 

on 

clinical 

performance, 

About  2500  pharmaceuticals  are  reimbursable  in 
Belgium.  The  initial  price  of  reimbursed  drugs  is 
based 
economic 
evaluation  and  cost  of  existing  treatments,  and 
looking  at  the  average  EU  price.  The  amount 
reimbursed  is  determined  by  the  pharmaceutical 
category  that  reflects  the  social  importance  of  the 
drug,  pharmacotherapeutic  criteria  and  price 
criteria.  The  patient  pays  only 
the  non-
reimbursable  amount  as  a  co-payment  to  the 
pharmacy.  Authorities  also  use  reference  pricing 
whereby  the  reimbursement  level  of  a  drug  is 
based  on  the  prices  of  drugs  that  have  the  same 
active ingredient. 

The  sickness  funds  negotiate  as  a  cartel  with  the 
drug companies on reimbursement rates under the 
supervision of the central government. The central 
government can also as an extreme measure oblige 
pharmaceutical  firms  to  pay  a  special  tax  when 
expenditures on pharmaceutics are too high (a sort 
of  payback  system).  However,  the  main  policy 
instruments  to  stem  (public)  cost  increases  during 
the  last  decade  have  been  price  regulation  and 
increases in co-payments. 

Since  2001, 
the  use  of  generics  has  been 
stimulated  by  introducing  lower  co-payments  for 
the  users  and  lower  reimbursement  levels  for 
branded  drugs  when  generics  are  available. 
Generic  drugs  must  be  at  least  30%  cheaper  than 
originators.  Doctors  are  encouraged  to  prescribe 
generic  medicines  through  prescription  quotas. 
Pharmacists are encouraged to provide the generic 
drug when available, for some categories of drugs, 
the  substitution  is  compulsory  (providing  the 
patient  with  the  cheapest  or  generic  variant  with 
the  same  active  molecule  of  a  prescribed  drug). 
Information  on  generics  is  provided  to  health 
professionals and to the public. 

 
                                                                                   
Health care systems 

2.2. Belgium 

quotas, 

Authorities  promote 
rational  prescribing  by 
physicians  through  compulsory  guidelines  and 
prescription 
with 
monitoring of prescribing behaviour and education 
and information campaigns on the prescription and 
use of medicines. They also promote education and 
information campaigns for patients. 

complemented 

Despite the success of the measures introduced so 
far,  research  (63)  suggests  that  there  is  scope  for 
further  cost  savings,  which  suggests  progress 
towards the  wider adoption of  more cost-effective 
solutions should be pursued. 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

The  Belgian  Health  Care  Knowledge  Centre  has 
played  a  major  role  in  conducting  and  gathering 
information on health technology assessment since 
2003.  Health  technology  assessment  information 
has  been  used  to  define  guidelines  and  determine 
coverage  and  level  of  reimbursement  of  new 
procedures,  new  medicines  and  new  high-cost 
equipment.   

eHealth (e-prescription, e-medical records) 

Belgium has established a public institution for e-
health  with  the  law  of  August  28  2008.  The 
organisation’s  mission  is  ‘to  optimise  the  quality 
and continuity of health care provision and patient 
safety and to streamline administrative procedures 
by  means  of  mutual  electronic  services  and  data 
exchange  between  all  health  care  actors,  while 
guaranteeing  information  security  and  respecting 
patient privacy (64). 

The mission translates into a number of tasks, such 
as the development of software platforms for safe 
information exchange between health professionals 
and  between  care  providers  and  administrative 
services  (the  Federal  Public  Service  for  Health, 
Food  Chain  Safety  and  the  Environment,  the 
National 
for  Health  and  Disability 
Insurance, etc.) and managing and coordinating the 

Institute 

(63)  Cornelis, K., Het geneesmiddelenbeleid inzake goedkopere 
geneesmiddelen  in  België,  Brussels,  September  2013; 
http://www.cm.be/binaries/CM-253-
Geneesmiddelen_tcm375-130001.pdf. 

(64)  See 

https://www.ehealth.fgov.be/nl/over-het-ehealth-
platform/wetgeving/wet  (only  available  in  Dutch  and 
French). 

patient 

functional 

organisational, 

ICT-related, 
and 
technical  aspects  of  data  exchange  related  to 
electronic 
electronic 
prescriptions.  The  organisation  also  acts  as  a 
‘trusted  third  party’  for  coding,  anonymising  and 
linking  data  requested  by  academic  or  public  or 
private sector researchers. 

records 

and 

Health  and  health-system 
reporting mechanisms 

information  and 

Monitoring  and  data  collection  has  been  widely 
implemented  in  the  Belgian  health-care  system. 
Dedicated databases like Pharmanet, NMDS (65) or 
HDS (66), allow the control of the medical practice 
of 
individual  physicians  (volume  of  activity, 
prescription activity) and whether it complies with 
treatment  guidelines.  It  also  enables  among  other 
things  the  monitoring  of  health  problems  and  the 
epidemiological  situation  or  the  effectiveness  and 
quality  of  hospital  care.  The  global  set  of  data  is 
very  wide  even  if  the  collection  of  data  about 
voluntary  private  health  insurance  or  about  care 
and  nursing  homes  could  be  improved.  The 
performance  of  the  Belgian  health  care  system  is 
monitored 
reported 
periodically (67). 

continuously 

and 

Health  promotion  and  disease  prevention 
policies 

In  Belgium,  the  communities  and  partially  the 
federal  state  are  responsible  for  prevention, 
promotion and education on health. In 2015, public 
expenditure  on  prevention  and  public  health 
services reached 0.2% of GDP, which is below the 
EU  average  for  the  same  year  (0.3%).  The  most 
included: 
recent  health  promotion  campaigns 
healthy  eating,  organ  donation,  deadly  accident 
prevention,  abuse  of  antibiotics,  promotion  of 
vaccinations  and  breast  and  cervical  cancer 
screening.  

Transparency and corruption 

In  2008  Belgium  signed  the  ‘Tallinn  Charter’  on 
‘Health  Systems  for  Health  and  Wealth’  at  a 
ministerial conference in Estonia organised by the 

(65)  Nursing Minimum Data Set. 
(66)  Hospital Data Set. 
(67)  See: Vrijens et al. 2016, De performantie van het Belgische 
gezondheidssysteem  -  Rapport  2015.  KCE  Rapport  259A 
(Dutch and French). 

25 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

World  Health  Organisation  European  Office.  One 
of  the  commitments  of  the  signing  member  states 
was  to  ‘promote  transparency  and  be  accountable 
to  achieve 
system  performance 
for  health 
measurable  results’.  This  commitment  has  fuelled 
an ongoing policy debate in Belgium regarding the 
best  ways  to  improve  the  transparency  of  health 
care  provision.  This  debate  focuses  mainly  on 
using  transparency  to  improve  informed  patient 
choice and quality of service. One example of this 
approach  is  to  measure  and  publicise  hospital 
performance indicators. The feasibility of this idea 
is currently being tested in Flanders as part of the 
‘Flemish Indicators Project’. Participating Flemish 
hospitals  measure  a  number  of  performance  or 
quality  indicators  on  a  voluntary  basis  and  decide 
whether  they  publish  the  results  online.  Many  of 
them also conduct patient satisfaction surveys on a 
regular basis (68). 

A recent government bill has been approved aimed 
at  improving  the  transparency  of  medical  costs 
charged  to  patients.  The  bill  aims  to  improve  the 
disclosure  of 
the  medical 
the  details  of 
interventions and the associated full costs, both for 
the  patients  (co-payments  and  supplements)  and 
for  the  health  insurance  funds  (reimbursements). 
Hospitals  will  have  to  provide  patients  with 
detailed information on expected costs before they 
are admitted. 

Recently 
reforms 

legislated  and/or  planned  policy 

The main change in health care policy legislated in 
the  recent  years  concerns 
the  devolution  of 
responsibilities  (and  shifts  in  associated  budgets) 
for a number of health care tasks from the federal 
to  the  regional  level  (Flanders,  Wallony  and 
Brussels)  as  a  consequence  of  the  6th  Reform  of 
the  State.  The  reform  was  signed  into  law  on 
January  31  2014  and  became  effective  on  July  1 
2014. While the transferred responsibilities mainly 
concern care for the elderly (see country document 
on  long-term  care),  some  may  be  classified  as 
acute  care  expenditures.  A  few  notable  examples 
are  geriatric  hospital 
revalidation, 
mobility  aides,  prevention  and  the  maximum 

services, 

(68)  See 

https://www.zorg-en-   
gezondheid.be/Beleid/Kwaliteit/Welke-ziekenhuizen-
meten-hun-kwaliteit-met-VIP%C2%B2/  (only  available  in 
Dutch). 

26 

billing  (MAB)  payments.  The  total  budget  shift 
from  the  federal  to  the  regional  level  is  estimated 
to  be  approximately  3.4  billion  euros  in  2015, 
almost  12%  (400  million  euros)  of  which  will  be 
(acute) health care expenditures (69). At the time of 
writing there is no information available as to how 
the  regional  authorities  will  manage  their  new 
responsibilities,  including  if  and  how  they  may 
change  the  rules  that  govern  the  use  of  services 
and 
expenditures. 
Consequently,  the  current  Belgian  projections  at 
the  national  level  assume  that  the  regionalised 
health  care  expenditures  will  evolve  according  to 
the same  mechanisms that pertained at the federal 
level. 

associated 

public 

the 

issued 

Ongoing efforts to improve the performance of the 
Belgian  health  care  system  are  detailed  in  the 
annual Policy Notes of the Minister responsible for 
public  health  and  health  care.  The  most  recent 
in  November  2014 (70), 
Policy  Note, 
discusses  a  government  bill  aimed  at  improving 
the  accessibility  of  health  care,  the  continuing 
integration  of  chronic  care,  the  execution  of  the 
eHealth platform and the strengthening of primary 
care.  Planned  structural  reforms  envisage  the 
reform  of  hospital  financing,  the  expansion  of 
mental health care services and a stronger focus on 
evidence-based medicine. 

An  important  recent  policy  reform  concerns  the 
pharmaceutical  industry.  The  Minister  of  Health 
and  Social  Affairs  has  signed  a  ‘Pact  for  the 
Future’  with  the  Belgian  pharmaceutical  sector, 
aimed at improving the accessibility to innovative 
therapies  while 
pharmaceutical 
spending.  The  agreement  provides  a  framework 
that  combines  cost  containment  with  measures  to 
stimulate  innovation,  especially  in  the  area  of 
orphan drugs. In order to achieve this, a multi-year 
budget  aimed  at  providing  perspective  and 
predictability  of  the  revenues  of  the  sector  has 
been agreed. 

containing 

(69)  RIZIV,  Budget  2016.  Technical  estimates  for  2015-2016 

(internal document). 

(70)  See 

http://www.deblock.belgium.be/sites/default/files/articles/2
014_11_25_Beleidsnota%20Gezondheidszorg_54K058800
7.pdf. 

 
                                                           
 
                                                           
Health care systems 

2.2. Belgium 

•  To  continue  to  improve  data  collection  and 
monitoring  of  inputs,  processes,  outputs  and 
outcomes,  focussing  in  the  areas  of  voluntary 
private  health  insurance  and  on  care  and 
nursing  homes,  so  that  regular  performance 
assessment  can  be  conducted  and  used  to 
continuously 
improve  access,  quality  and 
sustainability of care. 

•  To  further  enhance  health  promotion  and 
disease  prevention  activities,  i.e.  promoting 
healthy life styles and disease screening. 

Challenges 

The  analysis  above  shows  that  a  number  of 
reforms  have  been  implemented  over  the  years, 
aiming  to  improve  the  quality  and  efficiency  of 
care delivery, and which Belgium should continue 
to  pursue.  The  main  challenges  for  the  Belgian 
health system are as follows: 

quality 

spending, 

promoting 

•  To continue increasing the efficiency of health 
care 
and 
integrated care as well as a focusing on costs in 
view  of  the  relatively  high  spending  on  health 
care  as  a  share  of  GDP  and  increasing  health 
care  expenditure  over  the  coming  decades, 
which  will  accompany  the  high  projected 
demographic growth. 

•  To ensure that the recent responsibilities of the 
regional  governments  and  the  management  of 
the budgets they have acquired with the recent 
reform  of 
the  state  are  well  coordinated 
horizontally,  with  other  regions,  and  with 
decisions  at 
to  avoid 
federal 
duplications and inefficiencies. 

level 

the 

•  To 

in 

considering 

the  efforts 

the  area  of 
further 
pharmaceuticals 
additional 
measures  to  improve  the  rational  and  cost-
effective  prescribing  and  usage  of  medicines, 
such  as  information  and  education  campaigns, 
the monitoring of prescription of medicines and 
incentivising the uptake of generics, as already 
successfully implemented in the past years. The 
policies  could  help 
improving  population 
health  and  improving  access  to  cost-effective 
new medicines while generating savings to the 
public payer. 

•  To  strengthen  the  role  of  primary  care  as  a 
gatekeeper by expanding the current incentives 
in  place,  both  for  doctors  and  patients,  to 
contain  direct  access  to  specialist  care,  for 
instance,  by  making  referrals  compulsory.  To 
make  use  of  high  capacity  of  GPs  to  support 
their  management  of  chronic 
in 
patients 
conditions as envisaged. 

•  To  monitor  the  issue  of  financial  access,  in 
light  of  the  high  level  of  co-payment,  while 
ensuring  that  enough  incentives  to  discourage 
over-consumption  of  health  care  services  are 
preserved. 

27 

 
2
8

Table 2.2.1:  Statistical Annex – Belgium 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status
Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2005

311

30.9

1.5

:

2006

327

31.3

1.8

1.1

2007

345

31.8

2.7

3.1

2008

354

30.9

0.0

3.3

2005

2006

2007

2008

9.7

9.0

0.6

9.6

8.9

0.7

9.6

9.0

0.7

9.9

9.3

0.6

2,632

2,723

2,866

3,018

6.9

6.9

6.8

6.8

6.7

6.7

7.2

7.2

2009

349

29.5

-3.0

3.9

2009

10.7

10.1

0.6

3,160

7.8

7.8

2010

365

30.6

1.8

0.9

2010

10.6

9.9

0.6

3,253

7.7

7.7

2011

379

30.7

0.9

1.4

2011

10.6

10.1

0.5

3,345

7.8

7.8

2012

388

30.9

-0.4

2.2

2012

10.9

10.2

0.7

3,485

7.9

7.9

2013

392

30.6

-0.3

-3.2

2013

10.6

10.4

0.2

3,406

8.0

8.0

2014

400

31.2

0.9

1.1

2014

10.6

10.4

0.2

3,468

8.0

8.0

2015

410

32.2

0.9

-0.1

2015

10.5

10.5

0.0

3,503

8.1

8.1

EU- latest national data

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,745

2,895

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

1,884

1,924

2,010

2,185

2,316

2,368

2,458

2,533

2,587

2,635

2,715

2,153

2,263

2,324

2,609

0.01

71.6

13.5

99.0

18.2

0.01

70.6

14.6

99.0

18.8

0.01

70.1

15.2

99.0

19.2

0.01

72.4

15.1

99.5

18.5

0.01

73.3

14.8

100.5

18.3

0.01

72.8

14.8

101.5

18.3

0.01

73.5

14.8

98.8

18.3

0.01

72.7

14.5

99.0

18.0

0.01

76.0

14.8

99.0

18.1

0.02

76.0

14.6

99.0

18.2

0.01

77.5

14.2

99.0

17.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

10.4

81.9

76.2

62.3

62.4

58

3.7

10.5

82.3

76.6

63.2

63.0

54

4.0

10.6

82.6

77.1

63.9

63.5

53

3.9

10.7

82.6

76.9

64.1

63.4

52

3.8

10.8

82.8

77.3

63.7

63.9

50

3.5

10.8

83.0

77.5

62.6

64.0

:

3.6

11.0

83.3

78.0

63.6

63.4

106

3.4

11.1

83.1

77.8

65.0

64.2

104

3.8

11.1

83.2

78.1

63.7

64.0

104

3.5

11.2

83.9

78.8

63.7

64.5

95

3.4

11.2

83.4

78.7

64.0

64.4

94

3.3

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.3

0.3

2.0

1.6

0.1

0.2

0.4

1.9

0.3

1.6

0.9

0.1

0.2

0.3

2.5

0.1

1.6

1.5

0.1

0.2

0.4

2.0

0.1

1.2

0.9

0.1

0.2

0.3

2.5

0.1

1.6

1.5

0.2

0.2

0.4

2.0

0.1

1.2

0.9

0.1

0.2

0.3

2.6

0.1

1.6

1.5

0.2

0.2

0.4

2.1

0.1

1.1

1.0

0.1

0.2

0.3

2.8

0.2

1.7

1.6

0.2

0.2

0.4

2.2

0.1

1.3

1.0

0.1

0.2

0.3

2.8

0.2

1.7

1.6

0.2

0.2

0.4

2.2

0.2

1.3

1.0

0.1

0.2

0.3

2.8

0.2

1.8

1.6

0.2

0.2

0.4

2.2

0.2

1.3

1.0

0.1

0.2

0.3

2.9

0.2

1.9

1.5

0.2

0.2

0.4

2.2

0.2

1.3

1.0

0.1

0.2

0.3

2.9

0.2

1.9

1.5

0.2

0.2

0.4

2.3

0.2

1.4

1.0

0.1

0.2

0.3

2.9

0.2

2.0

1.4

0.2

0.2

0.4

2.3

0.2

1.4

1.0

0.1

0.2

0.3

3.0

0.2

2.0

1.5

0.2

0.2

0.4

2.3

0.1

1.4

1.0

0.1

0.2

0.3

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

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Table 2.2.2:  Statistical Annex – Belgium 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

25.2%

3.5%

21.7%

17.1%

1.5%

2.3%

4.5%

27.0%

4.2%

22.5%

13.3%

1.2%

2.9%

4.6%

2005

0.70

1.4

3.9

:

:

20.3

12.3

2006

27.7%

1.5%

17.9%

16.5%

1.6%

1.8%

4.7%

29.3%

1.5%

17.5%

12.7%

1.2%

2.2%

4.9%

2006

0.71

1.4

4.0

:

:

22.0

11.0

2007

27.8%

1.5%

18.3%

16.6%

1.7%

1.8%

4.1%

28.9%

1.5%

17.8%

13.1%

1.3%

2.2%

4.2%

2007

0.75

1.3

4.2

:

:

22.0

10.3

EU- latest national data

2008

28.2%

1.5%

16.6%

16.4%

1.7%

1.8%

4.4%

28.7%

1.5%

15.9%

13.5%

1.3%

2.2%

4.5%

2009

28.0%

1.5%

17.1%

15.8%

2.1%

2.2%

3.7%

28.2%

1.7%

16.4%

13.3%

1.3%

2.7%

3.7%

2010

28.0%

1.7%

17.4%

15.6%

2.1%

1.6%

3.7%

28.1%

2.0%

16.3%

13.5%

1.3%

2.0%

3.8%

2011

28.2%

1.8%

17.8%

15.4%

2.1%

1.7%

3.8%

28.4%

1.9%

16.3%

13.4%

1.3%

2.1%

3.6%

2012

28.1%

1.8%

18.3%

14.6%

2.1%

1.7%

3.5%

28.3%

2.0%

16.4%

12.9%

1.4%

2.0%

3.4%

2013

28.1%

1.8%

18.5%

14.3%

2.2%

1.7%

3.5%

28.3%

2.0%

16.8%

12.3%

1.4%

2.1%

3.4%

2014

28.0%

1.7%

18.8%

13.8%

2.2%

1.8%

3.6%

28.0%

1.9%

17.1%

12.1%

1.4%

2.2%

3.4%

2015

28.5%

1.4%

18.7%

14.2%

2.0%

1.7%

3.4%

28.4%

1.5%

16.7%

12.7%

1.1%

2.1%

3.1%

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

EU- latest national data

:

:

:

:

14.0

18.9

10.5

:

:

:

:

:

:

10.1

2009

292

942

112

553

2009

6.9

16

2005

2006

2007

2008

287

901

118

690

2005

7.2

16

289

912

116

617

2006

6.5

16

291

924

115

608

2007

6.5

16

292

932

114

559

2008

6.8

16

10,497

10,773

11,359

12,554

12,832

75.0

7.7

39.5

2016

5.9

5.9

2016

11.3

74.0

7.2

40.5

2020

5.9

6.0

2020

11.6

73.6

7.8

41.9

2025

6.0

6.1

2025

11.9

74.0

8.1

:

2030

6.0

6.2

2030

12.3

78.1

8.2

44.7

2035

6.1

6.3

2035

12.6

:

:

:

:

:

:

10.2

2010

291

957

112

546

2010

6.6

:

:

78.2

8.1

:

2040

6.2

6.5

2040

12.8

:

:

:

:

:

:

10.1

2011

291

980

111

535

2011

6.7

16

:

:

:

:

:

:

10.1

2012

293

1000

111

528

2012

6.7

16

:

:

:

:

13.7

:

11.8

2013

295

1028

112

523

2013

6.7

16

:

:

:

:

13.7

18.9

12.6

2014

298

1058

112

524

2014

6.7

16

15,149

15,546

15,343

15,922

78.0

8.0

48.9

2045

6.2

6.6

2045

13.1

78.4

7.9

49.5

2050

6.3

6.7

2050

13.3

79.6

7.8

49.4

2055

6.3

6.7

2055

13.4

78.4

7.6

50.1

2060

6.3

6.8

2060

13.6

:

:

0.0

:

:

:

:

2015

302

1083

113

518

2015

6.8

:

:

:

:

:

2065

6.3

6.8

2065

13.7

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

6.3

6.9

2070

13.9

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Belgium

0.4

0.9

EU

0.9

1.6

Change 2016-2070, in %

Belgium

23.0

EU

2.0

Source:  EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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9

 
 
 
 
 
 
 
 
 
 
2.3. BULGARIA 

General 
sustainability and demographic trends  

Expenditure, 

context: 

General  statistics:  GDP,  GDP  per  capita; 
population 

GDP per capita in PPS is at 12,500 and around half 
of the EU average of 29,600 in 2015. Bulgaria has 
a population of 7.1 million inhabitants. During the 
coming  decennia  the  population  will  steadily 
decrease,  from  7.1  million  inhabitants  in  2016  to 
4.9  million  inhabitants  in  2070.  Thus,  in  Bulgaria 
the  population  is  expected  to  decrease  by  32%, 
while it is expected to increase at the EU level by 
2%.  

Total and public expenditure on health as % of 
GDP 

Total expenditure (71) on health as a percentage of 
GDP  (8.9%  in  2015,  latest  available  data)  has 
increased over the last decade (from 7.3% in 2005) 
but remains below the EU-average (72) of 10.2% in 
2015.  Throughout  the  last  decade,  total  public 
expenditure  has  first  decreased  as  %  of  GDP  but 
has recently recovered from 4.6% in 2005 to 4.9% 
of  GDP  in  2015  (EU:  8.0%  in  2015).  Public 
spending as a share of GDP is one of the lowest in 
the  EU.  Looking  at  health  care  without  long-term 
care (73)  reveals  a  similar  picture  with  public 
spending below the EU average (4.9% vs. 6.8% in 
2015).  When  expressed  in  per  capita  terms,  also 
total  spending  on  health  at  1,232 PPS  in  Bulgaria 
in 2015 was far below the EU average of 3,305 in 
2015 (74).  So  was  public  spending  on  health  care: 
675  PPS  in  2015  vs.  an  average  of  2,609  PPS  in 
2015.  Overall,  Bulgaria  devotes  relatively  few 
resources to health care. 

(71)  Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
capital formation on health care from COFOG. 

(72)  The  EU-averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU-
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(73)  To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(74)  Note  that  these  PPS  figures  reflect  current  plus  capital 
health  expenditure  in  contrast  to  EUROSTAT  data  series, 
which reflect current expenditure only. 

30 

fiscal 

Expenditure projections and fiscal sustainability  

As a consequence of population ageing, health care 
expenditure  is  projected  to  increase  by  0.3  pps  of 
GDP,  below  the  average  growth  expected  for  the 
EU  of  0.9  pps  of  GDP,  according  to  the  "AWG 
reference scenario". When taking into account the 
impact  of  non-demographic  drivers  on  future 
spending  growth  ("AWG  risk  scenario"),  health 
care expenditure is expected to increase by 1.3 pps 
of GDP from now until 2070 (EU: 1.6) (75). 

to 

face 

fiscal 
Bulgaria  does  not  appear 
sustainability  risks.  In  the  short  and  medium-term 
risks  are  low.    Also  in  the  long  term,  Bulgaria 
faces  low  fiscal  sustainability  risks,  due  to  a 
initial  budgetary  position,  which 
favourable 
counterbalances  the  risks  associated  with  the 
projected  ageing  costs  (incl.  pensions  and  health 
care) (76).  

Health status 

Life expectancy at birth (78.2 years for women and 
71.2 years for men in 2015) is one of the lowest in 
the  EU,  while  healthy  life  years  (65.0  years  for 
women and 61.5 years for men in 2015) are above 
the  respective  EU  averages  (63.3  and  62.6  in 
2015). Mortality rates, which are thought amenable 
if appropriate and timely care is delivered, are also 
high (282 in Bulgaria vs. 127 deaths in the EU per 
100,000  inhabitants).  The  infant  mortality  rate  of 
6.6‰ is very high compared to the EU average of 
3.6‰ in 2015, having gradually fallen over the last 
decade (from 10.4‰ in 2005). 

As for the lifestyle of the Bulgarian population, the 
data indicates a high proportion of regular smokers 
(27.3%  in  2014),  being  above  the  EU  average  of 
21.8%.  The  proportion  of  the  obese  population  is 
below  EU  level  of  14.4%  (EU:  15.5%),  while  the 
alcohol consumption is above the EU level.  

(75)  The 

2018 

Ageing 

Report:   

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(76)  European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

 
                                                           
                                                           
 
System characteristics  

Overall description of the system 

contributions 

insurance  with 

The  health  system  is  a  system  of  compulsory 
health 
from 
employees  and  contractual  relationship  between 
the  National  Health  Insurance  Fund  (NHIF)  as 
purchaser  of  services  and  healthcare  providers. 
NHIF acts as a single buyer of health services and 
runs  the  mandatory  health  insurance  for  the 
Bulgarian  citizens.  NHIF  is  separated  from  the 
structure  of  the  public  healthcare  system  and  has 
its  own  governing  bodies.  The  mission  of  the 
NHIF  is  to  provide  free  and  equal  access  for  the 
insured  persons  to  medical  care  for  a  defined 
package of health services and the free choice of a 
contracted provider. 

Coverage 

A  system  of  mandatory  social  health  insurance  is 
designed  to  provide  coverage  for  the  residing 
population.  

The  majority  of  the  population  takes  part  in  the 
health  insurance  system.  The  share  of  the  people 
without  health 
insurance  payments  for  2014 
amounts  to  approximately  7  %  (516  753  people). 
The  2015  amendments  to  the  Health  Insurance 
Act (77)  led  to  recovery  of  the  health  insurance 
rights of 195 726 Bulgarian citizens for the second 
half of 2015. 

According  to  the  data  of  the  "Civil  Registration 
and  Administrative  Service  Directorate  General" 
(GRAO)  until  the  end  of  2014  approximately 
their  permanent 
1,630,000  people  who  have 
address  in  Bulgaria  had  foreign  residence  and  are 
not  legally  obliged  to  take  part  in  the  obligatory 
health insurance system (78). 

Health The structure of insured is as follows: 45% 
insured  by  the  employer,  4%  self-insured  and 
approximately 44% insured by the state.  coverage 
the  following 
the  state  for 
is  provided  by 
population  groups:  any  person  who  has  not 
attained the age of 18 years, if attending school as 

(77)  State  Gazette,  Vol.  72/18.09.  2015,  Vol.  79/13.10.2015, 

Vol. 98/15.12.2015. 

(78)  There  is  no  official  information  on  the  number  of  people 
insurance 

residing  in  Bulgaria  without  social  health 
coverage. 

Health care systems 

2.3. Bulgaria 

a  full-time  pupil  until  completion  of  secondary 
education,  but  not  later  than  the  attainment  of  the 
age of 22 years; any full-time student enrolled in a 
higher  school  until  attainment  of  the  age  of  26 
years,  and  any 
full-time  doctoral  candidate 
enrolled  within  the  state  quota,  as  well  as  all 
retired  people.  People  without  incomes  receive 
the  Social  Assistance 
social  assistance  from 
Agency.  Long-term  unemployed  people  without 
incomes  and  real  estate  have  the  right  to  get  their 
hospital  treatment  paid  for  by  the  Fund  of  the 
Ministry of Labour and Social Policy on the basis 
of their property status proven. This fund amounts 
to BGN 5 million per year. 

their  health 

All  women  in  Bulgaria  have  the  right  to  receive 
free  of  charge  health  services  for  giving  birth, 
regardless  of 
insurance  status. 
Similarly, all pregnant women have access to free 
health  care  services,  regardless  of  their  health 
insurance status. The access to emergency medical 
care  is  free  for  all,  regardless  of  health  insurance 
status. 

Administrative  organisation  and 
collection mechanism  

revenue 

tax 

non-working 

revenue  allocated  by 

The National Health Insurance Fund (NHIF) pools 
the  compulsory  social  health  insurance  wage-
related  contributions  of  employed  individuals  and 
the  general 
the 
government, which covers for the contributions of 
(pensioners, 
the 
population 
unemployed,  people 
taking  care  of  disabled 
members of the family, people with right to social 
welfare,  etc).  The  NHIF  carries  out  the  financing 
of  the  healthcare  network  through  its  28  regional 
authorities  (regional  health  insurance  funds).  The 
NHIF  contracts  health  services  from  general 
practitioners 
in  outpatient 
(GPs),  specialists 
departments,  medical  laboratories,  dentists  and 
hospitals  for  the  insured  population  and  provides 
for medication and medical devices. 

A  system  of  accreditation  of  medical  facilities  is  
organised  by  the  Ministry  of  Health  with  the 
participation  of 
the  Bulgarian 
the  NHIF, 
physicians’, dentists’ and patients’ associations. In 
addition,  a  system 
for  medical  audits  and 
monitoring  is  established  by  an  executive  agency, 
responsible  for  developing  uniform  criteria  for 
assessing the efficiency and effectiveness of health 
care services.  

31 

 
                                                           
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Bulgaria  has  a  mixed  system  of  health  care 
financing.  The  Bulgarian  health  care  system  is 
financed  from  three  main  sources:  compulsory 
health  insurance  contributions,  general  taxation, 
and household private expenditure.  

Role  of  private  insurance  and  out  of  pocket 
co-payments  

While  the  state  provides  free,  universal  access  to 
emergency  health  care,  private  expenditure  plays 
an  important  role  in  financing  health  care  in 
Bulgaria.  In  2015,  public  expenditure  accounted 
for  only  54.8%  of  total  health  expenditure  (EU: 
78.4%)  and  out-of-pocket  expenditure  was  at  the 
very  high 
total  health 
level  of  47.7%  of 
expenditure.  The role of private insurance is very 
limited. 

Out-of-pocket  payments  take  three  main  forms: 
informal 
direct  payments,  cost-sharing  and 
payments.  Direct  payments  in  Bulgaria  include 
payments  for  specialist  services  without  a  GP 
referral,  payments  to  the  providers  without  a 
contract  with  the  NHIF,  or  payments  not  covered 
within the benefit package. Cost-sharing applies as 
a flat mandatory fee for visits to a GP, a specialist 
or  a  health  diagnostic  laboratory  covered  by  the 
NHIF  and  for  hospital  stay ( 79).  Cost-sharing  also 
applies 
for 
treatment of chronic diseases.  

to  outpatient  medicines,  except 

In  mid-March  2016  the  Council  of  Ministers 
adopted  amendments  to  the  ordinance  on  the 
implementation  of  the  right  of  access  to  medical 
care.  It  defines  the  terms  and  conditions  under 
which  the  insured  persons  will  be  reimbursed  by 
NHIF  services  It  forbids  e.g.  hospitals  to  ask 
additional  payments  from  accompanying  persons 
of  children  up  to  seven  years  of  age,  in  case  they 
stay  in  the  hospital  with  their  child.  If  the  case 
requires extra care that the hospital cannot provide, 
children up to 18 years of age will be accompanied 
free of charge. In case of a need of hospitalisation, 
companions of disabled people who cannot be self-
served will have the right for free of charge stay in 
the hospital. 

(79)  According  to  the  new  text  in  the  Health  Social  Insurance 
Act,  Art.  37,  the  amount  of  cost-sharing  is  not  connected 
already  to  the  minimum  wage,  but  on  yearly  basis  is 
defined by a Decree of the Council of Ministers. 

32 

In case of emergency, all patients have the right to 
be  immediately  admitted  in  hospital.  Elective 
hospital admissions for the health insured are to be 
performed  within  two  months.  This  period  can 
only be prolonged on request of the patient or due 
to medical indications.  The ordinance furthermore 
prohibits  hospitals  to  require  patients  or  their 
relatives  to  make  any  donations,  i.e.  informal 
payments,  during  the  hospitalisation,  as  well  as 
one month before it. The ordinance does not allow 
patients  to  pay  extra  for  activities  funded  by  the 
NHIF. 

Types of providers, referral systems and patient 
choice 

legally  assigned 

Primary  care  is  provided  by  GPs  working  in 
private practices, group practices and in outpatient 
hospital departments. The citizens have free choice 
of  GPs,  whom  they  can  change  once  every  six 
the 
months.  GPs  are  being 
function  of  gatekeepers,  referring  patients  to  the 
specialists  and  hospitals.  Facilities  which  provide 
specialised  ambulatory  care  include  individual  or 
group  practices  for  specialised  medical  care 
within:  separate  medical  specialists;  health  care 
centres; diagnostic consultation centres (containing 
at  least  10  physicians  in  various  specialities); 
image  diagnosis  centres;  or 
laboratory  and 
individual  medical  and  diagnostic  or  technical 
laboratories.  

The density of physicians in  Bulgaria exceeds the 
average density in the EU. In 2015, there were 405 
practising  physicians  per  100,000 
inhabitants, 
compared  to 344  in  EU.  However,  Bulgaria  has  a 
low  number  of  general  practitioners  (62  per 
100,000 inhabitants vs. 78 in 2015 in the EU). The 
number  of  nurses  per  100,000  inhabitants  (437  in 
2015)  is  almost  half  the  EU  average  of  833.  The 
availability  and  quality  of  health  services  varies 
substantial 
across 
improvements  in  non-urban  areas.  The  ill-defined 
skill-mix  together  with  an  unequal  distribution  of 
physicians across the regions affects the provision 
and  use  of  primary  care,  resulting  in  bottlenecks 
and  limiting  the  effectiveness  of  the  system  and 
leading  to  strong  inequities  in  access  to  health 
care,  although  patients  can  travel  to  nearby  cities 
where access to care is easier.  

and  needs 

country 

the 

Hospital care in Bulgaria is provided by public and 
private hospitals.  

 
                                                           
Health care systems 

2.3. Bulgaria 

Similarly,  to  the  number  of  physicians,  hospital 
capacity  exceeds  EU  averages.  In  2015,  the 
number  of  acute  care  beds  was  601  compared  to 
402  per  100,000  inhabitants  in  the  EU.  The 
number  of  acute  care  beds  is  also  increasing 
contrary  to  the  general  trend  in  the  EU.  The 
number  for  all  hospital  beds  (incl.  long-term  care 
beds)  in  Bulgaria  is  also  higher  than  the  EU 
average  (Bulgaria:  681;  EU:  526  per  100,000 
inhabitants).  Further  reducing  hospital  capacity, 
optimising  bed  occupancy  rates  and  bed  turnover 
rates,  increasing  the  number  of  day  case  surgery 
and  outpatient  cases,  and  concentrating  high-tech 
complex  care  in  a  few  facilities  (centres  of 
excellence)  are  perhaps  areas  where  further 
improvements can be made. 

Treatment options, covered health services 

the  scope  of 

There is a defined basket of services that has to be 
delivered  to  the  whole  population  covered.  An 
ordinance  adopted  by  the  Ministry  of  Health 
regulates 
the  specific  medical 
activities  in  the  package  paid  with  funds  from 
NHIF.  The  outpatient  care  is  included  entirely  in 
the  basic  package.  For  primary  care  the  basic 
package  includes  provision  of  health  information, 
promotion, prevention, diagnostics and therapeutic 
activities. They aim at completing the provision of 
necessary medical care and services and to protect 
and  improve  the  health  of  patients  and  their 
families.  The  focus  is  put  on  health  education 
about  risk  factors  regarding  socially  significant 
illnesses  and  damages  from  unhealthy  habits  as 
well as on promoting positive health habits. 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Health  care  providers  are  mainly  reimbursed 
retrospectively  on  a  per-case  and  per-capita  basis. 
Actual  payment  rates  are  agreed  in  the  contract 
with the NHIF beforehand.  

Primary  health  care  providers  are  reimbursed  by 
the  NHIF  on  a  contractual  basis  according  to  the 
National  Framework  Contract.  The  contracts  are 
based on monthly per-capita payments per insured 
person  on  the  patient  list.  They  also  may  include 
additional  payments  for  additional  procedures, 
such  as  preventive  health,  immunisation,  regular 
medical  check-up,  dispensary 
treatment  and 
observation.  Moreover,  those  working  in  sparsely 

populated  and  remote  areas  receive  an  additional 
per-capita  remuneration  combined  with  periodic 
balancing. Outpatient specialists are paid on a fee-
for-service basis with different rates depending on 
the service provided. 

Hospitals  receive  funding  mainly  through  case-
(or  payments  per  clinical 
based  payments 
pathway),  based  on  a  single  flat  rate  per  pathway 
combined  with  global  budgets.  The  flat  rate  is 
calculated  according 
the  cost  of  medical 
to 
activities,  auxiliary  services  provided  to  patients 
and  up  to  two  outpatient  examinations  following 
the  patient's  discharge.  The  terms,  conditions  and 
the procedure for monitoring, analysis and control 
on  the  implementation  of  medical  care  providers, 
as well as of the volumes and the total value of the 
services  provided,  have  to  be  defined  in  the 
National  Framework  Agreement  for  Medical 
Activities.  In  case  such  an  agreement  is  not 
concluded  the  decision  is  be  taken  by  the  NHIF 
Supervisory Board.  

A  high  share  of  public  health  care  spending  is 
spent  on  inpatient  curative  and  rehabilitative  care 
(48.5% in Bulgaria in 2015 versus 32% in the EU 
in  2015),  while  a  low  share  of  spending  is 
allocated  to  outpatient  care  (12.4%  in  Bulgaria  in 
2015 versus 22.5% in the EU in 2015). 

The institutions  which are  financed from the state 
budget  (mainly  state  psychiatric  hospitals  and 
health  and  social  care  children's  homes)  follow 
different  procedures  and  are paid  per  diem  by  the 
Ministry of Health.  

The  mechanisms  for  paying  staff  employed  in 
inpatient  care  institutions  vary  according  to  the 
type of the institution and, generally, combinations 
of various payment methods are used. In the public 
inpatient  sector,  health  personnel  are  mostly 
salaried and receive additional performance-related 
bonuses. In private hospitals, payment mechanisms 
are  directly  negotiable  between  the  employer  and 
the employees under labour contracts for different 
personnel categories. 

The market for pharmaceutical products 

Medicinal products subject to medical prescription 
and  fully  or  partially  paid  by  public  funds  are 
included in the Positive Drug List and their prices 
are  formed  using  external  and  internal  reference 

33 

 
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prices.  For  external  reference  purposes,  producer 
prices from 10 EU reference countries are used. If 
there  are  producer  prices  in  those  10  reference 
countries,  the  rule  is  to  set  the  price  at  the  lowest 
price  for  the  same  medicinal  product  as  listed  in 
one of 7 additional EU reference countries. 

According  to  the  National  Health  Strategy  2014-
2020,  one  of  the  key  challenges  in  delivering 
quality, 
affordable  medicinal 
products is the design of  mechanisms to stimulate 
rational  use  of  medicinal  products  and 
the 
implementation of generic drug policy. 

effective 

and 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

The  adopted  amendments  to  the  health  insurance 
law  in  June  2015  initiated  the  following  reforms. 
An  obligatory  centralised  negotiation  of 
the 
discounts  paid  by  NHIF  for  innovative  medicines 
and products for cancer treatment is introduced, as 
well  as  a  mechanism  for  health 
technology 
assessment (HTA) for medicinal products.  

The  HTA  process  started  in  2016  with  the 
establishment  of  a  special  commission  at  the 
National  Centre  of  Public  Health  and  Analyses 
(NCPHA),  a  subordinate  body  of  the  Ministry  of 
Health.  HTA  is  to  be  carried  out  in  the  event  of 
inclusion 
list  of  new 
the  positive  drug 
innovative  medicinal  products.  HTA  aims  to 
provide  information  about  the  safety,  clinical 
effectiveness  and  efficiency,  as  well  as  on  the 
budgetary,  social,  legal  and  ethical  impacts  of  the 
application of medicinal products in healthcare.  

in 

However,  an  amendment  of  the  Ordinance  on  the 
conditions, rules and procedure for regulation and 
registration  of  the  prices  of  medicinal  products, 
adopted  by  a  Council  of  Ministers’  Decree  in 
January  2017,  allows  the  inclusion  of  medicines 
with  no  evidence  on  clinical  efficacy  or  cost-
efficiency  in  the  positive  drug  list.  A  decision  to 
reimburse  such  medicines  can  be  taken  by  the 
National Council on Prices and Reimbursement of 
Medicinal Products. 

eHealth, Electronic Health Record 

The  use  of 
information  and  communication 
technologies  (ICT)  is  growing  in  the  Bulgarian 
health  system.  The  health  portal  of  the  National 

34 

Health Insurance Fund enables the insured persons 
to  review  their  e-medical  record  online.  The 
electronic service for reviewing the medical record 
is  available  to  all  citizens  of  the  Republic  of 
Bulgaria, who are (or were) health insured, as well 
as citizens of  countries with which there are acting 
bilateral agreements can access the portal (80). 

Some  other  e-services  provided  by  NHIF  include 
checking  for GPs that have contracted  with NHIF 
and  medicines  paid  by  NHIF.  Additionally,  there 
are  electronic  submissions  of  reports  from  the 
inpatient  care  sector  to  NHIF,  electronic  daily 
registers  of  hospitalised  and  discharged  patients, 
electronic  checks  of  validity  of  health  insurance 
cards, verification of health insurance status, etc.  

Health  promotion  and  disease  prevention 
policies 

to  prevention  and  health 
Resources  directed 
promotion  policy  are  low  due  to  the  overall  low 
level of health spending.  

for  Health  2020” 

 In early 2015, the government adopted a national 
response  “Objectives 
for 
implementation  of  the  WHO  strategic  framework 
"Health 2020". This document formulates national 
goals in the field of improving the health status of 
the  population  as  a  factor  for  sustainable  growth 
and  defines  long-term  priorities  of  the  country  in 
the  health  sector.  Based  on  the  analysis  of  the 
health  status  of  the  population  in  Bulgaria,  the 
concept  defines  several  national  health  goals  by 
2020,  including  a  reduction  of  child  mortality,  an 
improvement  of  the  health  status  among  the 
economically active groups and an increase in life 
expectancy.  By  the  end  of  the  same  year  (81),  the 
National  Health  Strategy  2014-2020  that  sets  out 
the main goals of the health system until 2020 was 
adopted.  The  strategy  and  its  action  plan  for 
implementation  contain  the  priority  policies  and 
measures  for  addressing  the  increasing  health 
challenges.  Among  these  are  equal  treatment,  the 
impact of the social determinants on public health 

(80)  Users  may  access 

this  electronic  service 

through 
https://pis.nhif.bg/main/.  In  order  to  access  his/her  e-
medical  record  online  the  insured  person  should  possess 
Qualified Electronic Signature or should obtain an Unique 
Access Code from his/her Regional Health Insurance Fund. 
(81)  The  National  Health  Strategy  2014-2020  was  adopted  by 
the  National  Assembly  in  December  2015  (publ.  SG  No. 
101 from 2015). 

 
                                                           
Health care systems 

2.3. Bulgaria 

and  the  main  prerequisites  for  the  functioning  of 
the health system. 

Bulgaria  still  has  untapped  potential  to  achieve 
better health of the population and prevent most of 
the diseases and premature mortality, respectively. 
There  is  a  potential  to  increase  the  high  levels  of 
premature  mortality  by  a  stronger  focus  on  health 
promotion and disease prevention policies, e.g. by 
changing unfavourable life styles. 

As many of the state-owned hospitals struggle with 
continuously  persisting  debts,  in  April  2018,  the 
Ministry  of  Health  enacted  a  compulsory  tool  to 
report and monitor financial management of state-
owned  hospitals.  The  tool  is  based  on  a  set  of 
requirements  to  the  planning  and  accountability, 
investment  policy,  human  resource  management 
and public procurements; and on key performance 
indicators  such  as  average  length  of  stay,  bed 
turnover,  occupancy  rate,  liquidity  ratios,  net 
operating capital, debt to equity ratio, etc. 

Recently 
reforms  

legislated  and/or  planned  policy 

Challenges 

The  strategic  goals  set  out  in  the  National  Health 
Strategy  2014-2020  are  based  on  the  analysis  of 
the  health  and  demographic  situation  of  the 
Bulgarian  population.  There  are  five  national 
health priorities that focus the health policy on the 
sustainable improvement of the health of Bulgarian 
citizens in all age groups: 1) decrease of children’s 
mortality at age 0-1 year to 6.8 per 1,000 live born; 
2) decrease of children’s mortality at age 1-9 up to 
0.24 per 1,000; 3) decreasing of mortality of young 
and  teenagers  10-19  years  of  age  up  to  0.28  per 
1,000;  4)  decreasing  of  mortality  of  economically 
active  population  –  age  20-65  years  to  4.19  per 
1,000;  5)  increasing  of  average  length  of  life  of 
people above 65 with 16.4 years. 

With the latest amendments to the law on medical 
treatment  facilities  from  December  2015,  the 
National  Assembly  adopted  the  National  Health 
Map,  which  allows  determining  and  planning  the 
needs  of  the  population  for  health  services  access 
to  outpatient  and  hospital  care  on  geographical 
principles.  The  changes  also  provide  for  the 
formation of complex multidisciplinary centres for 
children with disabilities and chronic illnesses and 
people with rare diseases.  

Since 2016, in accordance with the changes in the 
law  on  health  insurance  adopted  in  December 
2015,  NHIF  applies  new  mechanisms  for  the 
implementation  of  control  activities,  to  reduce 
opportunities  for  fraud  and  abuse  in  the  health 
insurance  system.  NHIF  employees  together  with 
controllers  carry  out  unexpected  controls  over  the 
execution of contracts with medical and / or dental 
the 
care  providers,  pre-payment  control  of 
provided medical and / or dental care services and 
ex-post control. 

The analysis above shows  that a range of reforms 
have been implemented over the  years to increase 
the efficiency in the sector while trying to improve 
the  access  to  care.  However,  there  may  be  room 
for improvements in a number of areas. The main 
challenges for the Bulgarian health care system are 
as follows: 

•  To  guarantee  the  universality  of  health  care 
coverage  by 
the  mandatory 
implementing 
health  insurance  subscription  for  permanent 
residents;  to  limit  the  size  of  out-of-pocket 
payments  in  total  expenditure.  This  would 
contribute  to  reduce  inequalities  in  access  to 
and quality of health care. 

•  To improve the basis for more sustainable and 
efficient  financing  of  health  care  in  the  future 
(e.g.  considering  additional  sources  of  general 
budget  funds),  aiming  at  a  better  balance 
between  resources  and  spending,  as  well  as 
between  the  number  of  contributors  and  the 
number  of  beneficiaries.  This  can  reduce  the 
reduce 
size  of  private  payments 
inequalities  in  the  access  and  quality  of  care 
and  its  distribution  between  population  groups 
and regional areas. 

and 

In 

the 

•  To  continue  to  enhance  and  better  distribute 
primary  health  care  services  to  improve  the 
effectiveness  and  efficiency  of  health  care 
effective 
delivery. 
implementation  and  usage  of  the  recently 
deployed  eHealth  tools,  including  electronic 
patient  records,  can  help  ensuring  effective 
referral systems from primary to specialist care 
and improving care coordination between types 
of care.  

future, 

the 

35 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

ownership of the strategy by all stakeholders of 
the health system. 

a 

comprehensive 

•  To  increase  the  primary  care  staff  supply  by 
implementing 
human 
resources  strategy  that  adjusts  the  training  of 
doctors  to  ensure  a  balanced  skill-mix,  that 
avoids  staff  shortages  and  that  motivates  and 
retains staff to the sector, especially in view of 
migration.  In  addition,  consider  enhancing 
financial and institutional incentives for GPs to 
provide  adequate  levels  of  services  to  patients 
based on quality indicators, performance-based 
reporting and payment bonuses.  

•  To  increase  health  system  efficiency  by  the 
shifting excessive capacity and activity of acute 
inpatient 
and 
towards 
outpatient  care  services,  and  strategically 
directing  more  resources  towards  providers  of 
lower levels of care.  

ambulatory 

care 

•  To consider additional measures to improve the 
rational  prescribing  and  usage  of  medicines, 
such  as  information  and  education  campaigns, 
the monitoring of prescription of medicines and 
a  more  explicit  policy  on  incentivising  the 
uptake  of  generics.  The  policies  could  help 
improving population health, reducing the high 
level of out-of-pocket payments and improving 
access  to  cost-effective  new  medicines  by 
generating savings to the public payer.  

and  outcomes 

•  To  continue  improving  the  systems  for  data 
collection and monitoring of inputs, processes, 
regular 
outputs 
performance  assessment  can  be  conducted. 
Promote  the  use  of  ICT  in  the  gathering, 
storage,  use 
exchange  of  health 
information.  

that 

and 

so 

•  To  gradually 

increase 

the  use  of  cost-
effectiveness  information  in  determining  the 
basket of goods and the extent of cost-sharing.  

•  To  foster  public  action  in  the  area  of  health 
promotion  and  disease  prevention  on  the  basis 
of  the  defined  public  health  priorities  (diet, 
smoking,  alcohol,  lack  of  exercise)  and  given 
the recent pattern of risk factors.  

•  To  operationalise,  implement  and  adapt  as 
needed  the  National  Health  Care  Strategy 
increasing 
(2014-2020),  with  a  view  of 

36 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.3.1:  Statistical Annex – Bulgaria 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

3
7

2005

24

11.6

7.7

:

2006

27

11.7

7.4

1.2

2007

32

11.8

7.9

6.6

2008

37

11.7

6.5

9.0

2009

37

10.7

-3.1

0.5

2010

38

11.2

2.0

6.9

2011

41

11.2

4.5

6.4

2012

42

11.4

0.6

-4.8

2013

42

11.4

1.4

12.0

2014

43

12.0

1.9

14.6

2015

45

12.5

4.3

1.7

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

7.3

7.1

0.2

501

4.6

4.3

312

0.28

62.3

11.8

:

38.9

6.9

6.8

0.1

543

3.9

3.8

311

0.15

57.2

14.2

:

42.7

6.8

6.5

0.3

645

4.0

3.7

375

0.31

58.1

13.4

:

42.6

7.0

6.6

0.4

762

4.1

3.7

450

0.41

59.1

10.7

:

42.6

7.2

7.1

0.2

799

3.9

3.8

433

0.08

54.2

11.5

:

44.4

7.6

7.5

0.0

863

4.4

4.2

499

0.20

57.8

12.4

:

43.1

7.7

7.7

0.1

956

4.3

4.2

530

0.12

55.5

13.2

77.0

44.5

7.3

7.1

0.2

925

4.2

4.0

531

0.20

57.4

13.1

77.0

47.7

8.1

7.9

0.2

9.1

8.5

0.6

8.9

8.2

0.7

4.3

4.1

545

0.23

52.9

14.8

88.2

47.2

5.1

4.5

664

0.58

56.0

13.0

:

45.8

4.9

4.2

675

0.66

54.8

13.4

:

47.7

2005

7.7

76.2

69.0

:

:

210

10.4

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

7.6

76.3

69.2

71.9

66.2

210

9.7

7.6

76.6

69.5

73.9

67.1

209

9.2

7.5

77.0

69.8

65.7

62.1

201

8.6

7.5

77.4

70.2

65.9

62.1

189

9.0

7.4

77.4

70.3

67.1

63.0

191

9.4

7.4

77.8

70.7

65.9

62.1

280

8.5

7.3

77.9

70.9

65.7

62.1

300

7.8

7.3

78.6

71.3

66.6

62.4

275

7.3

7.2

78.0

71.1

66.1

62.0

289

7.6

7.2

78.2

71.2

65.0

61.5

282

6.6

EU- latest national data

2009

2011

12,451

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

1,030

1,185

1,232

2,745

2,895

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.9

:

1.0

2.4

0.1

0.2

0.1

2.5

0.0

0.6

0.5

0.0

0.2

0.1

2.6

:

0.9

2.5

0.1

0.2

0.1

2.2

0.0

0.5

0.5

0.0

0.2

0.1

2.5

:

0.8

2.3

0.2

0.3

0.1

2.2

0.0

0.5

0.5

0.0

0.2

0.1

2.7

:

0.8

2.3

0.1

0.3

0.1

2.3

0.0

0.5

0.4

0.0

0.3

0.1

:

:

:

:

:

0.3

0.1

:

:

:

:

:

0.2

0.1

:

:

:

:

:

0.3

0.1

:

:

:

:

:

0.3

0.1

:

:

:

:

:

0.3

0.2

:

:

:

:

:

0.3

0.2

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2.5

0.3

1.1

3.3

0.0

0.2

0.1

2.1

0.3

0.5

0.7

0.0

0.2

0.1

2.6

0.4

1.1

3.4

0.2

0.2

0.1

2.2

0.4

0.5

0.8

:

0.2

0.1

2.4

0.4

1.1

3.3

0.2

0.2

0.1

2.1

0.4

0.5

0.7

:

0.2

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
e
a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

2
.
3
.

l

B
u
g
a

r
i

a

 
 
 
 
 
 
 
 
 
 
 
3
8

Table 2.3.2:  Statistical Annex - continued – Bulgaria 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

40.3%

:

13.6%

34.3%

1.1%

3.1%

1.4%

58.8%

0.0%

13.3%

12.6%

0.0%

4.7%

2.6%

2005

0.27

0.6

1.6

:

:

:

10.5

2005

364

404

68

690

2005

5.4

20

:

:

:

:

2016

5.0

5.0

2016

7.2

2006

39.1%

:

12.9%

36.8%

1.6%

3.6%

1.5%

58.8%

0.0%

12.9%

13.7%

0.0%

5.5%

2.6%

2006

0.31

0.6

1.7

:

:

:

10.4

2006

365

410

67

617

2006

5.4

20

:

:

:

:

2020

5.1

5.3

2020

7.0

2007

39.1%

:

12.9%

35.2%

2.6%

4.0%

1.2%

58.9%

0.0%

12.9%

12.9%

0.0%

6.6%

2.2%

2007

0.31

0.7

1.9

:

:

39.7

10.9

2008

41.2%

:

12.4%

35.3%

1.5%

4.4%

1.1%

61.2%

0.0%

12.4%

11.6%

0.0%

7.3%

1.9%

2008

0.31

0.7

2.2

:

11.5

29.2

11.0

2007

2008

364

421

65

608

2007

5.4

21

:

:

7.2

:

2025

5.2

5.6

2025

6.7

360

424

63

559

2008

5.4

22

:

:

6.8

:

2030

5.3

5.9

2030

6.4

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

2014

30.7%

4.8%

13.2%

40.2%

2.5%

2.6%

1.4%

49.2%

9.1%

12.0%

17.3%

:

4.2%

2.7%

2014

0.71

1.1

3.4

0.0

14.4

27.3

12.0

2015

29.4%

4.6%

13.5%

40.7%

2.8%

2.6%

1.3%

48.9%

9.1%

12.4%

16.2%

:

4.5%

2.6%

2015

0.71

1.1

3.4

0.0

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2014

2015

2009

2011

2013

2015

399

442

63

524

2014

5.9

32

:

:

5.4

:

2060

5.5

6.5

2060

5.2

405

437

62

518

324

837

77

416

330

835

78

408

2015

2009

2011

5.9

31

:

:

5.3

:

6.2

17

6.2

16

6,362

6,584

77.1

8.0

28.0

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

2065

2070

5.4

6.4

5.2

6.3

2065

5.0

2070

4.9

Change 2016-2070, in pps.

Bulgaria

0.3

1.3

EU

0.9

1.6

Change 2016-2070, in %

Bulgaria

-31.9

EU

2.0

2009

2010

2011

2012

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

3.5%

1.4%

4.2%

1.3%

3.8%

2.0%

:

:

:

:

:

6.0%

2.6%

2009

0.40

:

2.7

:

:

:

10.9

2009

369

421

65

553

2009

5.4

23

:

:

6.5

:

2035

5.4

6.1

2035

6.2

:

:

:

:

:

6.7%

2.4%

2010

0.42

:

3.0

:

:

:

10.8

2010

375

426

64

546

2010

5.4

25

:

:

6.1

:

2040

5.5

6.3

2040

5.9

:

:

:

:

:

6.5%

3.6%

2011

0.63

1.0

2.9

0.0

:

:

10.7

2011

386

430

64

535

2011

5.4

26

:

:

6.0

:

2045

5.6

6.5

2045

5.7

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2012

0.74

1.0

3.2

0.0

:

:

11.0

2012

391

439

67

528

2013

31.7%

3.3%

13.6%

42.4%

0.0%

2.7%

1.4%

51.1%

6.4%

12.8%

16.5%

0.0%

4.4%

2.7%

2013

0.73

1.1

3.4

0.0

:

:

12.1

2013

398

447

63

523

2012

2013

:

27

:

:

5.8

:

2050

5.6

6.6

2050

5.6

:

30

:

:

5.6

:

2055

5.6

6.6

2055

5.4

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.4. CROATIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

2015  vs.  an  average  of  2,609  PPS  in  the  EU  in 
2015 (83). 

General  statistics:  GDP,  GDP  per  capita; 
population 

Croatia,  member  of  the  European  Union  since 
2013,  has  a  population  of  almost  4.2  million 
inhabitants,  which  is  roughly  0.8%  of  the  EU 
the  absence  of  any  sizeable 
population.  In 
immigration  and  a  decline 
the 
in 
population of Croatia is steadily decreasing. In the 
period  from  2016  to  2070  a  decrease  of  19%  can 
be  expected,  based  on  the  population  forecast  of 
Eurostat, leading to a population of 3.4  million in 
2070. 

fertility, 

In  current  prices  the  GDP  of  Croatia  has  been 
increasing fast from 2005 to 2008, from €37 to €48 
billion.  Since  2008  it  decreased  to  €43  billion  in 
2013  and  has  remained  roughly  stable  at  a  lower 
level  since  then  (€44  billion  in  2015).  GPD  per 
capita was in 2015 with 16,500 PPS well below the 
EU average of 29,600 PPS. 

Total and public expenditure on health as % of 
GDP 

Total  health  expenditure  was  at  7.7%  of  GDP  in 
2015,  lower  than  the  EU  average  of  10.2%. Total 
public  expenditure  on  health  as  a  percentage  of 
GDP  (6.0%)  remains  under  the  EU  average 
(8.0%).  Looking  at  health  care  without  long-term 
care (82)  reveals  a  similar  picture  with  public 
spending below the EU average (5.7% vs 6.8% in 
2015).  At  the  same  time,  the  share  of  health  in 
public  expenditure  is  with  13.4%,  recorded  in 
2015, of total government expenditure, close to the 
EU average of 15%. With some 77.7% the share of 
public  expenditure  in  total  expenditure  on  health 
was in 2015 also at the EU average of 78.4%. 

When expressed in per capita terms, total spending 
on  health  at  1,151  PPS  in  2015  was  significantly 
below  the  EU  average  in  the  same  year  (3,305 
PPS). So is public spending on health: 895 PPS in 

(82)  To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

Expenditure projections and fiscal sustainability 

As a consequence of population ageing, health care 
expenditure  is  projected  to  increase  by  0.7  pps  of 
GDP,  slightly  below  the  average  growth  level 
expected for the EU of 0.9 pps of GDP, according 
to the "AWG reference scenario" (84). When taking 
into  account 
impact  of  non-demographic 
drivers  on  future  spending  growth  ("AWG  risk 
scenario"),  health  care  expenditure  is  expected  to 
increase  by  1.5  pps  of  GDP  from  now  until  2070 
(EU: 1.6 pps). Overall, the country faces no fiscal 
risks  in  the  short-run  and  medium  risks  in  the 
medium and long-term ( 85). 

the 

Health status 

Life expectancy at birth for both  women and  men 
is  respectively  80.5  years  and  74.4  years  and  is, 
although  having  increased  during  the  decade, 
below  the  EU  average  (83.3  and  77.9  years 
respectively).  Similarly,  healthy  life  years  at  birth 
for  both  sexes  are  with  56.8  years  (women)  and 
55.3 years (men) lower than the EU average (63.3 
and  62.6,  respectively).  Infant  mortality  has 
gradually  declined  to  4.1  per  1,000  live  births  in 
2015, but is still higher than the EU average of 3.6. 

System characteristics  

Overall description of the system 

Since  1990,  Croatian  health  care  went  through  a 
series of reforms that have helped to transform the 
once  fragmented  and  highly  decentralised  health 
system,  inherited  from  former  Yugoslavia  and 
battered  by  five  years  of  war,  into  a  health  care 
system that maintains the principles of universality 
and solidarity. 

The  system  of  health  care  in  Croatia  is  based  on 
(with  predominant  public 
mixed 

financing 

(83)  Note  that  these  PPS  figures  reflect  current  plus  capital 
health expenditure in contrast to Eurostat data series, which 
reflect current expenditure only. 

(84)  The 2018 Ageing Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(85)  European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

39 

 
                                                           
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

is 

care 

financing,  nearly  78%  in  2015)  and  provision  by 
public  and  private  health  services  providers. 
Health 
from  mandatory 
financed 
contributions (approximately 91%) as well as from 
taxes,  co-payments  and  private  insurance.  Also  a 
share  of  compulsory  car  insurance  premiums  is 
part of the healthcare budget. 

Health  care  is  contracted  by  the  Croatian  Health 
Insurance  Fund  (HZZO),  counties  (20)  and  the 
City of Zagreb, and beneficiaries. The contribution 
rates  for  the  mandatory  health  insurance  are  15% 
of  gross  salary  (86)  and  an  additional  special 
contribution  of  0.5%  of  gross  salary  for  injuries 
and  occupational  diseases.  Since  2015, 
the 
Croatian  Health  Insurance  Fund  is  separated  from 
the  State  Treasury  and  is  functioning  as  an  extra-
budgetary fund. 

Two  basic  rights  arising  from  the  compulsory 
basic  health  insurance  include  in-kind  benefits 
(right  to  health  protection)  and  cash  benefits  (e.g. 
compensation  for  sick  leave,  travel  expenses  (87), 
etc). 

Coverage 

The  average  number  of  insured  persons  in  2015 
was 4,325,852, however, only 33% of the insured 
(1,446,654  persons)  contributed  the  full  premium 
of  15%  of  gross  salary  (88).  While  it  is  estimated 
that  only  1/3  of  the  population  is  liable  to  pay 
health care contributions, the remaining population 
includes pensioners (who pay a reduced healthcare 
premium  depending  on  their  pension),  insured 
persons’  family  members,  unemployed  (health 
contribution  5%  of  the  prescribed  base  amount, 
paid  from  the  state  budget)  and  other  inactive 
persons. 

(86)  In  order  to  boost the competitiveness  of  the  economy,  the 
healthcare insurance contributions were lowered from 15% 
to 13% in 2012, though this measure was revoked in 2014 
with  Act  on  Amendments  of  the  Contributions  Act,  OG, 
No. 41/14. 

(87)  Insured  persons  are  entitled  to  claim  reimbursement  of 
travel expenses if they used health services at a contracted 
health  facility  or  physician  which  is  more  than  50  km 
distant  from  their  residence, provided  they  are  not  able  to 
obtain  the  same  treatment  in  the  place  of  their  residence. 
However, complicated rules of reimbursement do not allow 
for a full reimbursement of costs in all cases. 

(88)  Source: Croatian Health Insurance Fund Annual Report for 

2015,  http://cdn.hzzo.hr/wp-
content/uploads/2016/04/Izvjesce_o_poslovanju_hzzo_za_
2015_godinu.pdf. 

40 

From  the  share  of  the  population  paying  the  full 
healthcare  insurance  contributions  in  2015,  47% 
(685,988) were women and 53% (780,666) persons 
were  men.  Furthermore,  1,061,553  pensioners 
were  registered  in  2015.  The  number  of  farmers 
was  21,845  (89).  Other  categories  of  insured 
(which comprises the unemployed, insured abroad 
-  pensioners,  students  and  high  school  students, 
persons  incapable  of  independent  life  and  work, 
etc.) marked an  yearly increase by 29.4% in 2015 
(90). 

Administrative  organisation  and 
collection mechanism  

revenue 

Contributions  are  paid  on  a  monthly  contribution 
base,  which  represents  the  salary  or  other  income 
from employment paid by employer and subject to 
income  tax  or  income  from  self-employment, 
which  is  calculated  as  the  product  of  monthly 
contribution  base  and  a  coefficient  depending  on 
the 
self-employment.  Health 
contributions  on  pensions  above  the  average  net 
wage amount to 3%.  

nature 

of 

In 2008, the efficiency of the sector was increased 
through  the  introduction  of  public  procurement  of 
medication,  centralised  procurement  of  medical 
to 
equipment,  better  supervision  of 
households,  reorganisation  of  emergency  medical 
services,  use  of  eHealth  tools  in  primary  health 
care  and  introduction  of  national  waiting  lists. 
Diagnoses  related  groups  (DRGs)  replaced  the 
unpopular  payment  per 
therapeutic  procedure 
(PPTPs)  in  2009  and  allowed  for  more  refined 
case-groupings.  

transfers 

Role  of  private  insurance  and  out  of  pocket 
co-payments  

Patients  have  to  pay  co-payments  for  medicines, 
which  are  on  a  complementary  list  of  medicines, 
even 
insurance. 
they  have  complementary 
Complementary insurance is a voluntary insurance. 
Patients  without  complementary  health  insurance 

if 

(89)  Source: Croatian Health Insurance Fund Annual Report for 
2015, 
http://cdn.hzzo.hr/wp-
content/uploads/2016/04/Izvjesce_o_poslovanju_hzzo_za_
2015_godinu.pdf.  

(90)  Source: Croatian Health Insurance Fund Annual Report for 

2015,  http://cdn.hzzo.hr/wp-
content/uploads/2016/04/Izvjesce_o_poslovanju_hzzo_za_
2015_godinu.pdf. 

 
                                                           
                                                           
Health care systems 

2.4. Croatia 

have  to  pay  additional  fixed  amount  of  HRK  10 
(€1.50)  per  prescription  and  HRK  10  (€1.5)  for  a 
GP  visit.  They  also  have  to  pay  20%  of  hospital 
the  maximum  amount  of 
expenditures  with 
approximately  €260  per  invoice  (for  treatments, 
medical tests, hospital bed). 

With the Healthcare Reform of 2008, the share of 
the population excluded from paying co-payments 
was reduced. At the same time, the HZZO offered 
a  voluntary  complementary  health 
insurance 
(CHI),  which  could  cover  these  co-payments 
(Voncina, 2012). Complementary health insurance 
may be provided by HZZO or by private insurers. 

The total number of insured persons by HZZO for 
complementary  health insurance  was 2,597,831 in 
2015.  From  them,  as  many  as  1,623,799  paid  the 
complementary  health 
insurance  policy  by 
themselves. For about 974,032 insured persons, the 
costs  of  complementary  health  insurance  policy 
were  covered  from 
the  state  budget  (these 
categories  include  persons  with  100%  disability, 
organ  donors,  blood  donors,  pupils  and  students 
under  26  years,  as  well  as  persons  below  the 
minimum income threshold) (91). 

HZZO  provided 
the  complementary  health 
insurance  at  a  yearly  loss  of  23  million  euro  in 
2012. Nevertheless, the HZZO reduced the price of 
complementary health insurance policy to HRK 70 
(€9)  for  all  insured  persons  in  September  2013. 
With  this  measure,  HZZO  hoped  to  retain  the 
majority of 2,370,000 insured persons and beat the 
competitors  in  the  market.  The  largest  private 
insurer 
their 
in  Croatia,  Osiguranje,  offered 
complementary health insurance policies at a price 
of  HRK  75,  and  with  the  opening  of  the  market 
after  Croatia  joined  the  EU;  additional  private 
insurance companies have announced their interest 
in this segment. HZZO is currently holding around 
98%  of  the  market  in  complementary  health 
insurance (Bodiroga-Vukobrat, 2013). 

Private voluntary supplementary insurance plays a 
minor  role  in  Croatia,  with  about  1.2%  of  the 

(91)  Source: Croatian Health Insurance Fund Annual Report for 

2015,  http://cdn.hzzo.hr/wp-
content/uploads/2016/04/Izvjesce_o_poslovanju_hzzo_za_
2015_godinu.pdf. 

population holding a private supplementary health 
insurance policy (92). 

Types of providers, referral systems and patient 
choice 

The  number  of  practising  physicians  per  100,000 
inhabitants (319 in 2015) is slightly below the EU 
average  (344  in  2015),  showing  an  increase  since 
2005  (250).  The  number  of  GPs  per  100,000 
inhabitants  (55  in  2015)  is  below  the  EU  average 
(78  the  same  year),  and  has  remained  roughly 
stable since 2009. The number of practising nurses 
per  100,000  inhabitants  (583  in  2015)  is  well 
below  the  EU  average  (833)  despite  having 
increased  throughout  the  decade,  from  a  level  of 
483 in 2005 (93). 

Teaching  hospitals,  clinical  hospital  centres  and 
state  institutes  of  public  health  are  state  owned. 
Health  centres,  polyclinics,  general  and  special 
hospitals,  pharmacies,  institutions  for  emergency 
medical  aid,  home  care  institutions  and  county 
institutes  of  public  health  are  county-owned.  In 
2002,  health  centres  started  merging  and  number 
decreased from 120 in 2001 to 49 in 2014. Out of 
73  hospital  institutions  and  sanatoria,  10  special 
hospitals and 5 sanatoria were privately owned. By 
the end of 2014, there were 5,399 private practice 
units 
laboratories,  private 
pharmacies, private physical therapy practices and 
home care services) registered (94). The majority of 
primary  health  care  general  practitioner  (GP) 
offices  located  in  health  centres  were  since  1991 
privatised, and the remaining ones were left under 
county ownership (Bodiroga-Vukobrat, 2013). 

(doctors’  offices, 

Treatment options, covered health services 

As  the  main  purchaser  of  health  services,  the 
HZZO  also  plays  a  key  role  in  the  definition  of 
basic  health  services  covered  under  statutory 
the  establishment  of  performance 
insurance, 

(92)  The  1993  Law  allowed  opting-out  of  the  public  insurance 
system  and  acquiring  substitutive  insurance  with  private 
insurers. This was abolished in 2002. 

(93)  Data  for  density  of  health  personnel  is  taken  from  the 
OECD  database.  As  this  figure  includes  only  nurses 
employed 
the  actual  number  may  be 
underestimated. 

in  hospitals, 

(94)  Croatian Institute of Public Health, Croatian Health Service 

Yearbook 2014,   http://www.hzjz.hr/wp-
content/uploads/2015/05/ljetopis_2014.pdf. 

41 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

standards and price setting for services covered by 
the HZZO (Vončina et al., 2006). 

With 1.8 hospitals and 358 acute hospital beds per 
100,000 inhabitants in 2015, Croatia is in line with 
older EU Member States and does not have excess 
hospital  facilities  like  many  other  countries  in 
the 
Central  and  Eastern  Europe.  However, 
Croatian  hospitals  have 
inadequate  medical 
technology and equipment. Comparing the number 
of  MRI  scans,  mammograms  and  CT  scans  per 
100,000  inhabitants  reveals  that  Croatia  is  in  the 
lower ranking within the EU. In addition, regional 
coverage varies and regional differences persevere, 
since  many  capacities  are  unequally  distributed 
and concentrated in metropolitan areas (Bodiroga-
Vukobrat, 2013).  

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

institutions  according 

Since  2015,  all  hospitals  and  primary  care 
providers are financed from the HZZO budget. The 
treatment  of  acute  patients  is  paid  to  clinical 
to  diagnostic-
medical 
therapeutic  groups  (DTS),  or  according  to  day  of 
clinical  (hospital)  treatment  (DBL)  for  chronic 
diseases.  Additional  coverage  is  provided  for 
particularly  expensive  medicines  and  certain 
complicated  procedures.  In  the  year  2015,  24,069 
beds have been contacted, of which 12,617 are for 
acute care, 1,324 for long-term care, 6,357 beds for 
chronic  diseases  and  3,771  day  care  beds.  The 
average  monthly  hospital  limit  in  2015  was  HRK 
664,907,700  (€8,981,231),  which  increased  from 
HRK 576.5 million in 2014 (95). 

In 2015, the average number of waiting days for all 
diagnostic  procedures  was  147  with  178,344 
orders  waiting  (decreased  from  166  with  189,540 
orders  in  2014);  the  average  number  of  days  for 
therapeutic procedures was 253 with 42,791 orders 
(down  from  267  with  44,822  in  2014),  and  the 
average  number of days for  first examination  was 
102  with  128,847  orders  (lower  than  111  with 
125,236 orders recorded the previous year).  

(95)  Network  of  Public  Health  Services  (Official  Gazette,  No 
101/12, 31/13, 113/15, 20/18). Depending on the structure, 
the majority of hospital expenses are spent on wages (57% 
in 2011). 

42 

In  2015,  there  were  76  hospital  institutions  and 
treatment  centres  in  Croatia:  5  clinical  hospital 
centres, 8 clinical hospitals and clinics, 20 general 
treatment 
hospitals,  32  special  hospitals  and 
centres,  1  hospice,  9  general  wards  and  1  out-of-
hospital maternity ward. 

In 2015, Croatian hospitals treated 748,159 people. 
The care included also hospital stays for childbirth, 
abortion,  and  hospital  rehabilitation.  According  to 
individual  reports  on  treated  patients  (excluding 
childbirth,  abortions  and 
the 
number of patients treated in Croatian hospitals in 
2015 was 589,215.  

rehabilitation), 

The  number  of  beds  (expressed  per  100,000 
population) in all hospital-type institutions in 2015 
was 583. By bed structure per 100,000 inhabitants 
in 2015, there were 362 acute beds (154 in general 
hospitals  and  225  in  teaching  hospitals).  For 
chronic  and  sub-acute  patients,  189  beds  per 
100,000 inhabitants were available.  

In Croatian hospitals, in 2015 there were 6,401,804 
days  of  hospital  treatment.  In  other  words,  the 
hospital  average  length  of  stay  was  8.6  days 
(against 15.4 days in 1990, but still higher than the 
EU average of 7.6 days in 2015) (96). 

It  is  recognised  that  a  reduction  of  existing 
inefficiencies  in  hospital  management  is  required 
in  the  short-run  in  order  to  decrease  the  debt  and 
arrears  of  hospitals.  Reconsidering  the  model  of 
financing of hospitals seems inevitable in the long 
run.  To  this  end,  the  Hospital  Master  Plan,  which 
is  the  National  plan  of  development  of  clinical 
hospital  centres,  clinical  hospitals  and  general 
hospitals in Republic of Croatia for 2015-2016, has 
come  into  force  in  March  2015  (97).  The  World 
Bank  supported  the  preparation  of  the  plan,  and 
provided  funds  to  hire  French  consultancy  firm 
Conseil Santé to assist with the writing of the plan. 

(96)  Average  length  of  stay  in  general  hospitals  has  been 
reduced from 12.3 days in 1990 to 6.68 days in 2015. The 
average length of stay in teaching hospital centres, teaching 
hospitals and clinics was reduced from 12.05 to 6.86 days 
and  in  special  hospitals  from  34.83  to  24.83  days  in  the 
same  period.  Source:  Croatian  Institute  of  Public  Health, 
Croatian 
2014, 
Service 
http://www.hzjz.hr/wp-
content/uploads/2015/05/ljetopis_2014.pdf. 

Yearbook 

Health 

(97)  http://narodne-

novine.nn.hr/clanci/sluzbeni/2015_03_26_544.html. 

 
                                                           
                                                           
The market for pharmaceutical products 

Croatia  spent  26%  of 
total  current  health 
expenditure  for  outpatient  pharmaceuticals  and 
medical  goods  in  2015,  almost  as  much  as  for 
inpatient  care.  In  2011,  there  were  16  licensed 
pharmaceutical  manufacturers 
Croatia. 
Domestic  manufacturers  held  20%  of  the  market 
share  by  value  produced  and  33%  by  volume 
produced  (Ministry  of  Health  and  Social  Welfare, 
2011).  The  major  domestic  pharmaceutical 
companies 
and 
JadranGalenskiLaboratorij. 

Belupo 

Pliva, 

are 

in 

The  HZZO  is  a  purchasing  monopoly.  It  controls 
drug prices and it has enforced price reductions in 
the market. The access of new drugs to the market 
used to take two to three years. However, the 2003 
Drugs  Law  introduced  a  new  Agency  for  Drugs 
and  Medical  Products  and  set  out  a  shorter,  more 
ambitious time frame for registration (210 days for 
ready-prepared drugs).  

The Drug Reference Price System  was introduced 
in  1999  in  an  attempt  to  contain  pharmaceutical 
expenditure. To further rationalise costs for drugs, 
the  HZZO  has  introduced  risk-sharing,  pay-back 
and cross-product agreements with pharmaceutical 
companies.  In  addition,  according  to  the  new 
model,  whenever both an off-patent and a generic 
are  available,  generics  are  preferred,  unless  there 
are  specific  medical  indications  to  the  contrary 
(Vončina, 2006). 

limited 

To  curb  the  volume  of  prescriptions,  the  HZZO 
has  imposed  annual  caps  on  the  number  of 
prescriptions  per  beneficiary  and 
the 
number of drugs per prescription, which, however 
were not successful as the number of prescriptions 
actually  increased  over  time.  The  HZZO  reviews 
prescribing practices but does not include them as 
part  of  performance  indicators  for  payments. 
Overspending  by  individual  GPs  is,  however, 
subject  to  financial  punishment  of  up  to  10%  of 
monthly capitation. The punishments are enforced 
(Vončina, 2006). 

Pharmaceuticals  covered  by 
the  HZZO  are 
classified  into  two  lists:  the  positive  list  covered 
entirely by HZZO, and the supplementary list with 
medicines  covered  partly  by  HZZO  and  partly  by 
OOP  payments.  Medicines  are  free  of  charge  if 
they  are  on  the  positive  list,  regardless  of  the 

Health care systems 

2.4. Croatia 

patient’s  situation  (age,  financial  status,  inpatient 
or  outpatient  setting,  etc.).  There  is  a  prescription 
fee  for  all  reimbursable  medicines  of  HRK  10 
(approximately  €1.5)  per  prescription.  Private 
health insurance schemes do not cover medicines. 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

In accordance to the Act on Quality of Health Care 
and  Social  Welfare  (Official  gazette,  no  124/11), 
the  Agency  for  Quality  and  Accreditation  in 
Health  Care  and  Social  Welfare  is  in  charge  of 
health  technology  assessment  (HTA).  However, 
the  use  of  HTA  is  optional  and  not  mandatory,  a 
circumstance 
rather 
underused  and  underdeveloped  in  Croatia.  The 
World  Bank  identifies  HTA  and  the  use  of 
protocols  as  a  field  for  improvement  (Bodiroga-
Vukobrat, 2013). 

to  HTA  being 

leading 

The HZZO is playing a big role in HTA decisions 
and, through its “Drugs Committee” and “Medical 
Devices  Committee”,  is  responsible  for  appraisals 
and  recommendations  to  the  Board  of  the  HZZO. 
The  Board  of  HZZO  makes  then  the  pricing  and 
reimbursement  decisions.  The  HZZO  can  make  a 
request 
and 
Accreditation  in  Healthcare  and  Social  Welfare  – 
HTA  Department  to  conduct  an  assessment.  The 
Ministry of Health is involved in the HTA process, 
when  it  comes  to  legislation.  As  a  member  state, 
Croatia  is  also  taking  part  in  EUnetHTA  and  is 
represented  in  some  of  the  work  groups  of  the 
network. 

the  Agency 

for  Quality 

to 

eHealth, Electronic Health Record 

the 

The  Croatian  Government  aims  at  improving, 
modernising 
existing 
and  maintaining 
information  systems  in  health  care.  Information 
and  eHealth  strengthening  is  the  first  priority 
identified  in  the  2012-2020  National  Health  Care 
Strategy.  The  aim  is  to  integrate  and  standardise 
health  information,  to  further  establish  Electronic 
Health  Records,  to  improve  the  use  of  statistical 
information  to  support  decision-making  and  to 
introduce a reporting and warning system.  

43 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Health  promotion  and  disease  prevention 
policies 

in 

The  Government  of  Croatia  confirms  in  the 
National Health Care Strategy 2012-2020 the need 
to  strengthen  disease  prevention. Therefore,  it  has 
committed  to  increase  gradually  the  share  of 
preventive  programmes  and  activities 
the 
healthcare budget. The primary focus in prevention 
must  be  on  the  biggest  health  problems  of  the 
Croatian  population  –  chronic  non-infectious 
diseases,  malignant 
injuries,  mental 
disorders  and  risk  behaviours,  including  smoking, 
misuse  of  alcohol  and  drugs,  physical  inactivity 
and poor nutritional habits. The broad ambitions of 
the  government  would  need  to  be  translated  in  to 
concrete actions.  

tumours, 

Recently 
reforms 

legislated  and/or  planned  policy 

The  focus  of  reforms  implemented  between  2006 
and  2013  was  on  the  financial  stabilisation  of  the 
health  care  system.  The  key  reform,  implemented 
between  2008  and  2011,  contained  a  number  of 
revenue 
measures:  diversification  of  public 
collection mechanisms through the introduction of 
new  mandatory  and  complementary  health 
insurance contributions; increases in co-payments; 
and  measures  to  resolve  accumulated  arrears. 
Other  important  reforms  included  changes  in  the 
payment  mechanisms  for  primary  and  hospital 
care;  pharmaceutical  pricing  and  reimbursement 
reform; and changes to  health care provision (e.g. 
emergency care reform). 

The  launch  of  many  of  these  reforms  was  not 
difficult, as for many of them policy options were 
not  publicly  discussed  and  no  comprehensive 
implementation  plans  were  developed.  However, 
as  a  result,  many  of  them  soon  faced  serious 
implementation  problems  and  some  were  only 
partially implemented. 

Planned  reform  activities  for  2014–2016  were 
mainly  directed  at  achieving  cost–effectiveness  in 
the hospital sector (98). 

(98)  Republic  of  Croatia  has  regulated  healthcare  by  Health 
Care  Protection  Act  ("Official  Gazette",  150/08,  71/10, 
139/10,  22/11,  84/11,,  12/12,  35/12,70/12,  82/13,  22/14, 
13/17),  Compulsory  Health  Insurance  Act  ("Official 

44 

spending  control, 

Based  on  the  National  Reforms  Programme  for 
2016 adopted by the Croatian Government in April 
2016, 
rationalisation  and 
optimisation of costs should ensure a high level of 
health protection. This should be achieved through 
changes of the  health insurance system, through a 
reform  of  emergency  care,  the  reorganisation  of 
the  rationalisation  and 
the  hospital  network, 
reorganisation  of  hospital  non-medical  services,  a 
reform of primary health care, further development 
and 
public 
of 
procurement  procedure,  and  through  the  stricter 
the 
control 
informatisation of the health system ( 99). 

implementation 

prescriptions 

joint 

drug 

and 

the 

of 

Gazette"  No.  80/13,  137/13)  and  Voluntary  Health 
Insurance Act ("Official Gazette", 85/06, 150/08, 71/10). 
Health Protection Act: regulates principles and procedures 
of health care, rights and obligations of persons in the use 
of  health  care  services,  social  welfare  holders  for 
population  health,  content  and  organisational  forms  of 
health  activities  and  supervision  of  the  performance  of 
health care activities.  
Compulsory  Health  Insurance  Act:  regulates  compulsory 
health  insurance  in  the  Republic  of  Croatia,  the  scope  of 
the right to health care and other rights and obligations of 
the  insured  persons,  acquiring  and  financing  terms  and 
manners of, as well as rights and obligations of compulsory 
health insurance, including the rights and obligations of the 
contracting  entities  for  the  implementation  of  health  care 
from  the  compulsory  health  insurance.  Under  this  Act  the 
Directive  2011/24/EC  of  the  European  Parliament  and  of 
the  Council  of  9  March  2011  is  transposed  into  national 
legal system and the application of patients' rights in cross-
border healthcare (OJ L 88,  2011). 
Voluntary  Health 
types, 
Insurance  Act: 
conditions  and  manners  of  implementation  of  voluntary 
health  insurance  (voluntary,  supplementary  and  private 
health insurance).  
National  Strategy  for  the  Development  of  Health  (2012-
2014)  sets  the  direction  of  development  of  the  Croatian 
Health  Care  ("Official  Gazette"  No.  116/12),  and  laws 
governing  the  conduct  of  certain  medical  procedures.  All 
those  laws  include  provisions  of  the  acts  of  the  European 
Union,  such  as  Transplantation  of  Human  Organs  for  the 
Purpose  of  Medical  Treatment  Act("Official  Gazette"  No. 
144/12),  Medically  Assisted  Reproduction 
("Official 
Gazette"  No.  86/12),  Application  of  Human  Tissues  and 
Cells Act ("Official Gazette" No. 144/12). 
The  organisation  itself,  as  well  as  conditions  for  carrying 
out  certain  health  activities  are  regulated  by  following 
laws: Medical Practice Act ("Official Gazette", no. 121/03 
and 117/08), Medical- Biochemical Activities Act ("Official 
Gazette"  No.  121/03 and 117/08),  Dentistry  Act  ("Official 
Gazette",  121/03,  117/08,  and  120/09),  Pharmacy  Act 
("Official  Gazette",  121/03,,35/08,  and  117/08),  Nursing 
Act ("Official Gazette", 121/03, 117/08, 57/11). Health care 
in  the  Republic  of  Croatia  is  also  regulated  by  other 
regulations  which  are  adopted  under  the  basis  of  the 
specified laws. 

regulates 

(99)  National 

Reforms 

2016, 
https://vlada.gov.hr/UserDocsImages//Sjednice/2016/17%2
0sjednica%20Vlade//17%20-%201a.pdf. 

Programme 

for 

 
                                                           
                                                                                   
 
 
 
 
 
Health care systems 

2.4. Croatia 

clinical  hospitals  at  a  cost  of  HRK  1.9  billion 
(€250  million)  and  an  additional  25  health  care 
facilities (mostly county-owned hospitals) at a cost 
of  HRK  1.13  billion  (€150  million)  (Bodiroga-
Vukobrat, 2013). The measure was to be applied to 
all hospitals whose expenditure exceeded revenues 
at  the  end  of  2013.  During  2013  and  2014  total 
amount  of  debt  settlement  was  HRK  3.5  billion 
(€461  million)  (101).  However,  both  the  hospitals 
and  the  HZZO  continued  to generate  new  arrears, 
while  at  the  same  time  both  the  State  budget  for 
health  care  and  co-payments  have  been  reduced. 
Problems  with  poor  hospital  management  also 
persist  due  to  the  political  designation  of  hospital 
directors and managers. 

In  2017,  the  government  allocated  approximately 
€13.3  million  to  settle  arears  of  state-owned 
hospitals.  The  amount  received  by  each  hospital 
was  determined  by  the  Ministry  of  Health,  taking 
into  account  the  amount  of  debt  and  how  long  it 
has  been  overdue  and  various  parameters  of 
hospital  activity.  The  same  amounts  are  to  be 
allocated in 2018 and 2019. Hospitals must submit, 
within  seven  days  of  receiving  funds,  a  report  on 
the  use  of  funds  and  show  evidence  that  funds 
were spent on debt settlement (102). 

Other reforms 

case-adjusted 

Some of the reforms that were introduced between 
2006  and  2013  were  encouraged  by  previous 
experiences  (for  example,  the  introduction  of  a 
prospective 
payment 
system,  based  on  DRGs,  was  encouraged  by 
evidence  on  efficiency  gains  reported  since  the 
implementation  of  the  payment  per  therapeutic 
procedure  (PPTP)  schedule  in  2005)  (Bodiroga-
Vukobrat,  2012),  however,  most  of  the  measures 
had not been tested before. 

hospital 

The  Government  Programme  for  the  2011–2015 
Mandate  recognised  that  citizens  have  over  the 
years  become  increasingly  burdened  with  health 
care  financing  and  the  focus  has  been  shifted  to 
policy,  maintaining 
patient-oriented 
solidarity between the healthy and the ill, the rich 

health 

Joint hospital procurement  

While  initially  the  health  care  sector  remained 
largely  unaffected  by 
the  austerity  measures 
implemented  in  response  to  the  financial  crisis, 
since  2012,  it  faced  more  pressure  to  rationalise 
health care costs. One of the  measures considered 
to have the potential to achieve significant savings 
joint  hospital 
implementation  of  a 
was 
procurement programme for public hospitals. 

the 

the 

that  account  for 

Public  hospitals,  which  previously  procured  all 
medical  products  and  other  goods  individually, 
were  directed  to  form  joint  purchasing  bodies  for 
items 
largest  share  of 
expenditure,  such  as  medicines,  medical  devices 
and energy. A decentralised approach was adopted, 
whereby  a  number  of  hospitals  were  assigned  to 
procure  categories  of  goods  for  all  participating 
hospitals.  Hospitals  that  had  previously  achieved 
best  value  for  money  for  certain  procurement 
categories  were  selected 
the  central 
purchasers. Central procurement  was launched for 
15 groups of goods and services in October 2012. 

to  be 

Despite substantial opposition from manufacturers 
and  retailers,  a  number  of  joint  procurement 
tenders  have  been  successfully  concluded.  So  far, 
the reform is proving to be successful in reducing 
prices and achieving savings, and in standardising 
the quality of procured goods. 

‘Sanation’ of public hospitals  

The  problem  of  poor  hospital  finances  has 
persisted over many years and in the last 15 years 
there were more than 10 cases where hospitals had 
to  be  financially  reorganised  in  the  short  term 
(Bodiroga-Vukobrat,  2013).  In  2012,  the  Act  on 
Sanation  of  Public  Institutions  (100)  was  adopted, 
mainly  with  the  aim  of  improving  the  finances  of 
It 
heavily 
enabled  temporary  centralisation  of  the  hospital 
management,  and  it  was  conceived  as  one  of  the 
measures aimed at reducing the overall public debt 
and  improving  the  efficiency  of  the  public  sector 
(measures were also undertaken in other sectors). 

indebted  county-owned  hospitals. 

In  April  2013,  the  government  adopted  decisions 
on the financial reorganisation of nine state-owned 

(100) The  word  “sanation”  in  the  context of  the  Croatian health 
care system means restoring a sound financial position and 
improving management. 

(101) Source: 

https://vlada.gov.hr/UserDocsImages/Sjednice/2016/272%
20sjednica%20Vlade/272%20-%201.pdf. 

(102) Source: 

https://vlada.gov.hr/UserDocsImages//Sjednice/2017/12%2
0prosinac/73%20sjednica%20VRH//73%20-%2013.pdf. 

45 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

and  the  poor,  and  the  young  and  the  elderly.  This 
was to be achieved through a number of measures, 
such  as  the  reorganisation  of  emergency  medical 
care,  primary  health  care  and  hospitals;  education 
of human resources; more emphasis on preventive 
measures; and the shortening of waiting lists. 

delays 

The  large  number  of  changes  that  have  been 
introduced  and  the  speed  of  their  implementation 
have  resulted  in  insufficient  preparation  of  some 
measures, 
with 
implementation. Nevertheless, several reforms (the 
pharmaceutical pricing and reimbursement reform; 
the  2013  payment  mechanisms  reform;  and  also 
the  EMS  reform)  seem  to  have  been  successfully 
implemented. 

problems 

and 

According  to  the  Hospital  Master  Plan,  in  2015 
reorganisation of hospitals was initiated. In the last 
quarter  of  2015,  the  Network  of  Public  Health 
a 
Services  was 
reclassification  of  hospitals  beds  from  acute  beds 
to palliative, chronic, prolonged and day-care beds. 
The  full  implementation  of  the  Master  Plan, 
including  the  reshaping  of  the  hospital  network, 
has started by the end of 2016 (103). 

changed  which 

implied 

is 

the  Government ( 104), 

As part of the 2017 National Reform Programme, 
the 
adopted  by 
continuation  of  reform  activities  directed  at  the 
reduction  of  healthcare  debts and  sustainability  of 
the healthcare system was established. The reform 
activities  continue  to  focus  on  establishing  a 
functional 
increased 
integration  of  hospitals, 
efficiency  and  quality  of  healthcare  services, 
implementation  of  human 
development  and 
in  healthcare, 
resource  management  policy 
non-
of 
rationalisation 
healthcare 
further 
in 
enforcement  of  strict  controls  of  prescribing 
medicines,  unified  public  procurement  and 
computerisation of the system, improving primary 
health  care  and  palliative  care,  and  increasing  the 
number of complementary health insurance users.  

and 
services 

reorganisation 

hospitals, 

(103) Source:  Convergence  Program  of  Republic  of  Croatia  for 

2016-2019, 
https://vlada.gov.hr/UserDocsImages//Sjednice/2016/17%2
0sjednica%20Vlade//17%20-%201b.pdf. 

(104) Resolution, Class No. 022-03 / 17-07 / 47, Reg. No. 50301-

25 / 05-17-3 dated April 27, 2017. 

46 

Challenges 

A  range  of  reforms  have  been  implemented  in 
recent  years  –  or  are  still  in  the  state  of  gradual 
implementation.  They  imply  substantial  structural 
changes, with a focus on controlling the growth of 
health  expenditure  and  improving  efficiency  and 
quality.  The  main  challenges  for  the  Croatian 
health care system are as follows:  

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the increasing health care expenditure over the 
coming decades. To this end, to strengthen the 
existing public procurement system. 

financing  of  health  care 

•  To improve the basis for more sustainable and 
efficient 
(e.g. 
considering  additional  sources  of  general 
budget  funds),  aiming  at  a  better  balance 
and 
between 
diminishing 
retroactive 
government transfers to cover deficits by health 
care providers and of regressive financing. 

resources 
the 

reliance  on 

spending, 

and 

adjusting 

providers 

•  To  increase  efficiency  in  hospital  productivity 
by 
are 
the  way 
remunerated,  including  staff  wages,  thereby 
containing the issue of deficits and arrears, the 
elimination of which is lagging behind. To this 
end, to further the efforts in the introduction of 
activity-based  systems  as  a  driver  of  cost-
efficiency. 

•  To  explore  how  current  financing  schemes 
could  be  adjusted  to  a  mix  of  capitation-based 
reimbursement  and  of  activity/quality  linked 
incentives, to increase efficiency and quality in 
the  delivery  of  services  at  all  levels  of  care 
(primary  and  specialist  care)  and  notably  to 
encourage  more  health  promotion  and  disease 
prevention activities (e.g. vaccination). 

•  To  optimise  the  configuration  of  the  hospital 
system  (including  capacity,  staff  and  service 
mix) to tackle existing regional differences and 
obstacles  to  access  to  services.  To  design  and 
implement  a  policy  of  human 
resources 
management  based  on  improved  training  and 
on  achieving  a  skill  mix  consistent  with  a 
primary-care based system. 

 
                                                           
•  To improve data collection, especially in some 
crucial  areas  such  as  resources  and  care 
utilisation;  to  improve  the  patient  information 
the  development  and 
system  promoting 
utilisation of e-health tools as envisaged by the 
2012 National Health Care Strategy, which can 
help  ensuring  effective  referral  systems  from 
primary  to  specialist  care  and  improving  care 
coordination between types of care. 

•  To consider additional measures to improve the 
rational  prescribing  and  usage  of  medicines, 
such  as  information  and  education  campaigns, 
the monitoring of prescription of medicines and 
a  more  explicit  policy  on  incentivising  the 
uptake  of  generics.  The  policies  could  help 
improving population health, reducing the high 
level of out-of-pocket payments and improving 
access  to  cost-effective  new  medicines  by 
generating savings to the public payer. 

•  To  gradually 

increase 

the  use  of  cost-
effectiveness  information  in  determining  the 
basket of goods and the extent of cost-sharing, 
increasing the use of HTA currently underused 
and  underdeveloped,  possibly  making  it  a 
compulsory  step  and  strengthening  the  role  of 
the  Agency  for  Quality  and  Accreditation  in 
Health Care and Social Welfare. 

•  To  further  enhance  health  promotion  and 
disease prevention activities, promoting healthy 
life styles and disease screening given the most 
recent  pattern  of  risk  factors  (such  as,  for 
instance alcohol consumption). 

• 

Implementing the Health  Care Strategy (2012-
2020),  with a  view of increasing ownership of 
the  strategy  by  all  stakeholders  of  the  health 
system. 

Health care systems 

2.4. Croatia 

47 

 
4
8

Table 2.4.1:  Statistical Annex – Croatia 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

EU- latest national data

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

2005

37

15.4

4.1

:

2006

40

16.4

4.8

5.7

2007

44

17.4

5.1

11.7

2008

48

17.0

2.1

5.0

2009

45

15.3

-7.3

-1.9

2010

45

15.1

-1.2

-1.4

2011

45

15.4

-0.1

-15.3

2012

44

15.5

-1.8

-2.5

2013

43

15.4

-0.4

7.9

2014

43

15.6

0.3

0.5

2015

44

16.5

3.3

0.9

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

7.4

6.9

0.5

899

6.4

5.9

778

0.48

86.6

14.0

:

13.4

7.4

7.0

0.5

998

6.5

6.0

871

0.49

87.2

14.2

:

13.4

7.9

7.4

0.5

8.1

7.7

0.4

8.6

8.2

0.4

8.6

8.3

0.3

7.3

7.8

-0.5

7.2

7.8

-0.6

7.8

7.3

0.5

7.8

7.5

0.4

7.7

7.4

0.3

1,159

1,307

1,296

1,293

1,092

1,070

1,150

1,144

1,151

2,745

2,895

7.0

6.5

6.9

6.5

7.4

7.0

7.4

7.1

1,021

1,114

1,118

1,120

0.47

88.1

14.6

:

12.5

0.43

85.2

13.4

:

14.5

0.42

86.3

12.8

:

13.7

0.34

86.6

13.0

:

13.8

5.9

5.5

883

0.36

80.8

13.6

100.0

13.4

6.0

5.6

881

0.35

82.4

13.6

100.0

12.8

6.1

5.9

903

0.29

78.5

13.2

:

12.1

6.2

5.8

900

0.36

78.7

13.3

:

15.0

6.0

5.7

895

0.30

77.7

13.4

100.0

15.2

2005

4.3

78.8

71.7

:

:

149

5.7

2006

4.3

79.3

72.4

:

:

142

5.2

2007

4.3

79.2

72.2

:

:

144

5.6

2008

4.3

79.7

72.3

:

:

136

4.5

2009

4.3

79.7

72.8

:

:

132

5.3

2010

2011

2012

2013

2014

2015

4.3

79.9

73.4

60.4

57.4

125

4.4

4.3

80.4

73.8

61.7

59.8

226

4.7

4.3

80.6

73.9

64.2

61.9

216

3.6

4.3

81.0

74.5

60.4

57.6

206

4.1

4.2

81.0

74.7

60.0

58.6

207

5.0

4.2

80.5

74.4

56.8

55.3

216

4.1

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2.0

0.2

1.7

:

0.2

0.1

0.2

1.8

0.2

1.3

1.3

0.1

0.1

0.2

1.9

0.2

1.7

2.0

0.2

0.2

0.2

1.7

0.2

1.4

1.3

0.1

0.2

0.2

1.6

0.2

1.7

2.4

0.1

0.2

0.2

1.5

0.2

1.4

1.6

0.1

0.2

0.2

1.6

0.3

1.9

2.2

0.2

0.2

0.2

1.5

0.3

1.4

1.4

0.1

0.2

0.2

1.7

0.3

1.9

1.9

0.2

0.2

0.2

1.5

0.3

1.4

1.1

0.1

0.2

0.2

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2.4.2:  Statistical Annex - continued – Croatia 

Composition of total as % of total current health expenditure

2005

2006

2007

2008

2009

2010

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2005

2006

2007

:

:

:

:

:

:

11.6

2005

250

483

:

690

:

:

:

:

:

:

11.8

2006

253

492

:

617

:

:

:

:

:

:

12.6

2007

266

503

:

608

2005

2006

2007

6.9

15

298

88.0

7.8

1.9

2016

5.2

5.2

2016

4.2

6.4

16

332

87.0

7.6

2.0

2020

5.4

5.5

2020

4.1

6.4

16

319

85.6

9.9

1.9

2025

5.4

5.6

2025

4.0

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2008

0.70

0.5

1.4

0.1

:

:

12.1

2008

266

522

:

559

2008

6.0

16

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2009

:

:

:

:

:

:

12.2

2009

267

511

55

553

2009

6.4

16

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2010

0.72

0.6

1.6

0.1

:

:

12.1

2010

278

531

50

546

2010

6.1

15

2011

25.1%

2.4%

22.1%

:

2.1%

1.8%

2.3%

32.2%

3.3%

24.1%

22.6%

1.3%

2.4%

2.9%

2011

:

:

:

:

:

:

12.2

2011

284

542

51

535

2011

6.0

15

2012

24.0%

2.4%

21.9%

26.2%

1.9%

2.1%

2.6%

30.7%

3.2%

24.1%

22.9%

1.3%

2.7%

3.2%

2012

0.98

0.6

1.6

0.1

:

:

11.5

2012

299

568

53

528

2012

6.9

15

2013

21.5%

3.3%

23.3%

32.6%

1.9%

2.3%

2.9%

24.7%

3.9%

23.4%

27.3%

1.2%

2.7%

2.6%

2013

1.06

0.7

1.6

0.1

:

:

12.4

2013

303

583

54

523

2013

6.1

15

2014

21.5%

4.0%

25.1%

29.4%

2.5%

2.5%

2.4%

25.3%

5.0%

24.7%

24.1%

1.2%

3.1%

2.6%

2014

1.04

0.8

1.5

0.1

18.0

24.5

12.1

2015

23.1%

4.5%

25.5%

26.1%

2.6%

2.8%

2.7%

27.2%

5.5%

25.3%

19.6%

1.2%

3.4%

2.8%

2015

1.12

1.6

1.5

0.1

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2014

2015

2009

2011

2013

2015

314

580

57

524

2014

6.3

15

319

583

55

518

2015

6.8

15

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

1,863

3,076

4,538

5,487

6,704

7,949

9,494

12,399

6,362

6,584

84.9

9.6

10.5

2030

5.5

5.8

2030

4.0

83.1

9.7

16.4

2035

5.6

6.0

2035

3.9

75.2

9.5

23.5

2040

5.7

6.2

2040

3.8

76.7

9.3

26.4

2045

5.8

6.4

2045

3.7

77.3

9.1

31.0

2050

5.8

6.5

2050

3.7

73.7

8.9

34.5

2055

5.9

6.6

2055

3.6

71.7

8.8

38.6

2060

5.9

6.7

2060

3.5

76.3

8.6

45.0

2065

5.9

6.7

2065

3.5

77.1

8.0

28.0

2070

5.9

6.7

2070

3.4

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Croatia

0.7

1.5

EU

0.9

1.6

Change 2016-2070, in %

Croatia

-18.8

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

H
e
a

4
9

2
.
4
.

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C
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a

t
i

a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

 
 
 
 
 
 
 
 
 
 
2.5. CYPRUS 

General 
sustainability and demographic trends   

Expenditure, 

context: 

fiscal 

to  the  risk  for  long-term  sustainability  of  public 
finances (107).  

General  statistics:  GDP,  GDP  per  capita; 
population 

GDP per capita in Cyprus was, in 2015, below EU 
average  with  23,818  PPS  (EU:  29,610).  The 
population  was  estimated  at  0.85  million  in  2016. 
According to Eurostat projections, total population 
is  projected  to  increase  from  around  0.85  million 
in 2016 to 1.0 million in 2070.  

Total and public expenditure on health as % of 
GDP 

Total expenditure on health has relatively stable in 
the  past  decade.  However  expenditure  as  a 
percentage  of  GDP  (6.8%  in  2015)  was  relatively 
moderate and well below the EU average of 10.2% 
in 2015. When expressed in per capita terms, also 
total  spending  on  health,  at  1,564  PPS  in  2015, 
was less than  half of the EU  average of 3,305 for 
the  same  year.  The  gap  is  more  marked  for  the 
GDP share of public spending on health care: 2.9% 
of GDP in Cyprus in 2015 vs. 8.0% of GDP in the 
EU; and 674 PPS in Cyprus vs. an EU average of 
2,609 PPS in 2015. Looking at health care without 
long-term  care ( 105)  reveals  a  similar  picture,  with 
public  spending  markedly  below  the  EU  average, 
but  it  reduces  the  relative  gap  (2.8%  vs  6.8%  in 
2015). 

Expenditure projections and fiscal sustainability  

As a consequence of population ageing, health care 
expenditure  is  projected  to  increase  by  0.4  pps  of 
GDP, below the average growth level expected for 
the EU of 0.9 pps of GDP, according to the "AWG 
reference scenario" (106). When taking into account 
the  impact  of  non-demographic  drivers  on  future 
spending  growth  ("AWG  risk  scenario"),  health 
care expenditure is expected to increase by 0.6 pps 
of  GDP  from  now  until  2070  (EU:  1.6).  Overall, 
projected  health  care  expenditure 
is 
expected to add to budgetary pressure, contributing 

increase 

Health status 

Life expectancy at birth (83.7 years for women and 
79.9 years for  men)  was above EU average levels 
of  83.3  and  77.9  years  in  2015.  The  same  is  true 
for  healthy  life  years,  with  63.4  years  for  women 
and 63.1 years for  men in Cyprus compared  with, 
respectively,  63.3  and  62.6  for  the  EU  in  2015. 
Similarly, the infant mortality rate of 2.7‰ was, in 
the  same  year,  below  the  EU  average  of  3.6‰, 
having  fallen  throughout  the  last  decade  from  a 
value of 4.6‰ in 2005. 

As for the lifestyle of the Cypriot population, data 
indicates  a  high  proportion  of  regular  smokers 
(25.2%  in  2014),  being  above  the  EU  average  of 
21.0 (value in 2015). Conversely, the proportion of 
obese population was below the EU level at 13.9% 
(EU:  15.4%),  and  the  latest  available  figure  on 
alcohol consumption is below the EU level for the 
same  year  (9.0  vs.  10.1  for  the  EU  in  2013)  and 
below the 10.2 value for 2015. Based on available 
data,  over  the  last  decade  the  proportion  of 
population  smoking  seems  relatively  unchanged 
and  the  average  alcohol  consumption  has  slightly 
decreased.  

System characteristics  

Overall description of the system 

The  Cypriot  health  system  is  made  up  of  two 
uncoordinated sub-systems of similar size: a public 
one and a separate private one.  The public system 
is  highly  centralised  and  planning,  organisation, 
administration and regulation are the responsibility 
of  the  Ministry  of  Health  (MoH).  It  is  mainly 
financed  by  the  state  budget,  as  well  as  by 
insurance  from  civil 
contributions 
servants and civil servant pensioners, with services 
provided  via  a  network  of  public  hospitals  and 
health  centres  directly  controlled  by  the  MoH. 
Public  providers’  employees  have  the  status  of 
civil servants and are salaried employees.  

to  health 

(105) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 
2018 

(106) The 

Ageing 

Report: 

The  current  system  has 

led 

to  an  unequal 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(107) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

50 

 
                                                           
                                                           
distribution of services and inequities in access to 
care. Also, prices, capacity, and care quality in the 
private sector are not sufficiently regulated. There 
is  no  implemented  coherent  framework  matching 
separate provision of public and private healthcare 
services,  leading  to  inadequate  and  ineffective 
coverage.  There 
is  an  over-burdened  public 
healthcare sector leading to high waiting times for 
selected  consultations,  surgical  procedures  and 
diagnostic  tests,  and  potentially  also  leading  to  a 
decrease  in  the  quality  of  care.  The  over-capacity 
of  private  health  care  providers  is  exacerbated. 
This has led to wasteful allocative inefficiencies in 
total health care resources in Cyprus. 

in  Cyprus  with 

To  address  these  inefficiencies  and  to  ensure 
efficiency  gains  in  the  mid-term,  the  Cypriot 
authorities  are  pursuing  to  implement  a  dual 
strategic  reform  program.  Firstly,  it  aims  to  raise 
resilience of the system and to improve the access 
the 
to  quality  health  care 
autonomisation  of  public  hospitals.  Public 
hospitals  financial  autonomy  can  facilitate  the 
improvement  of  access  to  quality  health  care  and 
foster  it,  thereby  administering  their  own  budgets 
based on available resources. The public hospitals’ 
autonomisation  should  lead  to  normalisation  of 
admissions  and  length  of  stay  as  well  as  the 
appropriate  utilisation  of  infrastructure,  staff  as 
well as the efficient use of hospitals’ properties.  

financing; 

overcoming 

(NHIS).  Both 

Secondly Cyprus will implement a National Health 
relevant 
Insurance  Scheme 
legislations for hospital autonomisation and NHIS 
were enacted on the 216th of June 2017. The main 
goals  of  NHIS  are: 
(i)  ensuring  universal 
healthcare  coverage;  (ii)  pooling  the  public  and 
the 
(iii) 
private 
fragmentation  of  provision  of  uncoordinated 
private  and  public  care;  (iv)  improving  system 
organisation and monitoring; (v) improving access 
to  and  quality  of  care.  According  to  the  enacted 
legislation, NHIS will become operational on June 
1st  2020,  with  the  first  phase  of  NHIS  (outpatient 
health  care:  Family  Doctors,  Specialists  for 
outpatient  care,  Pharmaceuticals  and  Labs  for 
outpatient  care)  are  due  to  become  operational  a 
year earlier (1st June 2019). 

Coverage 

Citizens below a determined income level used to 
be  free  health  care  beneficiaries  of  the  Public 

Health care systems 

2.5. Cyprus 

Health  System  (around  80%  of  the  population), 
while the rest of the population (non-beneficiaries) 
paid  according  to  fee  schedules  by  the  MoH.  As 
from  1  August  2013  new  fees  and  co-payments 
were set that reduced the share of free health care 
beneficiaries to around 70% of the population. As 
demand  exceeds  significantly  the  supply  for  free 
public  health  care  services,  long  waiting  lists  for 
some specialties create barriers to access for those 
services.  For  this  reason,  part  of  the  population 
uses  the  private  sector  health  care  services  for 
outpatient  consultations  and  routine  procedures 
while,  using  the  public  sector  health  care  services 
for  more  costly  services.  Overall,  the  recorded 
proportion  of  the  population  covered  by  public  or 
primary  private  health  insurance  was  reported  at 
83% in 2015 vs. the EU average of 98%. 

The  introduction  of  the  NHIS  is  expected  to 
increase  the  accessibility  of  the  whole  population 
and will provide free access to the private and the 
public health care sectors.  

Administrative  organisation  and 
collection mechanism  

revenue 

The  public  health  care  budget  is  financed  by  the 
state. In addition, a contribution-based health care 
scheme is implemented for civil servants, and there 
are co-payments defined for beneficiaries and non-
beneficiaries  of  public  health  care  services.  The 
public health sub-system as well as most decision-
making  processes  are  centralised.  Public  hospitals 
form  part  of  an  integrated  system  of  civil  service 
and  ministerial  control  management,  such  that 
managerial  decisions  are  taken  outside  of  the 
hospitals. 

Role  of  private  insurance  and  out  of  pocket 
co-payments  

The public health care system has since long been 
criticised  for  failing  to  effectively  cover  the 
population  leading  to  inadequate  and  ineffective 
coverage. The latter is associated with the fact that 
around  50%  of  people  eligible  for  free  public 
health  care  opt  to  visit  the  private  sector  and  pay 
out-of-pocket 
care 
services) to avoid long  waiting times.  As a result, 
the  combined  share  of  private  and  out-of-pocket 
spending out of total health expenditure (56.9% in 
2015,  with  43.9%  covered  by  out-of-pocket 
expenditure  alone)  is  the  largest  in  the  EU  (EU 

ambulatory 

(mostly 

for 

51 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

average:  21.6%  for  the  two  combined  and  15.9% 
for out-of-pocket alone in 2015, respectively). The 
population non eligible  for free public health care 
services  is  to  some  degree  covered  by  private 
health  insurance  schemes,  although  the  domestic 
private health insurance industry is still at an infant 
stage. 

Types of providers, referral systems and patient 
choice 

As  stated  above,  public  and  private  provision 
coexist. Public primary care is provided in hospital 
outpatient  departments,  urban  and  rural  health 
centres  and  sub-centres.  Public  dental  care  is 
provided  in  dental  clinics  in  hospital  outpatient 
departments  and  PHCCs.  Public  general  hospitals 
offer  specialist  outpatient  care  and  district 
hospitals  and  Specialist  Centres  such  as  the  Bank 
of  Cyprus  Oncology  Centre,  Cyprus  Institute  of 
Neurology  and  Genetics  offer  outpatient  and 
inpatient  hospital  care.  Private  health  services 
include  a  variety  of  specialists  and  dentists  who 
provide  their  services  in  their  own  facilities, 
typically in the largest urban areas. 

The  number  of  practising  physicians  per  100  000 
inhabitants has risen above the EU average in 2015 
(358  vs.  344  for  the  EU),  after  steadily  growing 
over  the  past  decade,  though  still  below  average 
during  that  time.  Also  the  number  of  general 
practitioners (GPs) per 100 000 inhabitants in 2015 
was above the EU average, with 87 vs. 78 for the 
EU in the same year. At the moment, besides some 
form  of  referral  in  the  case  of  public  provision, 
there is no formal referral system from primary to 
specialist and hospital care. A  main feature  of the 
NHIS  is  the  concept  of  family  doctors  and  the 
mechanism of referral system from primary care to 
specialist  doctors  and  other  providers.  In  other 
words,  all  citizens  would  register  with  a  family 
doctor,  who  would  act  as  a  gatekeeper  referring 
patients to specialist and other providers. 

Cyprus has seen a reduction in the number of acute 
care  beds  per  100  000  inhabitants  in  the  last 
decade  (342  in  2015  vs.  375  in  2005)  and  their 
number,  remains  below  the  EU  average  of  402. 
About  half  of  the  beds  are  publicly  owned.  The 
future  number  of  acute  care  beds  will  depend  on 
the combination of public hospitals’ reorganisation 
following 
the  NHIS 
implementation  with  optimal  use  of  effective 

autonomisation 

and 

52 

laparoscopic  services, 

modern technologies at  hospitals such as day-care 
and 
the  availability  of 
follow-up  care  and  the  availability  of  long-term 
care services. With the planned autonomisation the 
public  hospitals  shall  be  turned  into  independent 
and  autonomous  units  that  can  compete  with 
private  providers  on  an  equal  basis  to  establish 
contracts  with  the  purchasing  authority  (Health 
Insurance Organisation - HIO).  

Treatment options, covered health services 

The  benefit  package  is  explicitly  defined  and  is 
comprehensive.  It  covers  family  doctor  and 
specialist 
pharmaceuticals, 
laboratory 
inpatient  care,  allied  health 
professional  services,  A&E,  ambulance  services, 
rehabilitation and palliative care.  

outpatient 
tests, 

visits, 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Currently,  doctors  in  the  public  sector  are  paid  a 
salary, while in the private sector they are paid on 
a fee-for-service basis. Public sector remuneration 
is  determined  by  the  central  government.  The 
private  sector  fees  are  determined  by  the  free 
market  and  depend  on  reputation  of  each  specific 
doctor, although an indicator of private sector fees 
is set by the Medical Council. At the moment there 
is  no  activity  or  performance  related  payment  in 
the  public  sector.  With  the  implementation  of  the 
NHIS,  family  doctors'  (FDs)  reimbursement  shall 
entail  a  3-tier  payment:  (i)  an  age-adjusted 
capitation (per number of patients); (ii) an activity- 
based 
reimbursement,  depending  on  doctor 
activities  regarding  preventive  medicine  practices, 
a 
chronic  disease  management, 
performance  related  reimbursement  that  will  be 
tied  to,  among  others,  referral  and  prescribing 
behaviour.  The  details  of  how 
this  will  be 
implemented are in the process of being finalised. 
A uniform reimbursement policy is to be applied to 
both public and private sector providers.  

(iii) 

and 

Specialists’ outpatient  services  will be reimbursed 
on  a  fee  for  service  basis  (per  activity)  adjusted 
through  a  point  system  mechanism  in  order  to 
achieve  implementation  of  a  hard  global  budget. 
As  regards  to  the  reimbursement  of  specialists' 
inpatient  services  in  hospitals,  these  will  be 
incorporated into the DRG to which each case will 
its 
be  assigned. 

is  expected 

that  with 

It 

 
concerning 

transparency 

introduction,  the  DRG  system  will  promote  the 
containment  of  inpatient  expenditure  through  the 
increased 
clinical 
activities.  In  addition,  as  the  HIO  will  treat  the 
public  and  private  sectors  exactly  the  same,  it  is 
competitive 
expected 
through 
that, 
environment  which  will 
an 
improvement  in  hospital  efficiency  and  quality  of 
service provided will occur. 

the 
be 

created, 

Currently  the  annual  MoH  budget  includes  a 
specific  hospital  budget  allocated  to  each  hospital 
according  to  need,  primarily  on  a  historical  basis 
adjusted  to  inflation.  As  a  result,  there  are  no 
incentives for cost-awareness and control from the 
part  of  the  public  providers.  Consistently,  when 
looking at hospital activity, inpatient and day case 
discharges  ranked  much 
the  EU 
average in 2015 (respectively 7 discharges per 100 
inhabitants  vs.  16  in  the  EU  and  1,584  day  case 
discharges  vs.  7,635  in  the  EU  per  100  000 
inhabitants).  This  suggests  that  there  is  room  to 
increase hospital activity. It also suggests that as a 
result  of  hospital  inefficiency  patients  waiting 
times may be higher than otherwise possible.  

lower 

than 

The market for pharmaceutical products 

In  the  private  sector,  pharmaceutical  care  is 
provided  through  registered  private  pharmacies 
and  financed  with  out-of-pocket  payments.  The 
prices of imported pharmaceuticals are set through 
external price referencing. A 3% mark-up is added 
to  the  external  reference  price  (ERP)  to  cover  the 
cost of importing pharmaceuticals. The price set is 
the  wholesale  price.  The  wholesale  prices  include 
the  wholesale  margins  and  the  distribution  costs.  
Since early 2018, the Pharmacy margins have been 
set to be regressive, incorporating both percentage 
and  fee.  They  reach  37%  on  wholesale  price  for 
the  medicines  up  to  €10,  35%  for  the  medicines 
between  €50.01  –  250,  €  83  for  the  medicines 
between €250.01-1500 and €100 for the medicines 
above €150. Pharmacists also receive a flat fee of 
€1 per prescription. A 5% VAT is added to the net 
price. 

The  external  price  referencing  is  also  applied  for 
setting the prices of imported generics, in case the 
corresponding  originators  are  not  included  in  the 
price  list.  In  general,  the  price  of  the  generics 
cannot  exceed  80%  of  the  price  of  the  original 
branded  product  marketed  in  Cyprus.  For  locally 

Health care systems 

2.5. Cyprus 

manufactured generics, the ex – factory price is set 
on the basis of the production cost plus a mark-up 
of  20%,  in  cases  where  the  originator  is  not 
included in the price list. Along with the imported 
generics,  local  manufactured  generics  should  not 
exceed 80% of the original product included in the 
price list. Price revisions take place annually. A re-
calibration  of  the  pricing  method  is  performed 
semi-annually. 

Public  spending  on  pharmaceuticals  in  Cyprus 
looks  low  compared  to  the  average  for  EU 
countries,  with  0.2%  of  GDP  spent  on  the  area  in 
2015  compared  with  an  average  of  1.0%  of  GDP 
for the same year.   

There  are  no  lists  of  medicines  (positive  or 
negative)  in  the  private  sector  as  pharmaceutical 
care  is  not  reimbursed.  Prescribing  habits  of 
private  doctors  are  not  monitored,  although  the 
and 
issue 
authorities 
recommendations for the correct use of  medicines 
to the prescribing physicians. 

guidelines 

often 

is 
the  public  sector  pharmaceutical  care 
In 
provided  through  public  pharmacies  and  currently 
falls  under  the  Pharmaceutical  Services  of  the 
Ministry of Health.  The procurement of medicinal 
products is the responsibility  of the Directorate of 
Purchases  and  Procurement  of  the  Ministry  of 
Health  and  is  block-funded  by  the  Ministry  of 
Finance.  For  the  supply  of  medicines  a  public 
procurement  method  is  used.  Pharmaceutical  care 
is  provided  to  eligible  patients,  according  to  the 
Medical 
and  Services  General 
Regulations.  

Institutions 

information 

contemporary 

Pharmaceuticals  provided  to  the  eligible  patients 
are  included  in  the  Hospital  Formulary  which 
provides 
about 
medicines  available  from  public  hospitals  and 
health care centres. In the past years, a co-payment 
scheme  has  been  implemented  which  enables 
doctors to prescribe a limited number of drugs not 
included  in  the  approved  list,  but  available  in  the 
private  sector.  The  medicines  in  the  co-payment 
scheme are partly reimbursed by the Government. 
The  amount  reimbursed  is  based  on  the  price 
difference  between  the  price  of  the  co-payment 
drug  and  the  price  of  the  corresponding  available 
drug on the list of approved drugs. 

53 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

In  order  for  a  new  product  to  be  added  to  the 
Hospital  Formulary,  a  formal  pharmaceutical 
request  form  has  to  be  submitted  by  a  specialist 
physician practising in a public hospital. Generics 
and  generic  substitution  are  used  widely  in  the 
public  sector.  The  use  of  generics  provides  high 
cost  savings  in  the  public  sector.  Conversely,  the 
use of generics in the private sector is limited. One 
of  the  reasons  for  this  is  the  fact  that  pharmacists 
are 
original 
to 
pharmaceutical  products  for  generic  medicines. 
Furthermore,  the  promotion  of  generic  medicines 
is  still  limited,  and  the  Cypriot  government  does 
not  provide  any 
incentives  for  doctors  and 
pharmacists.    A  draft  legislation  allowing  for 
generic  substitution  in  private  pharmacies  as  part 
of  the  implementation  of  the  NHS  is  currently 
undergoing legal vetting.  

substitute 

allowed 

not 

the  Ministry 

Hospitals  (in  Nicosia  and  Famagusta)  and  some 
health  centres.  Furthermore, 
is 
exploring  the  conversion  of  the  existing  paper 
medical  records  into  digital  records  that  will 
complement the Electronic Health Records created 
by  IHIS.  At  the  same  time,  the  Ministry  is  in  the 
process  of  developing  the  National  Contact  Point 
for  e-Health  (under  Connecting  Europe  Facility 
funding),  as  part  of  the  e-Health  Network  project 
to  facilitate  cross  border  healthcare  between  the 
network’s  member  states.  Additionally,  it  will 
abide to the requirement of the EU regulations, to 
provide  by  the  end  of  2019  a  common  secure 
framework 
the  Electronic 
Exchange  of  Social  Security  Information  (EESSI) 
between  the  corresponding  institutions  or  the 
liaison bodies of each EU Member State. 

that  will  facilitate 

A general reform of the pricing and reimbursement 
system  is  expected  due  to  the  introduction  of  the 
NHIS. This reform will unify the pharmacy market 
under common pricing and reimbursement rules. 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

The  government  currently  builds  up  its  HTA 
capacity.  For  pharmaceuticals,  the  criteria  for 
inclusion  of  a  pharmaceutical  in  the  List  of 
Approved  Pharmaceuticals 
include:  product-
specific  criteria  (e.g.  medical  and  therapeutic 
therapies); 
value,  safety, 
economic  criteria  (e.g.  cost  effectiveness,  budget 
impact);  patient-specific  criteria  (e.g.  age,  sex, 
chronically or terminally ill patients); and disease-
specific  criteria  (e.g.  severity  of  illness,  special 
medical needs). The Drugs Committee assesses all 
of the above criteria. 

lack  of  alternative 

The  main  objective  is  to  provide  a  functional 
interoperable  solution  that  will  ensure  electronic 
data  exchange  of  patient  records  with  other  EU 
countries,  the  extension,  in  the  future,  of  services 
to 
sector, 
implementation  of  the  further  National  Health 
Insurance  System  (NHIS)  reform  and  other  major 
Cyprus  health  care 
involve 
that 
development of electronic data exchange. 

the  Cyprus  private  healthcare 

initiatives 

In  view  of  the  implementation  of  the  NHIS,  the 
Health  Insurance  Organisation  (HIO),  on  the  30th 
March  2017,  has  contracted    the  development, 
implementation,  operation  and  support  of  a  total 
solution for the information technology system and 
other business processes of the NHIS. Health care 
providers will have access to the system to submit 
claims  and  issue  prescriptions,  lab  orders  and 
referrals. The system will store clinical patient data 
as  they  emerge  from  the  activities  of  the  doctors 
such  as 
the 
submission of claims.  

referring  and  prescribing  and 

eHealth, Electronic Health Record 

The Ministry, as part of its ambitious health sector 
reform  program  that  requires  universal  access  for 
all  public  sector  health  providers  to  an  Integrated 
their 
Health  Information  System  (IHIS)  and 
routine  use  of  it,  is  in  the  process  of  a  tendering 
procedure to obtain a new enhanced IHIS that will 
incorporate  the  enhancements  and/or  amendments 
required  to  support  the  reform  process,  as  well  as 
to  expand  in  all  the  public  hospitals  and  health 
centres  all  over  Cyprus,  complementing 
the 
existing  IHIS  that  is  currently  used  in  2  Public 

Health  promotion  and  disease  prevention 
policies 

Though total expenditure on prevention and public 
health services as a share of GDP and as share of 
total current health expenditure were below the EU 
average  in  2015  (0.1%  of  GDP  and  1.7%  of  total 
current  health  expenditure  in  Cyprus  versus  0.3% 
and 3.2% in the EU, respectively), based on a self-
assessment of the country’s public health capacity 
and services, using the WHO tool for 10 Essential 
Public  Health  Operations,  Cyprus  obtained  a 

54 

 
Health care systems 

2.5. Cyprus 

positive  score  in  this  area (108).  The  assessment 
report  forms  the  basis  for  national  planning  and 
policy  in  the  area  as  well  as  to  monitor  progress 
and  further  enhance  the  delivery  of  public  health 
services. Prevention is expected to increase further 
with the introduction of the NHIS and the concept 
of the Family Doctor since the design includes the 
provision of incentives for specific preventive and 
screening activities. 

Recently 
reforms 

legislated  and/or  planned  policy 

Health  sector  reforms  gained  some  momentum 
under  the  Economic  Adjustment  Programme.  A 
Memorandum  of  Understanding  on  Specific 
Economic  Policy  Conditionality  (MOU)  attached 
to  this  economic  adjustment  programme  included 
fiscal and structural measures intended to “control 
the  growth  of  healthcare  spending,  strengthen  the 
funding 
sustainability  of 
structure  and  improve  the  efficiency  of  public 
healthcare provision”. 

the  health  sector's 

development 

implemented: 

Based upon the MOU a number of initiatives have 
been 
and 
the 
implementation  of  the  information  technology 
infrastructure  for  the  NHΙS,  the  review  of  income 
thresholds  for  free  access  to  health  care,  the 
creation of evidence-based protocols for laboratory 
tests  and  prescribing  medicines,  the  establishment 
of  a  system  for  health  technology  assessment 
(HTA),  the  preparation  of  new  clinical  guidelines 
for  the  management  of  high-cost  diseases,  the 
introduction of coding for diagnosis-related groups 
(DRGs)  in  both  public  and  private  hospitals  to 
provide the basis for a future payment mechanism, 
shadow-budgeting 
for  public  hospitals,  and 
periodic  reviews  of  various  other  measures  (using 
HTA  to  define  the  scope  of  publicly  covered 
services,  user  charges  policy  and  the  introduction 
of  income-related  contributions  earmarked  for  the 
NHIS),  introduction  of  working  time  flexibility, 
definition  of  a  basket  of  publicly  covered 
(reimbursable) medical services and establishment 
of  a  system  of  family  doctors  to  refer  patients  to 
other levels of care, etc. 

for 

Specific  measures  were  intended  to  increase  the 
availability of publicly financed health services, to 
initiate processes to improve the quality of care in 
public provision of health services and to increase 
revenue for the health sector. These included: (a) a 
revision  of  exemptions  from  user  charges  and  the 
introduction of a new contribution of 1.5% on the 
gross salary or pension for active and retired civil 
servants;  (b)  a  30%  increase  in  user  charges  for 
publicly  provided  health  services 
‘non-
beneficiaries’  and  the  introduction  of  new  user 
charges  (co-payments)  and  increased  user  charges 
for higher levels of care; (c) financial disincentives 
for using emergency care in non-urgent situations; 
financial disincentives in the form of co-payments 
to minimise medically unnecessary laboratory tests 
and  use  of  pharmaceuticals;  (d)  MOU  measures 
provided  for  the  restructuring  and  autonomisation 
of  public  hospitals, 
the 
of  Health,  Associated  Facilities/ 
Ministry 
Organisations 
Insurance 
the  Health 
Organisation  (HIO).  They  provided  also  for  the 
implementation  of  the  National  Health  Insurance 
Scheme.  

the  restructuring  of 

and 

(108) The  assessment  was  based  on the  revised  2014  version  of 
the WHO tool for 10 Essential Public Health Operations. 

include 

The current planning of the comprehensive reform 
of  the  healthcare  sector  is  soon  to  be  completed 
the  Autonomisation  of  Public 
and  besides 
Hospitals,  will 
the  modernisation  of 
Primary Healthcare, the eHealth, the establishment 
of  University  Clinics, 
the  setup  of  National 
Medicines  Organisation  and  the  introduction  of 
National Health Insurance System that will  be key 
for  accelerating  reforms  and  provide  citizens  with 
high  level  healthcare  services,  in  a  single  market, 
without  public  –  private  boundaries,  with  the 
patient  in  the  centre,  able  to  choose  healthcare 
provider.  The  NHIS  will  be  developed  and 
implemented  based  on  the  fundamental  principles 
of  free  choice  of  provider,  social  equality  and 
solidarity,  financial  sustainability  and  universal 
coverage.  The  NHIS  will  be  based  on  a  single 
payer system. 

Challenges 

The  analysis  above  demonstrates  the  various 
challenges  that  the  health  system  faces  and  that 
health  reforms  have  to  tackle.  The  highlighted 
intrinsic distortions in the system cause inequality, 
inefficiencies  and  prevent  access  to  health  care. 
The  reforms  planned  by  the  MoH  in  the  next  two 
years  have  the  potential  to  tackle  many  of  these 
issues,  but  given  the  anticipated  resistance  on  the 

55 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  To  define  a  comprehensive  human  resources 
strategy  to  ensure  a  balanced  skill-mix  that 
allows a strong primary care sector to develop.  

hospital. 

•  To continue to improve data collection and data 
exchange  by  monitoring  of  inputs,  processes, 
outputs  and  outcomes 
including  putting 
interoperable  IT-systems  into  place  in  every 
public 
and 
interoperability  should  be  extended  to  allow, 
with  the  consent  of  the  patient  and/or  health 
professional, access and exchange of data with 
private  sector  ehealth  systems  as  well  as  with 
the  patient,  to  eventually  achieve  a  patient-
centred eHealth system.  

Accessibility 

•  To  make  systematic  use  of  cost-effectiveness 
information,  as  planned,  in  determining  the 
basket of goods and the extent of cost-sharing.  

•  To 

foster  health  promotion  and  disease 
prevention  activities,  promoting  healthy  life 
styles  and  disease  screening  given  the  pattern 
of  risk  factors  (smoking,  alcohol,  obesity, 
circulatory system diseases). 

side of stakeholders, a strong political commitment 
is  of  the  essence  and  will  be  a  key  driver  of 
success  in  responding  to  the  challenges.  These 
following can currently be identified: 

•  To  achieve  the  full  implementation  of  the 
NHIS  with  the  aim  to  ensure  equal  access, 
financial sustainability and quality health care. 
This, in turn,  would ensure  universal coverage 
and  the  pooling  of  financing  to  the  sector, 
currently non-existent. The full implementation 
of 
the 
the  NHIS  would  also  address 
inefficiencies  related  to  the  fragmentation  of 
care provision characterised by separate public 
and private provision that do not make part of a 
whole coherent framework.  

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the increasing health care expenditure over the 
coming  decades  that  is  a  risk  to  the  long-term 
sustainability of public finances.  

•  To  implement  a  comprehensive  reform  of  the 
their 
increasing 
sector 
hospital 
public 
managerial  capacity  and 
legal  ability  for 
autonomous decision making within a strategic 
framework of public  health policies aiming at: 
an increase of hospital output, an improvement 
of  the  provision  of  after-hours  primary  care 
services,  and 
integrated 
networks of public primary health care centres 
working  in  a  coordinated  fashion  with  public 
hospitals.  

the  creation  of 

•  To  reorganise  and  promote  public  hospitals 
autonomy  so  as  to  ensure  equal  competition 
between  private  and  public  health  providers 
and  ease  failure  of  coordination  between  the 
public  and 
to 
the  private  sector 
duplication and waste of resources.  

leading 

•  To  focus  on  enhancing  primary  health  care 
services  and  to  implement  a  comprehensive 
reform  of  the  primary  health  care  centres  to 
improve  efficiency  and  care  coordination 
between types of care and to encourage patients 
to first  make  use of primary care vs. specialist 
care vs. hospital care. 

56 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.5.1:  Statistical Annex – Cyprus 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

5
7

2005

15

27.1

2.2

:

2006

16

27.6

2.8

1.3

2007

18

28.9

2.6

-1.2

2008

19

28.1

1.3

15.4

2009

19

26.3

-4.4

2.7

2010

19

25.4

-1.3

-2.9

2011

20

24.6

-2.2

1.8

2012

19

23.2

-4.5

-6.8

2013

18

21.9

-5.7

-4.9

2014

18

22.1

-0.3

-1.5

2015

18

23.8

2.6

-4.9

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

6.4

6.4

0.0

6.3

6.3

0.0

6.1

6.1

0.0

6.9

6.9

0.0

7.4

7.4

0.0

7.3

6.3

1.0

7.6

6.6

1.0

7.4

6.7

0.7

7.5

6.9

0.6

7.4

6.8

0.6

6.8

6.8

0.1

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

1,428

1,500

1,535

1,844

1,895

1,875

1,947

1,829

1,708

1,653

1,564

2,745

2,895

2.8

2.5

617

0.27

43.2

7.7

:

50.1

2.9

2.6

683

0.27

45.5

7.3

:

48.6

2.6

2.6

669

0.09

43.6

7.7

:

49.1

2.8

2.8

761

0.05

41.3

7.5

:

51.3

3.1

3.1

804

0.06

42.4

7.3

:

49.9

3.1

3.0

795

0.06

42.4

7.4

:

41.0

3.2

3.1

815

0.07

41.9

6.9

83.0

42.8

3.1

3.0

767

0.06

41.9

6.7

83.0

44.0

3.3

3.2

747

0.07

43.8

6.1

83.0

43.1

3.1

3.0

686

0.08

41.5

5.4

:

44.8

2.9

2.9

674

0.06

43.1

6.3

83.0

43.9

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0.7

80.8

76.5

58.2

59.8

55

4.6

0.7

82.0

78.1

63.4

64.2

63

3.1

0.8

82.1

77.6

62.8

63.1

54

3.7

0.8

82.9

78.2

64.5

63.9

49

3.5

0.8

83.5

78.5

65.3

64.8

45

3.3

0.8

83.9

79.2

64.2

65.1

46

3.2

0.8

83.1

79.3

61.0

61.6

103

3.1

0.9

83.4

78.9

64.0

63.4

107

3.5

0.9

85.0

80.1

65.0

64.3

92

1.6

0.9

84.7

80.9

66.3

66.1

93

1.4

0.8

83.7

79.9

63.4

63.1

98

2.7

EU- latest national data

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

8.0

7.7

7.8

7.6

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

1.8

0.1

:

1.3

0.1

0.0

0.1

1.4

0.0

0.3

0.3

0.0

0.0

0.2

1.8

0.1

:

1.3

0.1

0.0

0.1

1.4

0.0

0.3

0.3

0.0

0.0

0.2

1.8

0.1

:

1.2

0.1

0.0

0.1

1.4

0.0

0.3

0.3

0.0

0.0

0.2

2.3

0.2

:

1.2

0.2

0.0

0.1

1.7

0.0

0.4

0.3

0.0

0.0

0.2

2.6

0.2

:

1.3

0.1

0.0

0.1

1.9

0.0

0.4

0.3

0.0

0.0

0.3

2.0

0.2

:

1.0

0.1

0.1

0.1

1.5

0.1

0.7

0.2

0.0

0.1

0.1

2.1

0.2

2.0

1.1

0.1

0.1

0.1

1.5

0.1

0.7

0.2

0.0

0.0

0.1

2.0

0.2

2.1

1.1

0.1

0.1

0.1

1.4

0.1

0.7

0.2

0.0

0.0

0.1

2.1

0.2

2.1

1.2

0.1

0.1

0.1

1.5

0.1

0.7

0.3

0.0

0.0

0.1

2.0

0.2

2.1

1.1

0.2

0.0

0.1

1.4

0.1

0.7

0.2

0.0

0.0

0.1

2.0

0.2

2.1

1.2

0.2

0.1

0.1

1.3

0.1

0.7

0.2

0.0

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

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5
8

Table 2.5.2:  Statistical Annex - continued – Cyprus 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

27.6%

1.4%

:

2006

29.3%

1.6%

:

2007

29.6%

1.5%

:

2008

33.7%

2.3%

:

2009

34.5%

2.3%

:

2010

31.8%

3.3%

:

20.6%

20.4%

20.5%

18.0%

17.3%

15.9%

2.2%

0.5%

1.6%

54.4%

0.8%

12.9%

12.1%

0.0%

1.2%

8.1%

2005

0.66

0.8

2.0

0.0

:

:

11.4

2005

257

409

:

690

2.1%

0.6%

1.6%

55.6%

1.2%

13.1%

10.8%

0.0%

1.2%

8.1%

2006

0.65

0.8

1.9

0.0

:

:

11.5

2006

249

450

:

617

2.1%

0.7%

1.5%

54.9%

0.8%

12.9%

11.0%

0.0%

1.2%

8.2%

2007

0.89

0.8

3.6

0.0

:

:

11.6

2007

270

458

:

608

2.3%

0.6%

1.6%

61.1%

0.7%

13.2%

10.7%

0.0%

1.1%

8.6%

2008

1.64

0.8

3.5

0.0

:

25.9

12.0

2008

276

450

:

559

1.9%

0.5%

1.5%

61.0%

1.0%

13.6%

10.4%

0.0%

1.0%

8.4%

2009

1.86

0.7

3.3

0.0

:

:

10.8

2009

281

471

:

553

2005

2006

2007

2008

2009

2.1

7

632

84.0

6.0

8.7

2016

2.8

2.8

2016

0.8

2.0

7

701

79.0

5.8

9.7

2020

2.9

2.9

2020

0.9

2.1

7

749

76.0

:

9.1

2025

2.9

3.0

2025

0.9

2.1

7

701

88.2

:

9.7

2030

2.9

3.0

2030

0.9

2.3

8

935

84.7

:

11.1

2035

3.0

3.1

2035

0.9

1.9%

0.8%

1.3%

48.5%

4.0%

22.8%

7.6%

0.3%

1.7%

2.6%

2010

1.93

0.7

3.3

0.0

:

:

11.3

2010

289

476

:

546

2010

2.3

8

1,574

84.2

:

16.9

2040

3.0

3.2

2040

1.0

2011

31.6%

3.3%

30.0%

16.2%

2.0%

0.8%

1.5%

48.4%

3.9%

22.6%

7.7%

0.3%

1.3%

3.2%

2011

2.00

0.8

3.2

0.0

:

:

10.7

2011

297

487

:

535

2011

2.3

8

1,437

90.9

:

15.3

2045

3.1

3.2

2045

1.0

2012

30.5%

3.3%

30.6%

16.4%

2.1%

0.7%

1.5%

47.4%

3.9%

23.0%

7.6%

0.3%

1.3%

3.3%

2012

1.97

0.8

3.2

0.0

:

:

10.6

2012

302

475

:

528

2012

2.4

8

2013

30.4%

3.3%

30.4%

16.6%

2.0%

0.7%

1.6%

46.4%

4.1%

22.9%

8.2%

0.3%

1.3%

3.4%

2013

1.97

0.8

3.3

0.0

:

:

9.0

2014

29.6%

3.4%

31.1%

16.8%

2.2%

0.6%

1.5%

46.3%

4.0%

23.8%

7.7%

0.3%

1.3%

3.4%

2014

1.99

0.8

3.3

0.0

13.9

25.2

:

2015

29.2%

3.4%

30.6%

17.1%

2.2%

0.7%

1.5%

46.2%

4.2%

22.6%

7.6%

0.3%

1.7%

3.5%

2015

2.01

0.8

3.4

0.0

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2013

2014

2015

2009

2011

2013

2015

320

492

:

523

2013

2.4

8

338

501

80

524

2014

2.2

8

358

523

87

518

2015

2.2

7

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

1,505

1,672

1,737

1,584

6,362

6,584

76.4

7.8

29.1

75.8

6.0

15.7

2050

3.1

3.3

2050

1.0

74.4

6.1

17.7

2055

3.1

3.3

2055

1.0

74.7

6.4

18.2

2060

3.1

3.4

2060

1.0

72.2

6.2

16.7

2065

3.2

3.4

2065

1.0

77.1

8.0

28.0

2070

3.2

3.4

2070

1.0

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Cyprus

0.4

0.6

EU

0.9

1.6

Change 2016-2070, in %

Cyprus

20.2

EU

2.0

Source:  EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.6. CZECH REPUBLIC 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

spending  (notably  health  care,  long-term  care  and 
pensions) (112). 

General  country  statistics:  GDP,  GDP  per 
capita; population 

GDP per capita in PPS is at 23,700 and below EU 
average  of  29,600  in  2015.  The  Czech  Republic 
has  a  population  of  10.5  million  inhabitants. 
During  the  coming  decennia  the  population  will 
slightly decrease to 10.0 million.  

Total and public expenditure on health  

Total  expenditure  on  health  as  a  percentage  of 
GDP  (7.7%  in  2015)  is  below  the  EU  average 
(10.2%). It has increased from 6.7% in 2006. Total 
public  expenditure  on  health  as  a  percentage  of 
GDP is below the EU average (CZ: 6.4% vs. EU: 
8.0%).  Looking  at  health  care  without  long-term 
care (109)  reveals  a  similar  picture  with  public 
spending below the EU average (CZ: 5.5% vs. EU: 
6.8%  in  2015).  In  2015,  total  (1,734  PPS)  and 
public  (1,447  PPS)  per  capita  expenditure  were 
lower  than  the  EU  average  (3,305  PPS  and  2,609 
PPS) (110). 

Expenditure projections and fiscal sustainability  

("AWG 

Public  expenditure  on  health  care  is  projected  to 
increase  by  1.1  pps  of  GDP  ("AWG  reference 
scenario"),  above  the  average  increase  of  0.9  pps 
for the EU. When taking into account the impact of 
non-demographic  drivers  on 
future  spending 
growth 
risk  scenario"),  health  care 
expenditure  is  expected  to  increase  by  1.9  pps  of 
GDP  from  now  till  2070  compared  to  the  EU 
average  of  1.6  pps  (111).  Overall,  projected  health 
care  expenditure  poses  a  risk  to  the  long-term 
sustainability  of  public  finances.  Over  the  long 
run,  medium  fiscal  sustainability  risks  appear  for 
the  Czech  Republic.  These  risks  derive  primarily 
from  the  projected  impact  of  age-related  public 

(109) To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(110) Note  that  these  PPS  figures  reflect  current  plus  capital 
health  expenditure  in  contrast  to  EUROSTAT  data  series, 
which reflect only current expenditure. 
2018 

(111) The 

Ageing 

Report,  

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

Health status  

Despite showing an improvement, the health status 
of  the  Czech  population  lags  slightly  behind  the 
EU average. While showing  a consistent increase, 
life  expectancy  (81.6  years  for  women  and  75.7 
years  for  men  in  2015)  is  still  below  the  EU 
average (83.3 and 77.9 years of life expectancy in 
2015). However, healthy life years are close to the 
respective EU averages (63.7 years for women and 
62.4 years for men in 2015 vs. EU average of 63.3 
and  62.6,  respectively).  Amenable  mortality  rates 
show a consistent decrease over the decade but are 
still fairly high (179 deaths per 100 000 inhabitants 
in CZ vs. 127 in the EU). Infant mortality is below 
the EU average (2.5‰ vs. 3.6‰). 

System characteristics  

System financing 

insurance 

The  Czech  health  care  system  is  a  compulsory 
social  health 
(SHI)  system  with 
universal  coverage.  Entitlement  to  coverage  is 
based  on  permanent  residence  and  each  person 
must  be  covered  through  either  a  SHI,  a  foreign 
social 
insurance  system  or  a  private  health 
insurance.  

The  SHI  system  plus  contribution  from  the  state 
budget comprises 83% of total health expenditure. 
State  budget  contribution  is  devoted  to  capital 
investments  in  facilities  directly  managed  by  the 
Ministry of Health (teaching hospitals, specialised 
health  care,  research  and  postgraduate  education 
facilities)  or  by  regional  authorities  (regional  and 
municipal  hospitals),  as  well  as  to  public  health 
services  (training  costs  of  medical  personnel, 
and  disease 
variety  of  health  promotion 
prevention,  medical 
postgraduate 
research, 
education, etc.). 

In 2016, mandatory SHI contributions account for 
75% of revenues of the SHI system. The remaining 
25% come from the state contributions for certain 
groups  of  economically  inactive  people  (children, 

(112) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

59 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

tax 

employers 

split  between 

students,  women  or  men  on  parental 
leave, 
pensioners,  unemployed,  imprisoned  and  asylum 
seekers).  SHI  contributions  take  the  form  of  a 
and 
payroll 
employees;  self-employed  must  contribute  a  fixed 
percentage  of  13.5%  of  half  of  their  profits. 
Contributions  of  employed  people  amount  to 
13.5%  of  gross  monthly  wages,  with  employees 
paying  4.5%  and  employers  9%.  The  state-
financed  monthly  contributions  represented  969 
CZK 
for  every 
economically  inactive  person.  These  revenues  for 
the Czech health system are set by law and consist 
in a fixed amount of money, occasionally adjusted 
– "valorised". 

(approx.  €37.5) 

in  2018 

Next,  SHI  contributions  are  redistributed  among 
the  existing  health  insurance  funds  (see  section 
"Administrative organisation") according to a risk-
adjustment  scheme  based  on  age,  gender,  ex-post 
compensation  of  the  most  expensive  cases  and 
from  January  2018  onwards, 
the  mechanism 
adjusts  for  chronic  diseases  as  identified  by 
Pharmaceutical  Cost  Groups  (PCGs).  The  VZP  is 
the  largest  fund,  covering  approximately  57%  of 
the population in 2016. It was the first one created 
in 1992, covering at that time 100% of the market. 
However,  it  is  supposed  to  have  the  worst  risk-
structure of the members, as funds established later 
have  been 
taking  over  mainly  younger  and 
healthier part of the population.  

Private  spending  includes  mainly  three  categories 
of  expenditures:  out-of-pocket  payments  for  over-
the-counter  pharmaceuticals  and  some  dental 
procedures;  co-payments  on  medical  aids  and 
prescription pharmaceuticals, whose price exceeds 
the  reimbursement  amounts.  Private  expenditure 
accounted  for  17%  of  total  health  expenditure  in 
2015. This amount is still among the lowest in the 
EU,  well  below  the  average  of  22%.  Although 
available, voluntary health insurance plays a minor 
role  in  health  care  financing  (less  than  1%  of 
health  expenditure  in  2015),  which  is  mainly  due 
to  the  broad  range  of  benefits  available  under  the 
SHI schemes. 

Administrative organisation 

SHI is assured by health insurance funds (in 2017 
there  were  7  of  them,  down  from  27  in  the  mid-
1990s),  which  are  quasi-public,  self-governing 
bodies  that  act  as  payers  and  purchasers  of  care. 

60 

Patients  can  change  their  choice  of  a  fund  once 
every  12  months.  Funds  are  obliged  to  accept  all 
applicants and not allowed to make risk selection. 

Even  if  the  state  has  been  decentralised  (end  of 
1992)  –  and  therefore  competencies  given  to 
regional  authorities  beside  the  state  level  –  the 
level  of  expenditure  in  administering  such  a 
system does not seem high, though its share in the 
total  health  expenditure  has  slightly  increased  in 
recent years. Public and total expenditure on health 
administration 
a 
percentage of GDP, both 0.2% in 2015, are below 
the respective EU average (0.3% and 0.4%).  

and  health 

insurance 

as 

Coverage  of  services,  types  of  providers, 
referral systems and patient choice 

individual's  health  status". 

The  range  of  coverage  includes  "any  medical 
treatment delivered with the aim of maintaining or 
In 
improving  an 
practice the benefits are rationed at the point of use 
by the provider, based on four factors: the negative 
lists  of  procedures  and  services  excluded  from 
reimbursement;  the  positive  lists  of  approved 
pharmaceuticals, medical aids and dental aids that 
may  be  reimbursed  (together  with  the  depth  of 
coverage); the annual negotiation process between 
health  insurance  funds  and  health  care  providers 
resulting in establishment of specific conditions of 
reimbursement  attached  as  amendments  to  the 
existing  long-term  contracts  between  them;  the 
List  of  Health  Services,  being  a  fee  schedule  of 
rationed benefits updated annually by the Ministry 
of Health. 

Primary care is provided by physicians working in 
in  health  centres  and 
private  practices  or 
polyclinics.  Currently  95%  of  services  are 
provided in private – mainly individual – practices. 
Polyclinics  and  health  centres  are  usually  private 
legal entities,  which additionally offer ambulatory 
specialist  care.  Sometimes  health  centres  are 
owned  by  the  municipalities,  and  primary  care 
physicians pay a rent for the use of the facilities.  

Patients  register  with  a  primary  care  physician  of 
their  choice  and  can  switch  to  a  different  doctor 
once  every  three  months.  The  gatekeeper  role  of 
general practitioners (GPs) is limited. The primary 
care physicians can refer patients to specialists, but 
is  neither 
the  direct  access 
economically 
institutionally 

restricted 

latter 

nor 

the 

to 

 
discouraged.  The  patients  frequently  use  this 
option  in  practice,  circumventing  the  GPs  and 
addressing  directly  the  specialists.  The  referral  is, 
however,  obligatory  for  admissions  to  secondary 
inpatient  care  (except  for  emergency  cases). 
Moreover, visits to the dentists and gynaecologists 
are always direct and without referral. 

Secondary  care  services  are  provided  by  private 
practice  specialists,  hospitals  and  specialised 
inpatient facilities. Following a series of reforms in 
the  1990s,  formerly  state-owned  hospitals  are 
currently owned and  managed by a  wide range of 
entities:  ministries,  regions  and  municipalities, 
private entities and churches. 

Empirical  evidence  suggests  a  deficit  of  GPs  and 
an overutilisation of secondary and tertiary care in 
comparison  with  primary  care.  The  number  of 
practising physicians (369 per 100 000 inhabitants 
in  2013)  and  nurses  (801  per  100  000  inhabitants 
in  2015)  slightly  exceeded  or  was  at  the  EU 
averages  (338  and  833,  respectively).  However, 
the  number  of  GPs  is  lower  than  the  EU  average 
(70 vs. 78 per 100 000 in 2013).  

On the other hand, these figures suggest relatively 
easy access and possibly excessive use of inpatient 
care.  All  indicators,  although  falling  over  the  last 
years,  still  exceed  significantly  respective  figures 
for the entire EU on average: number of acute care 
beds  (425  vs.  402  per  100  000  of  population  in 
2015),  number  of  inpatient  hospital  discharges 
(19.4  vs.  16.2  per  100  inhabitants  in  2015)  and 
average  length of stay in acute care hospitals (9.3 
vs. 7.6 days in 2015). Those figures, together with 
the  data  on  the  share  of  hospital  day  case  in  total 
discharges (3.3% in the Czech Republic vs. 32.3% 
in  the  EU  in  2015),  may  suggest  an  inadequate 
allocation  of  resources  between  acute  health  care 
on  the  one  hand  and  outpatient  care  on  the  other 
the 
hand, 
reimbursement system (see below). 

explained 

partially 

only 

by 

Purchasing  and  contracting  of  health  care 
services and remuneration mechanisms 

insurance 

funds  conclude 

Health 
long-term 
contracts with the providers, for five or eight years. 
Only the framework of such contracts is defined by 
for 
law.  They 
providing 
payment 
care, 
mechanisms,  conditions  for  ending  the  contract, 

include  necessary  conditions 
health 

general 

Health care systems 

2.6. Czech Republic 

other  rights  and  obligations  of  both  sides,  but  do 
not  include  specific  conditions  of  reimbursement, 
which are subject to annual negotiations. 

GPs are paid according to a system of risk-adjusted 
capitation fees, accounting for age, but not gender 
of  the  patients.  The  number  of  patients  per 
physician  is  subject  to  a  limit  above  which  the 
payment is reduced. However, some services (such 
as  preventive  examinations  and  visits  to  patients' 
homes, accounting in 2011 for approximately 30% 
of physicians' income) are still paid on the fee-for-
service basis. 

Ambulatory care specialists are reimbursed using a 
digressive fee-for-service system, based on the List 
of Health Services. This List defines the number of 
points  for  each  service  and  the  threshold  of  the 
amount of services up to which providers are fully 
reimbursed. In case the limit is exceeded, the value 
of  points  is  reduced.  The  financial  value  of  the 
point  is  bargained  annually  between  insurance 
funds and provider organisations. 

Payments to hospitals are very diverse. Mainly, the 
system of prospective global  budgets is used. The 
budget's  level  is  based  on  the  amount  of  services 
provided during the relevant period of the previous 
year and the sum of points from the List of Health 
Services.  A  growing  number  of  cases  are  paid  on 
the  basis  of  diagnosis-related  groups  (DRGs) 
system: each year an updated version of the list of 
relative  weights  is  published  and  the  base  rate  is 
set. This system is supplemented with flat fees per 
insured person, which are applied according to the 
thresholds  based  on 
the  amount  of  services 
provided during the previous year.  

The  market  for  pharmaceutical  products,  the 
use  of  Health  Technology  Assessment  and 
cost-benefit analysis 

Public  and  private  pharmaceutical  expenditure 
accounts  for  17.4%  of 
total  current  health 
expenditure,  which  is  slightly  more  than  the  EU 
average  (14.6%  in  2015).  The  pharmaceutical 
reimbursement  system 
is  based  on  reference 
pricing, whereby the basic reimbursement level for 
each  reference  group  of  substitutes  is  set  at  the 
price  of  the  least  expensive  of  those  in  the  entire 
for 
EU.  Also  maximum  ex-factory  prices 
international 
pharmaceuticals  are  based  on 
reference 
benchmarking,  and 

the  group  of 

61 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

includes  eight  EU  Member  States 
countries 
(Estonia,  France, 
Italy,  Lithuania,  Hungary, 
Portugal,  Greece  and  Spain).  The  combined 
maximum amount of mark-ups by pharmacies and 
wholesalers  is  set  by  the  Ministry  of  Health.  The 
system  is  regressive,  with  maximum  surcharges 
being  reduced  in  line  with  growing  ex-factory 
prices. 

In  order  to  constrain  pharmaceutical  expenditure, 
health  insurance  funds  are  allowed  to  introduce 
pharmaceutical  budgets  for  each  provider  and 
impose penalties in case of overspending. 

E-health  (e-prescription,  e-medical  records) 
and information and reporting mechanisms 

The  information  and  communication  technologies 
are still not sufficiently spread in the Czech health 
system.  Health 
of 
technology 
assessment 
is  practically  not 
treatments  and  procedures 
available due to the lack of technical infrastructure. 
For  the  same  reason,  the  information  on  patients 
owned  by  the  health  insurance  funds  is  not 
efficiently used in practice. 

The  use  of  electronic  medical  records  is  being 
currently  developed  with  a  number  of  projects 
allowing  physicians  to  share  patient  information 
between  physicians  and  with 
the  concerned 
patient.  Information  systems  are  broadly  used  for 
reimbursement  and  accounting  purposes,  and  the 
use  of  web  pages  is  being  increasingly  spread 
among health insurance funds, health care facilities 
and  physicians.  A  system  of  mandatory  e-
prescriptions  was  approved  to  be  effective  from 
January 2018. 

the  quality  of  health  services, 

Although  the  country  lacks  a  unified  system  for 
assessing 
the 
providers  in  some  sectors  of  care  (mainly  those 
under  direct  responsibility  of  the  Ministry  of 
Health) are more and more frequently assessed via 
surveys,  patient  satisfaction  questionnaires  and 
accreditations.  

The  government  aims  to  ensure  secure  sharing  of 
important  health  and  economic 
information, 
thereby  achieving 
improved  quality,  comfort, 
security  and  transparency  of  the  health  care 
system. Computerisation  allows  professionals  and 
patients  to  make  the  right  decisions  based  on 
of  modern 
correct 

information. Full 

use 

62 

communication  technologies  will  contribute  to  a 
better and more cost-effective care. In this context, 
the aim is to create a working government strategy 
to ensure standards necessary for the development 
and  sustainability  of  e-health  and  to  oversee  their 
implementation.   

Health  promotion  and  disease  prevention 
policies 

The need to improve  health status further through 
promotion  and  prevention  activities  is  a  policy 
priority.  The  government  intends  to  support  the 
implementation  of  health  promotion  projects 
aimed  at  promoting  and  optimisation  of  physical 
activity  among  the  general  public  and  specific 
target groups. It will also support health promotion 
projects  aimed  at  achieving  changes  in  eating 
habits  and  increasing  health  literacy,  especially 
among children and the youth. It will also focus on 
reducing the health risks of the living and working 
environment and reducing health risk behaviour, in 
particular  regarding  protection  against  addictive 
substances. The government will also promote the 
infectious  diseases,  particularly 
prevention  of 
through measures aimed at antimicrobial resistance 
and  vaccination  programs.  Currently,  total  and 
public expenditure on prevention and public health 
services as a % of GDP (0.2% in 2015) are below 
the EU average (0.3%). 

Recently 
reforms 

legislated  and/or  planned  policy 

in 

the  priorities 

A  number  of  measures  aimed  at  improving  the 
cost-effectiveness  and  governance  of  the  health 
care  sector,  based  on 
the 
Government´s manifesto and the National Strategy 
for  Health  2020,  are 
in  various  stages  of 
implementation.  In  order  to  provide  for  a  better 
hospital  financing  system,  the  ‘diagnosis-related 
group  re-start’  project  formally  commenced  in 
January 2015, with the aim of full implementation 
by  2019-2020.  In  order  to  improve  the  economic 
database  of  the  DRG  system,  as  part  of  this 
project,  a  reference  network  of  hospitals  has  been 
established  in  2016.    Conversely,  user  fees  in  the 
outpatient sector were eliminated in 2015.    

As  regards  sources  of  healthcare  financing,  the 
Government approved, with effect from 1 January 
2018,  a  medium-term  measure  introducing  stable 
year-on-year  increases  of  state  payments  for  state 

 
to 

insured  persons 
in  2018,  2019  and  2020  
(Government  Regulation  No.  140/2017  Coll.  and 
Act  No.  297/2017  Coll.).  The  purpose  of  this 
measure  is  to  introduce  a  certain  level  of  stability 
and 
the 
development of part of the public health insurance 
system revenues. In 2018–2020, there will thus be 
regular  year-on-year  increases  in  state  payments 
for  state  insured  persons  by  approx.  CZK  3.5 
billion (approx. €136 million). 

the  predictability  of 

increase 

With effect from 2018 (bill amendment to Act No. 
592/1992  Coll.),  redistribution  of  funds  among 
health  insurance  companies  has  been  changed  to 
include  Pharmaceutical  Cost  Groups  (PCGs)  to 
enable more equitable distribution of funds among 
health  insurance  companies  and  thus  improve  the 
quality of care for chronically ill patients. As many 
as  25  PCGs,  such  as  diabetes,  depression, 
transplantation,  renal  failure  or  HIV,  have  been 
introduced.  The  system  allows  for  patients  to  be 
categorised into more than one PCG.  

to 

ensure 

temporary 

legislation 

New 
availability  of 
pharmaceuticals is effective since April 2017 (Act 
No.  378/2007  and  Act  No.  48/1997  amended  by 
Act  No.  66/2017  Coll).  It  allows  the  Ministry  of 
Health  to  monitor  and  limit  or  ban  export  of 
low 
certain  pharmaceuticals  with 
supply,  which  may  endanger  their  availability  to 
Czech  patients  and  therewith  threaten  patients’ 
health or life. In cases of unauthorised export, the 
law foresees penalty fees of up to 20 million CZK 
(approx.  €740740)  and  a  ban  of  distributor’s 
activities. Furthermore, the availability of drugs is 
to  be  guaranteed  along  the  distribution  chain. 
There is an obligation for the producers to deliver 
requested  drugs  to  distributors  up  to  a  respective 
market  share  and  for  distributors  to  provide 
ordered  drugs  to  pharmacies  within  2  working 
days.  The  law  also  decreases  the  maximum  price 
for  newly  introduced  generic  biological  drugs 
(biosimilars) from previously 85% to now 70% of 
the price in the reference group. 

of 

process 

determining 

There  are  governmental  plans  to  replace  the  non-
transparent 
the 
reimbursement  of  medical  devices  with  a  new 
at 
system.  The 
the 
strengthening, 
state supervision  of  health  insurance  flows  and 
over  the  functioning  of  the  health  insurance 
introduce  a 
companies. The  government  will 

also 
aims 
legal  measures, 

government 

through 

Health care systems 

2.6. Czech Republic 

indicators 

transparent  system  of  quality 
for 
comparing and publishing of quality of health care 
in individual health care facilities, so that these are 
specialists 
to  both  patients  and 
accessible 
(113).  Competencies  between 
the  Ministry  of 
Health  and  the  National  Reference  Centre  shall 
also be specified.  

still 

the  health 

The  government’s  commitment 
to  effectively 
define  the  process  of  entry  of  new  technologies 
into 
continues. A 
system 
methodology  has  been  established  within  the 
project  of  implementation  of  health  technology 
assessment  (HTA),  which  should  ensure  that  new 
technologies,  which  are  to  be  covered  by  the 
public health insurance system, bring adequate and 
to 
documented  counter  value. It 
decide  on 
institutional 
form  of 
the 
arrangements  for  HTA  and  the  manner  of  its 
inclusion  in  the  process  of  determining  the  extent 
of  medical  care  covered  by  public  health 
insurance. In 
the 
the 
methodology has been tested further as well as its 
eventual deployment via a law. 

is  necessary 
the 

usability 

2017 

of 

Challenges 

The  analysis  above  has  shown  that  many  reforms 
improved 
are  ongoing,  aiming  mainly  at  an 
efficiency  of 
the  health  system  via  cost-
containment  and  more  market-oriented  solutions, 
and  its  results  are  yet  to  be  evaluated.  The  main 
challenges  for  the  Czech  health  system  are  as 
follows:  

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the increasing health care expenditure over the 
coming  decades,  which  is  a  risk  to  the  long-
term sustainability of public finances.   

•  To clearly define a basic package of the health 
care  services  which  are  covered  from  the 
general  insurance  (i.e.  to  have  a  more  explicit 
definition of SHI benefits).  

•  To  develop  a  comprehensive  human  resources 
strategy  that  tackles  spatial/regional  disparities 

(113) The  authorisation  will  have  to  be  embedded  in  the 
amendment  to  the  Act  No.  372/2011  Coll.  on  Health 
Services. 

63 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  To 

foster  health  promotion  and  disease 
prevention  activities,  promoting  healthy  life 
styles  and  disease  screening  given  the  pattern 
of  risk  factors  (smoking,  alcohol,  obesity, 
circulatory system diseases).  

in health care accessibility (physicians' density, 
waiting times). 

care 

either 

through 

•  To  enhance  primary  care  provision  and  tackle 
the  excessive  use  of  specialist  and  hospital 
care,  in  particular  with  a  referral  system  to 
specialist 
financial 
incentives  or  by  making  it  compulsory;  to 
promote use of GPs' services, by strengthening 
organisational and financial incentives for both 
doctors and patients; to foster the coordination 
of  care  between  primary,  secondary  and 
hospital  care  in  order  to  reduce  redundant  and 
duplicated  medical 
and 
laboratory  tests,  doctor  visits  and  unnecessary 
drug prescriptions; to monitor the impact of the 
abolishment of patient cost-sharing at different 
levels  of  care,  especially  with  regard 
to 
avoidable use of services. 

examinations 

•  To 

the 

improve 

cost-efficiency  within 
hospitals,  ensuring  that  care  is  provided  in  the 
most  clinically  appropriate  and  cost-effective 
way,  by  implementing  the  new  DRG  based 
financing  system,  by  increasing  the  proportion 
of  elective  care  provided  on  a  day-case  basis 
and  day-of-surgery  admissions;  to  consider 
reducing  the  high  number  of  acute  care  bed 
capacity.  

•  To  fully  implement  the  e-prescription  tool  for 
pharmaceuticals, 
rational 
prescription  and  use  of  medicines  and 
enhancing  access  to  cost-effective  medicines, 
while generating savings to payers.  

improving 

the 

•  To introduce a system of quality indicators for 
comparing  and  publishing  of  quality  of  health 
care  in  individual  health  care  facilities,  that 
should be accessible to patients and clinicians.  

•  To  foster  the  use  of  centralised  procurement 
procedures  for  pharmaceuticals,  but  also  for 
other  medical 
and  non-medical  goods, 
generating  savings  to  payers,  while  ensuring 
access  to  high-quality  products  in  the  health 
system. 

•  To ensure a greater and more systematic use of 
to  achieve 
technology  assessment 
health 
decisions, for example about the SHI coverage 
or reimbursement rates.  

64 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.6.1:  Statistical Annex – Czech Republic 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

6
5

EU- latest national data

2005

110

20.0

6.3

:

2006

124

21.0

6.5

2.1

2007

138

22.2

5.0

2.2

2008

161

22.2

1.6

2.7

2009

149

20.6

-5.4

8.9

2010

157

21.1

2.0

-3.3

2011

164

21.7

2.0

1.8

2012

161

21.6

-0.9

6.4

2013

158

21.8

-0.5

5.3

2014

157

22.5

2.6

0.4

2015

168

23.7

5.1

1.9

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

6.9

6.2

0.7

6.6

6.6

0.1

6.5

6.4

0.1

6.5

6.4

0.1

7.5

6.2

1.3

7.1

6.0

1.1

7.1

6.4

0.7

7.6

7.3

0.3

8.1

7.8

0.3

7.9

7.7

0.3

7.7

7.2

0.4

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

1,054

1,139

1,233

1,442

1,518

1,511

1,574

1,660

1,714

1,667

1,734

2,745

2,895

5.4

5.3

5.5

5.5

6.4

6.4

6.1

6.0

6.5

6.2

6.5

6.2

6.8

6.5

6.6

6.3

6.4

6.0

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

1,032

1,222

1,298

1,288

1,441

1,421

1,442

1,388

1,447

2,153

2,263

2,324

2,609

5.9

5.8

894

0.07

84.8

17.7

100.0

11.1

5.7

5.6

972

0.06

85.3

17.9

100.0

11.7

0.07

83.7

19.2

100.0

13.6

0.08

84.8

16.8

100.0

16.1

0.08

85.5

18.0

100.0

15.1

0.05

85.3

18.6

100.0

15.3

0.34

91.6

17.6

100.0

15.0

0.32

85.6

16.7

100.0

15.3

0.27

84.1

17.6

100.0

13.6

0.25

83.3

17.9

100.2

14.1

0.43

83.4

17.9

100.0

14.8

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

10.2

79.2

72.9

60.0

58.0

128

3.4

10.2

79.9

73.5

59.9

57.9

119

3.3

10.3

80.2

73.8

63.3

61.4

97

3.1

10.3

80.5

74.1

63.4

61.3

94

2.8

10.4

80.5

74.3

62.7

61.1

95

2.9

10.5

80.9

74.5

64.5

62.2

88

2.7

10.5

81.1

74.8

63.6

62.2

196

2.7

10.5

81.2

75.1

64.1

62.3

193

2.6

10.5

81.3

75.2

64.2

62.5

194

2.5

10.5

82.0

75.8

65.0

63.4

177

2.4

10.5

81.6

75.7

63.7

62.4

179

2.5

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.1

0.1

1.5

1.7

0.2

0.1

0.2

2.1

0.1

1.3

1.3

0.1

0.1

0.2

2.1

0.1

1.5

1.5

0.2

0.1

0.2

2.0

0.1

1.4

1.1

0.1

0.1

0.2

2.0

0.1

1.6

1.4

0.2

0.1

0.2

1.9

0.1

1.4

0.9

0.1

0.1

0.2

2.0

0.1

1.8

1.4

0.3

0.2

0.2

1.9

0.1

1.4

0.9

0.1

0.2

0.2

2.3

0.1

2.1

1.7

0.2

0.2

0.3

2.2

0.1

1.7

1.2

0.1

0.1

0.2

2.2

0.1

2.1

1.5

0.2

0.2

0.2

2.1

0.1

1.7

0.9

0.1

0.1

0.2

2.2

0.1

2.1

1.5

0.2

0.2

0.2

2.1

0.1

1.8

0.9

0.1

0.1

0.2

2.2

0.1

2.2

1.6

0.2

0.2

0.2

2.1

0.1

1.8

1.0

0.1

0.1

0.2

2.0

0.1

2.1

1.4

0.2

0.2

0.2

1.9

0.1

1.8

0.9

0.1

0.2

0.2

1.9

0.1

2.1

1.3

0.2

0.3

0.2

1.8

0.1

1.7

0.8

0.1

0.2

0.2

1.8

0.1

2.0

1.3

0.2

0.2

0.2

1.7

0.1

1.6

0.8

0.1

0.2

0.2

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

2
.
6
.

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t
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s

 
 
 
 
 
 
 
 
 
 
 
 
6
6

Table 2.6.2:  Statistical Annex - continued – Czech Republic 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

34.0%

1.1%

24.0%

27.7%

3.9%

1.9%

3.7%

35.5%

1.2%

23.1%

22.4%

1.7%

1.7%

3.6%

2005

0.31

0.6

1.2

0.1

:

24.3

13.2

2006

31.6%

1.1%

23.0%

23.1%

3.5%

2.1%

3.3%

36.4%

1.3%

24.3%

19.3%

1.6%

2.1%

3.8%

2006

0.38

0.6

1.3

0.1

:

23.4

13.0

2007

30.5%

1.3%

24.9%

21.9%

3.8%

2.2%

3.6%

35.6%

1.6%

26.0%

17.2%

1.7%

2.2%

3.9%

2007

0.44

0.7

1.3

0.1

:

24.0

13.4

2008

31.3%

1.9%

27.4%

21.7%

3.9%

2.8%

3.8%

35.5%

2.2%

26.2%

15.8%

1.5%

3.7%

4.2%

2008

0.50

0.8

1.3

0.1

18.3

21.8

13.3

2009

36.7%

1.8%

34.2%

27.2%

3.5%

2.7%

4.0%

34.2%

1.7%

26.6%

19.1%

1.3%

2.2%

3.8%

2009

0.57

0.8

1.4

0.1

:

23.8

13.2

2010

36.0%

1.9%

34.0%

24.5%

3.8%

3.0%

4.0%

34.5%

1.9%

28.5%

15.6%

1.3%

2.5%

3.8%

2010

0.63

0.8

1.5

0.1

:

22.8

12.7

2011

34.5%

2.0%

33.4%

23.5%

3.6%

2.7%

3.8%

34.4%

2.1%

29.0%

15.2%

1.3%

2.3%

3.7%

2011

0.69

0.7

1.5

0.1

:

21.7

12.4

2012

29.6%

1.7%

29.6%

21.8%

3.1%

2.1%

3.1%

33.0%

2.0%

29.6%

16.4%

1.3%

2.1%

3.5%

2012

0.69

0.8

1.5

0.1

:

22.9

12.7

2013

25.9%

1.5%

26.9%

18.2%

2.9%

2.9%

2.9%

29.6%

1.8%

27.0%

13.8%

1.4%

3.2%

3.5%

2013

0.74

0.9

1.5

0.1

:

22.2

12.4

2014

24.8%

1.7%

27.1%

17.3%

2.9%

3.3%

2.7%

28.8%

2.1%

27.2%

12.8%

1.4%

3.0%

3.3%

2014

0.74

0.9

1.5

0.1

18.7

22.3

12.7

2015

24.3%

1.7%

27.5%

17.4%

2.9%

2.8%

2.6%

28.1%

2.0%

27.5%

12.6%

1.3%

3.0%

3.2%

2015

0.83

0.9

1.6

0.1

:

18.2

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

355

809

73

690

2005

13.2

22

343

78.0

7.1

1.6

2016

5.4

5.4

2016

10.6

356

805

72

617

2006

13.0

21

364

:

:

1.7

2020

5.6

5.7

2020

10.7

356

800

71

608

2007

12.6

21

378

:

10.3

1.8

2025

5.7

6.0

2025

10.7

354

794

70

559

2008

11.4

20

440

:

10.0

:

2030

5.9

6.3

2030

10.7

356

806

70

553

2009

11.2

20

439

75.3

10.0

2.1

2035

6.1

6.6

2035

10.6

359

808

70

546

2010

11.0

20

466

73.8

9.9

2.3

2040

6.2

6.8

2040

10.6

364

803

70

535

2011

11.1

19

524

72.8

9.8

2.6

2045

6.3

7.0

2045

10.5

367

806

70

528

2012

11.1

19

585

73.1

9.5

2.9

2050

6.5

7.2

2050

10.5

369

799

70

523

2013

11.1

20

642

73.9

9.4

3.2

2055

6.5

7.3

2055

10.4

:

793

:

524

:

801

:

518

2014

2015

:

20

669

74.9

9.4

3.3

2060

6.6

7.4

2060

10.3

:

19

666

74.3

9.3

3.3

2065

6.6

7.4

2065

10.2

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

6.5

7.3

2070

10.0

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

CZ

1.1

1.9

EU

0.9

1.6

Change 2016-2070, in %

CZ

-5.4

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.7. DENMARK 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

GDP per capita in PPS is at 34,800 and far above 
EU  average  of  29,600  in  2015.  Denmark  has  a 
population  of  5.7  million  inhabitants.  During  the 
coming decennia the population will steadily grow, 
from 5.7 million inhabitants in 2016 to 6.8 million 
inhabitants  in  2070.  This  19%  increase  is  much 
higher than the EU average of 2%.  

Total and public expenditure on health as % of 
GDP 

Total  expenditure  on  health  as  a  percentage  of 
GDP  (11%  in  2015)  has  increased  over  the  last 
decade (from 9.8% in 2005), although down  from 
a peak of 11.5% of GDP in 2009, and is above the 
EU average (114) of 10.2% in 2015. Throughout the 
last decade, total public expenditure has increased 
as % of GDP: from 8.1% in 2005 to 9.2% of GDP 
in  2015  (EU:  8.0%).  Looking  at  health  care 
without  long-term  care (115)  reveals  a  different 
picture  with  public  spending  not  above  but  at  the 
EU  average  (DK:  6.8%  vs.  EU:  6.8%  in  2015). 
When expressed in per capita terms, total spending 
on health at 3,956 PPS was above the EU average 
of 3,305 in 2015. So was public spending on health 
care: 3,308 PPS vs. an EU average of 2,609 PPS in 
2015 (116).  

Expenditure projections and fiscal sustainability 

As a consequence of population ageing, health care 
expenditure  is  projected  to  increase  by  1.0  pp  of 
GDP, at the average growth level expected for the 
EU  of  0.9  pps  of  GDP,  according  to  the  "AWG 
reference scenario". When taking into account the 
impact  of  non-demographic  drivers  on  future 
spending  growth  ("AWG  risk  scenario"),  health 
care expenditure is expected to increase by 1.8 pps 

(114) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(115) To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(116) Note  that  these  PPS  figures  reflect  current  plus  capital 
health  expenditure  in  contrast  to  EUROSTAT  data  series, 
which reflect current expenditure only. 

of  GDP  from  now  until  2070  (EU:  1.6)  (117). 
Overall, projected health care expenditure increase 
is expected to add to budgetary pressure. However, 
currently  no  fiscal  sustainability  risks  appear  for 
Denmark over the long run. This risk-free outlook 
derives  primarily  from 
initial 
budgetary  position,  which  fully  mitigates  the 
projected ageing costs increase over the long term 
(118).  

the  favourable 

Health status 

Life expectancy at birth (82.7 years for women and 
78.8 years  for  men) is around the EU averages of 
83.3  and  77.9  years  in  2015.  With  57.6  years  for 
women and 60.4 years  for  men, healthy life  years 
are  below  the  averages  in  the  EU  (63.3  and  62.6, 
for  women  and  men)  (119).  The  infant  mortality 
rate of 3.7‰ is at EU average (3.6‰) in 2015. 

As  for  the  lifestyle  of  the  Danish  population,  the 
data  indicates  an  average  number  of  regular 
smokers  (17%  in  2015),  being  below  the  EU 
average of 21%, having declined in the past years. 
The proportion of the obese population was below 
EU  level  at  14.4%  in  2014  (EU:  15.4%  in  2015), 
and alcohol consumption is slightly below the EU 
level.  

System characteristics  

Overall description of the system 

Denmark  has  a  universal,  tax-based  decentralised 
health  care  system.  The  five  Regional  Authorities 
are  responsible  for  hospital  and  psychiatric  care 
funding  as  well  as  for  establishing  collective 
agreements  with  providers  of  ambulatory  care, 
while  98  local  authorities  are  in  charge  of  mainly 
rehabilitation  and  health  promotion  and  disease 
prevention policies.  

(117) The 2018 Ageing Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(118) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(119) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

67 

 
                                                           
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Coverage 

The  system  provides  full  population  coverage. 
Primary, specialist and hospital care are free at the 
point  of  use  for  most  services.  Children,  senior 
citizens, those with certain medical conditions and 
disabilities  and  those  who  have  reached  an  upper 
limit  for  out-of-pocket  payments  are  exempted 
from cost-sharing. 

Administrative  organisation  and 
collection mechanism  

revenue 

between 

agreements 
the 

The budget for public spending in the health sector 
is  decided  by  the  Parliament  on  the  basis  of 
(yearly) 
the 
budget 
local  authorities.  The 
government  and 
financing  of  the  system  comes  from  central  and 
local taxes (regions are not allowed to levy taxes). 
State  funding  is  distributed  to  the  regions  and  98 
local  authorities  via  block  grants.  Part  of  the 
funding  attributed  to  the  regions,  including  local 
authorities  funding,  is  activity-related,  an  element 
that came into place in 2002, and revised in 2007 
and 2012. Today, around 20 percent of the funding 
of the regions is activity-related, within an overall 
framework  with  fixed  spending  caps  set  by 
Parliament. 

The  funds  to  be  allocated  to  hospitals,  GPs  and 
specialist,  within  the  agreed  overall  budget,  are 
determined  by  the  regional  authorities.  Funds  for 
remuneration  of  medicines  are  earmarked.  The 
Ministry  of  Health,  through  the  National  Health 
Board,  provides  guidelines  and  regulation  (the 
overall 
legal  framework)  for  care  provision, 
supervises  care  delivery  and  sets  public  health 
priorities. It is, however, for hospitals to define the 
remuneration  of  other  health  staff,  for  regions  to 
plan  hospital  capacity  and  equipment  and  for  the 
regions  and  local  authorities  to  pay  providers  for 
the  delivery  of  care  (regions  buy  curative  care, 
local  authorities  pay  for  promotion,  prevention, 
rehabilitation, children dental care).  

Role  of  private  insurance  and  out  of  pocket 
co-payments  

Supplementary  private  insurance  (to  cover  the 
services  not  covered  by  public  provision/funding) 
is  used  by  33%  of  the  population,  and  40%  buys 
complementary  health  insurance  to  cover  cost-
sharing. 

68 

In  2015,  private  expenditure  and  out-of-pocket 
expenditure were 16.4% and 15.3% of total health 
expenditure,  below  the  EU  averages  (21.6%  and 
15%, respectively). 

Types of providers, referral systems and patient 
choice 

Primary  care  is  provided  by  general  practitioners 
(GPs)  working  in  private  individual  or  group 
practices and outpatient specialist care is provided 
in private individual practices. They receive almost 
all  of  their  income  from  services  paid  by  the 
regions.  Most  hospitals  are  owned  by  the  regions 
(about  97%  of  all  hospital  beds  are  public)  and 
hospital  doctors  are  employees  of  the  regions.  In 
general,  providers  are  paid  by  the  regions  on  the 
basis  of  contractual  arrangements  with  relevant 
unions.  

The  density  of  physicians  in  Denmark  is  at  the 
average density in the EU. In 2014, there were 366 
practising  physicians  per  100  000  inhabitants, 
compared  to  344  in  EU  in  2015.  The  number  of 
general  practitioners  is  below  the  EU  average  (71 
per  100  000  inhabitants  vs.  78  in  the  EU).  The 
number of nurses per 100 000 inhabitants is 1,670 
in  2014  and  is  double  the  EU  average  of  833. 
Authorities  have  put  strong  efforts  to  use  primary 
care  vis-à-vis 
specialist  and  hospital  care. 
Residents have to register with a GP and there is a 
compulsory  referral  system  from  primary  care  to 
specialist  doctors  i.e.  GPs  act  like  gatekeepers  to 
specialist and hospital care. 

recruit  medical 

Regional  authorities  decide  on  hospital  capacity 
and equipment capacity. Hospitals have autonomy 
staff  and  other  health 
to 
professionals, within the budget set by the regional 
authorities  and  within  pay  scales  set  by  the 
agreements  between  the  regional  authorities  and 
the  unions.  Private  hospitals  are  free  to  establish 
and  expand  their  capacity  in  compliance  with 
quality  and  safety  requirements.  In  2015,  the 
number  of  acute  care  beds  was  246  compared  to 
402  per  100  000  inhabitants  in  the  EU.  The 
average length of stay of hospital inpatients is one 
of  the  lowest  in  the  EU,  such  that  with  low 
capacity,  Denmark  still  achieves  high  discharge 
rates  (15  discharges  in  Denmark  versus  16  in  the 
EU per 100 inhabitants). 

 
Treatment options, covered health services 

The  benefit  package  is  not  explicitly  defined  but 
the  health  interventions  provided  are  based  on 
clinical effectiveness. 

Price  of  health  care  services,  purchasing, 
contracting and remuneration mechanisms 

Outpatient and inpatient specialists in hospitals are 
paid  a  salary.  GPs  are  paid  a  mix  of  a  capitation 
and  a  consultation  fee  by  the  regional  authorities, 
within  an  overall  spending  cap  for  GP’s  set  by 
agreement  with  the  relevant  organisations.  GP’s 
performance  based  payment  includes  a  variety  of 
fees  for  different  kinds  of  consultation,  including 
advice on prevention. General fiscal consolidation 
also  involves  more  focus  on  monitoring  and 
control of activity and spending in private practise 
(GP’s etc.).  

Regional authorities decide how hospitals are paid 
in  combination  of  prospective  global  budgets  and 
activity-related  payments  based  on  diagnosis-
related  groups  (DRGs).  DRG  weights  are  defined 
at central level with hospital remuneration methods 
and  negotiation  of  rates  taking  place  at  regional 
level.  

The market for pharmaceutical products 

The authorities have implemented some policies to 
control  expenditure  on  pharmaceuticals.  There  is 
no direct price regulation although the government 
and the industry have agreed on a scheme for price 
reductions  for  medicines  used  in  hospitals.  The 
regional  authorities  have  also,  according  to  the 
budget  agreement  for  2011,  established  a  new 
committee 
to  establish  a  better  coordination 
between  the  regions  on  recommended  use  of 
expensive  medicines  in  hospitals  to  ensure  use  of 
the  most cost-effective  medicines and at the  same 
time establish a potential for lower prices through 
procurement. 

In  2016  the  Danish  Parliament  agreed  on  seven 
principles for prioritising of hospital medicine, e.g. 
the  efficiency  and  cost  effectiveness  of  different 
medicines.  

The  authorities  also  apply  reference  pricing  on 
reimbursed  medicines,  whereby  the  maximum 
reimbursement  level  of  a  medicine  is  the  lowest 

Health care systems 

2.7. Denmark 

price  of  the  products  in  each  group  of  products, 
defined  on  the  basis  of  same  active  ingredient, 
form  and  strength  and  package  size  (with  some 
deviation  allowed).  There  is  a  positive  list  of 
reimbursed  products  which  is  based  on  health 
technology 
information  when 
available.  

assessment 

treatment 

rational  prescribing  of 
Authorities  promote 
physicians 
guidelines 
through 
complemented  with  monitoring  of  prescribing 
behaviour 
information 
education 
and 
and 
the  prescription  and  use  of 
campaigns  on 
medicines.  Authorities  monitor 
the  general 
consumption  of  prescribed  medicines  closely.   
Generic substitution ( 120) is obligatory in Denmark. 
A  public  webpage  indicates  which  products  can 
replace  each  other 
to  help  pharmacists  and 
consumers choose.  

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

data, 

including 

Comprehensive 
comparable 
information on physician and hospital activity and 
care quality (clinical outcomes, use of appropriate 
processes)  and  on  patient's  experience  and 
satisfaction with the care obtained through surveys 
is  publicly  available.  Authorities  also  encourage 
providers'  self-assessment  and  want  to  conduct 
regular  comparisons  with  health  care  activity  in 
other  countries  and  develop  further  statistics  on 
areas such as waiting times and choice.  

The  Danish  Centre  for  Evaluation  and  Health 
Technology  Assessment  and  various  regional 
resource centres conduct and gather information on 
health  technology  assessment  which  is  used  to 
define  coverage  of  new  medicines,  new  high-cost 
equipment and new procedure as well as their level 
of 
clinical 
and 
guidelines.  Existing  clinical  guidelines  and 
practice  protocols  are  coupled  with  financial 
incentives and the monitoring of physician activity 
to encourage compliance with those guidelines. 

reimbursement 

respective 

(120) Generic  substitution  is  normally  defined  as  a  right  or  an 
obligation  of  pharmacists  to  substitute  a  brand  medicine 
with  a  cheaper  (generic)  medicine  with  the  same  active 
ingredient(s). 

69 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

E-Health, Electronic Health Record 

Under  the  current  National  IT  Strategy  for  the 
Danish  Health  Care  Service  authorities  have  been 
introducing  a  number  of  ICT  and  e-health 
solutions 
to  allow  for  nationwide  electronic 
exchange  of  medical  data,  including  the  patient 
electronic  medical  records  and  e-prescribing  to 
support  and  render  the  referral  system  and  care 
coordination more effective, reduce medical errors 
and  increase  cost-efficiency.  A  system  with  a  full 
overview  of  all  medical  records  of  a  patient  from 
GP’s, hospitals etc. is now fully operational in  the 
hospitals  and  GP’s  and  was  implemented  in  the 
local  municipalities in 2015. A  system  with a  full 
overview  of  all  records  of  a  patient  was  fully 
implemented in 2013. The strategy ended in 2018 
and  currently 
(regions  and 
local 
municipalities) and the government are preparing a 
new  E-health  strategy.  The  focus  of  the  new 
strategy is supposed to be on developing common 
IT  infrastructure  in  order  to  share  more  patient 
information  between  health  care  providers  for 
better coordination and continuity of care. 

level 

the 

Health  promotion  and  disease  prevention 
policies 

Authorities  have  strongly  emphasised  health 
promotion  and  disease  prevention  measures  in 
recent years. Promotion and prevention are seen by 
authorities  as  a  means 
long-term 
sustainability  of  the  health  budget.  Total  and 
public expenditure on prevention and public health 
services  as  a  %  of  GDP  were  above  the  EU 
average.  

to  ensure 

Recently 
reforms 

legislated  and/or  planned  policy 

A  number  of  initiatives  aimed  at  improving  the 
transparency  on  quality  and  results,  patient  rights, 
psychiatry,  cancer  care  for  children  and  public 
health 
of 
in 
implementation:  

various 

stages 

care 

are 

Transparency  reform  –  greater  focus  on  quality 
and results. The aim is to create greater and more 
systematic  knowledge  about  quality  and  best 
practice,  as  well  as  achieving  better  management 
of the health care and long-term care system based 
on  improvements  in  the  overall  health  of  the 
population, a high level of patient involvement and 

70 

lower  expenditure  per  capita.  Large  funds  have 
been transferred to building a national platform for 
valid  and  up  to  date  health  data.  The  accessible 
for 
health  data  should  provide  a  platform 
transparency and dissemination of best practice as 
well  as  management  and  priorities  in  the  health 
care sector on the basis of key goals and results. 

The right to assessment and identification of needs 
and  to  treatment  of  somatic  and  psychiatric 
patients.  The  rights  aim  to  secure  a  short  and 
effective  diagnosing  and  treatment  of  all  patients. 
Under  current  rules  patients  have  the  right  to 
assessment  and  identification  within  1  month  and 
the  right  to  treatment  within  1  month.    If  the 
capacity of the public hospital cannot ensure that a 
given  treatment  or  assessment  can  be  initiated 
within 1 month, patients have the right to extended 
free choice of hospital.  

the  psychiatry.  The 
Massive  prioritising  of 
parliament  has  agreed  to  invest  2.2  billion  DDK 
(appx.  €295  million)  in  the  psychiatry  over  the 
period  2015-2018.  This  means  a  massive 
development  of  capacity,  professionals  and 
facilities  and  environment  to  secure  an  ambitious 
lift of the psychiatry in terms of quality and equal 
and  fast  diagnosis  and  treatment  of  the  patients. 
The  government  has  along  with  the  regions  and 
municipalities  initiated  a  review  of  the  regulation 
and  administration  of  the  psychiatric  sector  in 
Denmark. The aim is to issue recommendations for 
better value for money in psychiatric care.   

Partnerships  to  reduce  the  use  of  force.  In  2014 
Finance  Act,  it  was  agreed  to  set  a  target  that  the 
use  of  force  in  the  psychiatric  health  services 
should  be  reduced  by  50  per  cent.  A  permanent 
grant has been allocated to form partnerships with 
the  regions  to  meet  the  target.  For  instance,  the 
funds  may  be  spent  on  regional  initiatives  on 
patient involvement, competency development and 
dissemination and implementation of methods that 
have  proven  successful  based  on  national  and 
international experience.  

Stronger health care agreements. Five health care 
agreements  have  been  made  for  2015-2018  –  one 
for each region. They include new mandatory key 
action  areas  and  specific  objectives.  Across  the 
boundaries  of  key  action  areas,  the  health  care 
agreements  have  a  focus  on  inequality  in  health 
and  active  involvement  of  patients  and  their 

 
is 

to 

ensure 

coherence 

relatives.  The  aim  with  the  five  health  care 
agreements 
and 
coordination of efforts in the patient care that goes 
and 
across  hospitals,  general  practice 
on 
municipalities  so  that  each  patient  and  citizen 
receives  a  treatment  that  is  consistent  and  of  high 
quality at the lowest effective cost.  

National  quality  goals.  The  Government,  Danish 
Regions and Local Government Denmark have set 
eight ambitious goals for the overall quality of the 
Danish  health  care.  The  national  goals  set  a 
framework  for  the  continuous  improvement  of 
quality  and  efficiency.  The  national  goals  are 
supported  by  a  number  of 
local  goals  and 
activities,  which  lead  to  local  improvements.  The 
national  goals  are  a  part  of  a  national  programme 
to improve the quality and efficiency in the health 
care system in Denmark. Beside the national goals, 
the  quality  programme  consist  of  e.g.  quality 
leadership 
improvement 
programme and enhanced patient involvement and 
empowerment.   

a  national 

teams, 

interregional  differences 

In addition, the Danish government has identified a 
number  of  future  priorities  for  health.  Thus,  the 
government  has  presented  a  cancer  plan  which 
aims  at  reducing 
in 
treatment  and  outcomes  and  the  national  cancer 
mortality  rate.  Moreover,  the  government  has 
presented a national plan targeting elderly patients. 
The plan aims at improving the general conditions 
for  patients  and  reducing  overcrowding  in  the 
hospitals.  The  third  priority  targets  enhancements 
in quality, coherence and cost-effectiveness, which 
are  the  keywords  in  order  to  maintain  a  resilient 
and  sustainable  health  care  system  in  the  future. 
With an ageing population and increasing demand 
for  health  care  services  is  it  crucial  to  map  and 
spread best practices and secure a coherent  health 
care  system  so  that  high-quality  health  care 
services  are  carried  out  as  cost-effective  as 
possible.  

Furthermore, the government has initiated work on 
a  comprehensive  plan  to  strengthen  integrated 
care, including extended responsibility of the GP’s 
for  the  care  of  elderly  or  chronically  ill  patients. 
The  aim  is  a  more  cost-effective  treatment  of  this 
group,  which  is  expected  to  grow  significantly 
over  the  coming  years,  and  at  the  same  time 
securing  a  better  quality  of  care  closer  to  the 
patient. Finally, the government has initiated work 

Health care systems 

2.7. Denmark 

on  a  review  of  the  financial  regulation  and 
management  of  the  hospital  sector.  The  aim  is  to 
develop  an  improved  management  model  that 
secures most value from spending.  

Challenges 

The  analysis  above  shows,  that  a  wide  range  of 
reforms  have  been  implemented  over  the  years. 
Denmark  should continue to  pursue  such reforms. 
In  this  regard  the  main  challenges  for  the  Danish 
health care system are as follows: 

quality 

spending, 

promoting 

•  To continue increasing the efficiency of health 
care 
and 
integrated  patient  packages  as  well  as  a 
focusing  on  productivity  and  costs  in  view  of 
the relatively high spending on health care as a 
share  of  GDP  and  increasing  health  care 
expenditure  over  the  coming  decades,  due  to 
and  non-demographic 
population 
factors. 

ageing 

•  To continue strengthening the integrated health 
care  system,  such  that  general  practitioners, 
municipalities  and  hospitals  work  closely 
together to give citizens a coordinated package 
of treatment. 

•  To implement and monitor the effectiveness of 
the  plans  to  foster  quality  and  access  to 
psychiatric  are,  while  ensuring  the  high  value 
for money for current investments.  

•  To  implement  the  reform  on  transparency  of 
results to inform best practice and contribute to 
faster diagnosis, treatment and care of the best 
quality. 

•  To 

the 

continue 

consolidation  of 

the 
administrative  reform  and  the  new  decision-
making structure that resulted from it, ensuring 
coherence of responsibilities. 

•  To  continue  to  focus  on  a  balanced  mix  of 
skills  in  all  parts  of  the  health  sector,  for 
instance  for  nurses  to  handle  tasks  in  private 
practice and acute wards, and on a clear referral 
system, to ensure an effective use of resources. 

71 

 
7
2

Table 2.7.1:  Statistical Annex – Denmark 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

EU- latest national data

2005

213

32.8

2.0

:

2006

226

34.2

3.6

5.2

2005

2006

9.8

8.7

1.1

9.9

8.9

1.0

2007

233

34.7

0.5

1.2

2007

10.0

9.0

1.0

2008

242

33.9

-1.1

0.8

2008

10.2

9.1

1.1

2009

231

31.7

-5.4

6.6

2009

11.5

9.2

2.3

2010

243

32.9

1.4

-2.0

2010

11.1

9.3

1.8

2011

248

33.3

0.9

-1.0

2011

10.9

10.2

0.7

2012

255

32.9

-0.1

0.9

2012

11.0

10.3

0.7

2013

259

33.0

0.5

0.0

2013

10.9

10.2

0.7

2014

265

33.6

1.1

2.1

2014

11.0

10.3

0.8

2015

272

34.8

0.9

0.4

2015

11.0

10.3

0.6

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,885

3,095

3,213

3,372

3,613

3,655

3,638

3,760

3,786

3,904

3,956

2,745

2,895

8.1

7.8

8.2

7.9

8.3

8.0

8.6

8.2

9.7

9.3

9.4

9.0

9.3

8.9

9.6

9.0

9.1

8.6

9.1

8.6

9.2

8.7

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,390

2,571

2,674

2,832

3,065

3,103

3,109

3,280

3,146

3,234

3,308

2,153

2,263

2,324

2,609

0.28

82.8

14.9

100.0

14.7

0.31

83.1

15.6

100.0

14.5

0.30

83.2

16.1

100.0

14.6

0.34

84.0

16.5

100.0

14.1

0.40

84.8

15.6

100.0

13.7

0.38

84.9

14.9

100.0

13.7

0.42

85.5

15.4

100.0

13.3

0.55

87.2

14.6

100.0

12.9

0.46

83.1

15.4

100.0

13.8

0.52

82.8

15.2

100.0

14.0

0.49

83.6

15.3

100.0

13.7

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

5.4

80.5

76.0

68.4

68.4

72

4.4

5.4

80.7

76.1

67.2

67.7

71

3.5

5.4

80.6

76.2

67.4

67.4

63

4.0

5.5

81.0

76.5

60.8

62.4

60

4.0

5.5

81.1

76.9

60.4

61.8

58

3.1

5.5

81.4

77.2

61.4

62.3

:

3.4

5.6

81.9

77.8

59.4

63.6

116

3.5

5.6

82.1

78.1

61.4

60.6

112

3.4

5.6

82.4

78.3

59.1

60.4

104

3.5

5.6

82.8

78.7

61.4

60.3

99

4.0

5.7

82.7

78.8

57.6

60.4

98

3.7

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.6

0.0

2.5

0.8

0.4

0.2

0.1

2.4

0.0

2.0

0.5

0.2

0.2

0.1

2.7

0.0

2.5

0.8

0.4

0.2

0.1

2.5

0.0

2.0

0.5

0.2

0.2

0.1

2.7

0.0

2.5

0.9

0.4

0.2

0.2

2.5

0.0

2.0

0.5

0.2

0.2

0.1

2.9

0.0

2.6

0.8

0.4

0.2

0.1

2.6

0.0

2.1

0.4

0.2

0.2

0.1

3.2

0.0

2.9

0.8

0.4

0.3

0.2

3.0

0.0

2.4

0.5

0.2

0.2

0.1

3.1

0.0

2.8

0.8

0.4

0.3

0.2

2.9

0.0

2.3

0.4

0.2

0.2

0.1

3.0

0.0

2.9

0.7

0.4

0.2

0.2

2.8

0.0

2.4

0.4

0.2

0.2

0.1

3.0

0.0

3.0

0.7

0.4

0.2

0.3

2.8

:

2.5

0.3

0.2

0.2

0.2

2.8

0.0

3.0

0.7

0.3

0.3

0.2

2.5

:

2.4

0.3

0.1

0.2

0.2

2.7

0.0

3.0

0.7

0.3

0.2

0.2

2.5

0.0

2.5

0.3

0.2

0.2

0.2

2.7

0.0

3.0

0.7

0.4

0.3

0.3

2.5

0.0

2.5

0.3

0.2

0.3

0.2

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

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Table 2.7.2:  Statistical Annex - continued – Denmark 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

30.1%

0.0%

28.7%

9.2%

4.5%

2.4%

1.4%

31.0%

0.0%

25.4%

5.8%

2.3%

2.6%

1.2%

2006

30.2%

0.0%

28.5%

9.2%

4.5%

2.2%

1.3%

31.3%

0.0%

25.6%

5.7%

2.3%

2.4%

1.3%

2007

30.2%

0.0%

27.8%

9.4%

4.4%

2.3%

1.7%

31.2%

0.0%

24.6%

5.7%

2.4%

2.5%

1.5%

2008

31.5%

0.0%

28.4%

8.9%

4.4%

2.3%

1.5%

32.0%

0.0%

25.1%

5.4%

2.3%

2.4%

1.3%

2005

2006

2007

2008

:

:

1.4

0.4

11.4

26.0

11.3

2005

331

1439

69

690

2005

4.5

16

:

:

1.6

0.4

:

25.0

11.0

2006

338

1448

69

617

2006

4.5

16

:

:

1.9

0.4

:

24.0

11.0

2007

340

1429

69

608

2007

4.5

16

:

:

2.2

0.5

:

23.0

10.7

2008

349

1490

71

559

2008

4.6

16

2009

35.3%

0.0%

32.0%

9.2%

4.7%

2.7%

1.7%

31.9%

0.0%

25.2%

4.8%

2.3%

2.6%

1.3%

2009

1.54

:

2.4

0.6

:

19.0

10.1

2009

354

1561

71

553

2009

4.6

16

EU- latest national data

2010

33.5%

0.0%

30.2%

8.8%

4.3%

2.7%

1.6%

31.9%

0.0%

24.9%

4.8%

2.2%

2.7%

1.3%

2011

29.6%

0.0%

28.8%

7.2%

3.7%

2.4%

1.5%

31.1%

0.0%

26.8%

4.1%

2.0%

2.6%

1.2%

2012

29.5%

0.0%

29.6%

6.7%

3.7%

2.3%

2.5%

2013

27.2%

0.0%

29.1%

6.9%

3.3%

2.5%

2.1%

30.8%

29.6%

:

:

27.6%

28.4%

3.5%

2.1%

2.5%

2.4%

3.6%

1.7%

2.9%

2.4%

2014

26.6%

0.0%

29.6%

6.7%

3.3%

2.3%

2.2%

28.9%

0.0%

28.4%

3.6%

1.9%

2.8%

2.6%

2015

26.3%

0.0%

29.4%

6.8%

3.4%

2.4%

2.4%

28.5%

0.0%

28.3%

3.6%

1.8%

2.9%

2.8%

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

EU- latest national data

:

:

2.8

:

13.4

20.9

10.3

2010

358

1583

71

546

2010

4.6

16

:

:

2.9

0.5

:

:

10.5

2011

363

1601

71

535

2011

4.8

15

:

:

3.3

:

:

:

9.3

2012

366

1631

72

528

2012

4.7

15

:

:

3.8

0.6

14.2

17.0

9.5

2013

365

1652

72

523

2013

4.6

15

:

:

3.8

:

14.4

17.0

9.6

2014

366

1670

71

524

2014

4.5

15

:

:

3.8

:

:

17.0

:

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2015

2009

2011

2013

2015

:

:

0

518

2015

4.4

:

:

:

5.5

:

2065

7.8

8.6

2065

6.8

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

7.9

8.7

2070

6.8

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Denmark

1.0

1.8

EU

0.9

1.6

Change 2016-2070, in %

Denmark

19.6

EU

2.0

4,134

4,445

4,620

4,666

5,158

5,546

5,896

5,969

6,043

6,194

:

3.5

21.4

2016

6.9

6.9

2016

5.7

:

:

22.4

2020

7.0

7.1

2020

5.9

:

6.6

23.0

2025

7.2

7.4

2025

6.1

:

6.9

:

2030

7.3

7.6

2030

6.3

:

6.1

24.5

2035

7.4

7.7

2035

6.5

:

5.9

25.9

2040

7.4

7.9

2040

6.6

:

5.8

27.6

2045

7.5

8.1

2045

6.6

:

5.7

28.2

2050

7.6

8.3

2050

6.7

:

5.6

28.8

2055

7.7

8.4

2055

6.7

:

5.5

29.3

2060

7.7

8.5

2060

6.8

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.8. ESTONIA 

General 
sustainability and demographic trends  

Expenditure, 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

Estonia, the most northerly of the Baltic states, is a 
member of the European Union since 2004, has a 
GDP of around €24 bn., or 23.7 thousand PPS per 
capita,  below  the  EU  average  of  30.0  thousand 
PPS  per  capita  (121).  Population  was  estimated  in 
2018 at almost 1.3 million inhabitants.  

During  the  coming  decennia  the  population  will 
steadily  decrease,  from  1.3  million  inhabitants  in 
2016  to  1.2  million  inhabitants  in  2070.  Thus, 
Estonia  is  facing  a  considerable  decrease  of  its 
population  by  11%,  while 
the  EU  average 
population is estimated to increase by 2%. 

Total and public expenditure on health as % of 
GDP 

Total expenditure(122) on health as a percentage of 
GDP (7.1% in 2015) is well below the EU average 
(123)(10.2%),  having  significantly  increased  since 
2005  (5%).  Public  expenditure  on  health  as  a 
percentage  of  GDP  (5.5%)  is  also  below  the  EU 
average  (8%  in  2015),  but  is  still  significantly 
higher than in 2005 (4.1%). Looking at health care 
without  long-term  care(124)  reveals  a  different 
picture  with  public  spending  being  closer  to  the 
EU  average  (5.2%  vs  6.8%  in  2015).The  growing 
ratios  may  underestimate  the  actual  growth  in  the 
health  sector  due  to  very  high  GDP  growth:  prior 
to  the  crisis  Estonia  registered  one  the  highest 
GDP  growth  in  the  EU  reaching  a  double-digit 
output  growth.  Indeed,  total  (1650  PPS  in  2015) 
and  public  (1265  PPS 
in  2015)  per  capita 
expenditure  have  more  than  doubled  since  2005. 
However, they are still considerably lower than the 
EU average (3305 PPS and 2609 PPS respectively 

in  2015).  Note  though  that  the  share  of  public 
expenditure  in  total  expenditure  on  health  is 
relatively  high  (76.7%,  slightly  below  the  EU 
average of 78.4% in 2015).  

Expenditure projections and fiscal sustainability  

Public  expenditure  on  health  care  is  forecast  to 
increase by 0.3 pps by 2070 according to the 2018 
Ageing  Report  reference  scenario  (125).  Under  the 
risk scenario this could go up by 1.1 pps of GDP.  

Overall,  for  Estonia  significant  no  sustainability 
risks appear over the short-term and risks over the 
medium and long run are low (126). 

Health status (127) 

is  also  explained  by  differences 

Life  expectancy  in  2015  (82.2  years  for  women 
and  73.2  years  for  men)  and  healthy  life  years 
(56.2 years for women and 53.8 years for men) are 
below  the  EU  average  and,  particularly  for  men, 
amongst  the  lowest  in  the  EU  (128).  The  large 
difference  in  male  and  female  life  expectancy  in 
in 
Estonia 
avoidable  mortality.  Specifically,  cardiovascular 
diseases  and  external  causes  account  for  29.6% 
and  21.1%,  respectively,  of  deaths  among  men 
under-65  years,  while  accounting  for  only  22.4% 
and  12.2%,  respectively,  among  women (129).  It 
should  be  noted  that  Estonia  has  had  the  highest 
gains  in  health-adjusted  life  expectancy  in  the 
life 
OECD  between  2000  and  2015.  Men's 
expectancy shows a consistent increase from 1995 
onwards  but  suffered  a  significant  decline  in  the 
early  1990s,  a  period  of  substantial  economic  and 
political  transition.  Additionally,  infant  mortality 
has fallen from 5.4 per 1000 live births in 2005 to 
2.5 in 2015, falling below the EU average (3.6). 

It  should  also  be  noted  that  Estonia  has  an 
amenable  mortality  rate  per  100,000  inhabitants 

(121) See  page  84  http://www.oecd.org/health/preventing-

(125) The 

2018 

Ageing 

Report: 

ageing-unequally-9789264279087-en.htm. 

(122) Please  note  that  these  figures  reflect  current  plus  capital 
expenditure  in  contrast  to  OECD  and  EUROSTAT  data 
series, which reflect only current expenditure. 

(123) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions  of  units  or  units  of  staff  where  relevant.  The  EU 
average  for  each  year  is  based  on  all  the  available 
information in each year. 

(124) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

74 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(126) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(127) As  well  as  the  statistical  annex,  this  section  draws  on  the 
State 
for  Estonia 
https://ec.europa.eu/health/sites/health/files/state/docs/chp_
et_english.pdf. 

of  Health  Country 

profile 

(128) Data  on  life  expectancy  and healthy  life  years  is  from  the 

Eurostat database. 

(129) Data referenced in this sentence comes from 2017. 

 
                                                           
                                                           
Health care systems 

2.8. Estonia 

are  still  uninsured  and  have  access  to  emergency 
care only. 

Administrative  organisation  and 
collection mechanism  

revenue 

The  EHIF  establishes  contracts  with  care 
providers,  including  General  Practitioners  (GPs). 
However,  access  to  primary  care  is  considered  to 
be  very  good.  Cost-sharing  also  appears 
to 
encourage greater use of primary care services vis-
à-vis  specialist  and  inpatient  care,  which  can  be 
cost-effective.  

Nevertheless,  different  measures  of  the  reform  of 
the sickness insurance regime may have important, 
if  not  reverse  effects  in  the  future.  For  instance, 
EHIF  compensations  are  only  paid  now  from  the 
9th  sickness  day.  Before  that,  the  employer  has  to 
cover  the  costs.  First  three  sickness  days  are 
compensated  voluntarily  by  the  employer.  While 
some informal payments exist in the health sector, 
they do not appear to be widespread or significant 
in magnitude. 

The  EHIF  (which  has  four  regional  branches  but 
acts  as  one  purchaser  of  care)  uses  its  budget  to 
establish  contractual  arrangements  with  providers, 
remunerate doctors, and reimburse medicines.  

associated 

that is, at 224, far above the EU average of 127 for 
2015.  Mortality 
with 
rates 
cardiovascular  diseases  nearly  double  the  EU 
average. The incidence rate of tuberculosis is high 
as  is  the  incidence  rate  of  lung  cancer.  Estonia 
however registers a relatively moderate proportion 
of people that smoke regularly: 22.1% of adults in 
the  EU  average. 
2014,  only  slightly  above 
However,  smoking  rates  are  much  are  higher 
amongst  men  than  women.  Alcohol  consumption, 
at  10.3  litres  per  capita  is  also  close  to  the  EU 
average  of  10.2,  although,  again,  binge  drinking 
among  men  is  high.  In  2014,  19.7%  of  the 
population  was  obese,  above  the  EU  average  of 
15.5%.  These  values  on  the  health  status  of  the 
population  deserve  attention  and  action  to  protect 
population health outcomes and reduce the burden 
of disease. 

System characteristics  

Overall description of the system 

is 

system 

financed  primarily 

The 
through 
mandatory contributions (earmarked payroll tax on 
employees  and 
through 
taxation  revenues  that  pay  for  ambulance  and 
emergency  care  and  health  promotion  and  disease 
prevention. 

self-employed)  and 

government 

Health  expenditure  funding  comes  from  social 
insurance  contributions  (earmarked  payroll  tax) 
out-of-pocket 
plus 
taxation, 
contributions,  private 
insurance  and  financial 
contributions  from  the rest of the  world.  An issue 
of  concern  is  that  funding  is  strongly  based  on 
employment-related  contributions  but  the  share  of 
non- contributing individuals such as children and 
pensioners  is  almost  half  of  the  insured.  The 
authorities  recognise  the  narrow  revenue  base, 
strongly based on wages (notably in the context of 
ageing)  and  there  is  the  intention  to  enlarge  the 
revenue base for the sector to ensure the long-term 
sustainability of the sector financing. 

Coverage 

revenue 

revenue.  However, 

There  is  an  overall  budget  constraint  defined 
annually  for  public  spending  on  health  which  is 
quite detailed and transparent. Expenditure cannot 
exceed 
and 
expenditure  do  not  necessarily  have  to  match  in 
each  financial  year,  as  the  EHIF  has  some 
accumulated  reserves  (around  1%  of  GDP)  and 
could in principle use those to finance expenditure. 
In  practice 
indeed 
followed  the  same  pattern  as  revenue.  Therefore, 
when for example the budget has run out, hospitals 
may  in  theory  postpone  surgical  interventions  for 
the following year or else the patient has to pay for 
the  full  cost.  However,  in  practice  such  cases  are 
extremely rare. 

though,  expenditure  has 

The  Estonia  Health  Insurance  Fund  (EHIF) 
purchases and reimburses care for about 93.6% of 
the  population  based  on  residence  and  group 
membership 
children, 
pensioners, full time carers). 6% of the population 

unemployed, 

(e.g. 

Role  of  private  insurance  and  out  of  pocket 
co-payments 

Cost-sharing applies to home and outpatient visits, 
hospital  stays  and  medicines,  though  pensioners 
and  children  below  16  have  lower  out-of-pocket 
payment. Adult dental care and plastic surgery are 

75 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

not  covered  by  the  EHIF.  The  share  of  private 
expenditure  on  health  in  total  health  expenditure 
(23.3% in 2015) is slightly above the EU average 
(21.6%).  Out-of-pocket  expenditure  constitutes 
about 22.8% of total health expenditure and stands 
above  the  EU  average  (15.9%  in  2015).  Despite 
having  one  of  the  highest  levels  of  self-reported 
unmet need for care in the EU (130), from the point 
of  view  of  access,  a  smaller  share  of  private 
expenditure  than  that  of  its  Baltic  neighbours  and 
the  way  cost-sharing  is  applied  across  services 
may  ensure  better  access  to  basic  health  care 
services  in  Estonia  than  in  Latvia  and  Lithuania. 
This  hypothesis 
life 
expectancy  and  lower  amenable  mortality  than  in 
those  countries.  Out-of-pocket  expenditure  may 
still  pose  barriers  to  access  to  low  income  groups 
and  uninsured  (authorities  do  acknowledge  that 
socioeconomic  differences  have  an  impact  in  the 
use of health services). 

is  supported  by  higher 

While some informal payments exist in the health 
sector,  they  do  not  appear  to  be  widespread  or 
significant in magnitude. 

Types of providers, referral systems and patient 
choice 

Primary  care  is  provided by  self-employed  family 
practitioners  (FPs,  equivalent  to  GPs)  and  nurses 
or  by  family  practitioner  group  practices  (owned 
by  family  practitioners).  Ambulatory  specialist 
care  is  provided  in  health  care  centres,  hospital 
outpatient  departments  and 
specialists'  own 
practices.  Inpatient  hospital  care  is  provided  in 
regional, central, general or local hospitals (state or 
municipally  owned).  Outpatient  and 
inpatient 
providers establish contracts with the EHIF. 

to 

Access  to  primary  care  is  considered  to  be  very 
good  due 
the  high  numbers  of  general 
practitioners (GPs), the ability to see the GP within 
3  days,  and  a  24-hour 
free  primary  care 
counselling  phone  line.  Cost-sharing  also  appears 
to  encourage  greater  use  of  primary  care  services 
vis-à-vis specialist and inpatient care, which can be 
cost-effective. 

(130) State  of  Health  Country 

(2017):  Estonia 
https://ec.europa.eu/health/sites/health/files/state/docs/chp_
et_english.pdf. 

  Profile 

76 

Authorities acknowledge long delays for specialist 
consultations  and 
inpatient  care.  They  have 
therefore  established  centrally  managed  waiting 
lists  and  additional  resources  to  services  with  the 
longest lists. 

The total number of practising physicians per 100, 
000  inhabitants  has  been  fairly  stable  during  the 
last  decade  (342  in  2015),  slightly  under  the  EU 
average  (344).  Data  on  the  physician  skill/mix 
indicates  that  the  number  of  general  practitioners 
(GPs)  per  100  000  inhabitants  (71  in  2015)  has 
also  remained  relatively  flat  since  2005  and  is 
slightly below the EU average (78.3) as part of the 
authorities'  long  term  effort  to  improve  primary 
care  provision.  This  has  resulted  in  a  relatively 
good  access  to  primary  care  to  the  insured 
population.  The  number  of  nurses  (601  in  2015) 
per  100  000  inhabitants  is  significantly  below  the 
EU average (833). Estonia may have suffered from 
staff  migration  to  other  EU  countries  where 
qualified  health  staff  was  needed  and  wage  levels 
were higher. There is also a problem of ageing of 
the  workforce,  in  2017  –  73.1%  of  all  physicians 
had  more  than  40  years  of  age  (including  age 
groups:  40-49;  50-59;  60+)    To  retain  staff  the 
authorities had increased wages in the sector prior 
to  the  crisis  but  this  trend  was  reversed  with  the 
fiscal  balances. 
economic  crisis 
However, there have been constant wage increases 
since  2011  for  doctors  (44%)  and  nurses  (42%) 
between  2011  and  2017,  similar  to  that  of  the 
overall  wage  increase  in  the  country  (46%). 
However,  if  there  is  no  political  will  to  increase 
total  public  spending  on  health  care,  salary 
increases  will  need  to  be  covered  by  efficiency 
gains  of  hospitals  and  other  health  care 
organisations, as well as a limited increase in OOP 
payments. 

improve 

to 

Note  that  the  authorities  have  made  strong  efforts 
to concentrate medical training, emphasise primary 
care  training  of  doctors  and  nurses  and  bring 
to  start 
training 
law,  and 
line  with  EU 
developing  human  resources  planning 
the 
in 
sector. 

in 

Since  the  early  1990s,  national  authorities  have 
made a significant and successful effort to enhance 
primary  care  provision  and  to  strengthen  the 
referral  system  from  primary  care  to  specialist 
doctors and the gatekeeping role of FPs (to reduce 
the  unnecessary  use  of  specialist  and  hospital 

 
                                                           
care).  All  inhabitants  have  to  register  with  a  FP, 
who  acts  as  family  doctor  and  as  a  gatekeeper 
referring  patients  to  other  specialists  and  hospital 
care.  Patients  can  choose  their  FP  and  choose  the 
specialist after referral.  

Estonia has seen a large reduction in the number of 
acute care beds per 100 000 inhabitants in the last 
decades,  and  its  number  is  now  below  the  EU 
average  (368  vs.  402  in  2015).  Bed  occupancy 
rates  have  stayed  relatively  constant  and,  at  67%, 
are  slightly  below  the  EU  average  at  78.3%  in 
2015.  

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Payments  systems  have  evolved  much  over  the 
years  and  consist  of  a  mix  of  remuneration  types. 
GPs receive a mix of capitation, base fee, distance 
fee  for  remote  practices,  fees  for  defined  services 
and bonus payments for health promotion, disease 
prevention  and  disease  management  activities. 
This  mixed system  intends  to render primary care 
more  attractive  and  to  provide  incentives  for 
primary  care  provision  including  some  health 
promotion,  disease  prevention  activities  and 
disease management. All other staff is remunerated 
on a salary basis. 

Hospital average length of stay (7.6 days in 2015) 
is  at  the  EU  average  (7.6  days),  having  remained 
relatively  flat  from  2010.  The  proportion  of 
hospital  surgery  performed  as  day  cases  was 
31.7% in 2011, a significant increase from 4.3% in 
2001, close to the EU average of 32.3%. Hospitals 
remuneration  is  a  mix  of  activity-based  payment 
using  DRGs  (diagnosis  related  groups),  fee-for-
services  and  bed-days.  Further 
reliance  on 
prospective  payment  on  the  basis  of  DRGs  was 
planned.  Although  significantly  improved  and 
for 
based  on  complex  criteria, 
establishing  contracts  between  the  EHIF  and  the 
various  providers  could  perhaps  be 
further 
improved  in  the  long  run  to  favour  cost-effective 
interventions  when  health  technology  assessment 
is applied more regularly. 

the  basis 

Health care systems 

2.8. Estonia 

The market for pharmaceutical products 

Total  (1.2%)  and  public  (0.6%)  expenditure  on 
pharmaceuticals(131)  as  a  percentage  of  GDP  are 
below the EU average (1.4% and 1% respectively 
in  2015)  and  have  been  relatively  constant  since 
2003  (even  since  1999,  earliest  available  data). 
Public  expenditure  on  pharmaceuticals  as  a  share 
of public current health expenditure is close to the 
EU  average  (12.4%  compared 
in 
2015).This 
regarding 
suggests 
pharmaceuticals  have  been  fairly  successful  at 
controlling pharmaceutical expenditure. 

that  policies 

to  12.7% 

Imported  medicines  now  come  from  Western 
Europe rather than the former Soviet Union, which 
resulted  in  a  large  increase  in  prices.  In  order  to 
control  overall  expenditure  the  authorities  have 
implemented a large number of policies. The initial 
price  decision  is  based  on  a)  international  prices, 
as  well  as  b)  economic  evaluation  and  c)  the  cost 
of  existing  treatments.  In  addition,  authorities 
implement  1)  price-volume  agreements,  together 
with  2)  reference  pricing,  whereby  the  maximum 
reimbursement level of a prescribed drug is based 
on  the  second  lowest  price  of  existing  drugs  that 
have  the  same  active  ingredient  and  form,  and  3) 
the definition of positive lists (as much as possible 
based  on  economic  evaluation).  The  authorities 
implement  prescriptions  guidelines  and 
also 
monitor  prescription  patterns  of  physicians  who 
get feedback once a year. These policies have been 
very 
pharmaceutical 
expenditure  growth.  Perhaps  the  authorities  could 
explore  if  these  policies,  which  currently  apply 
only  to  reimbursable  pharmaceuticals,  could  be 
extended to non-reimbursable medicines especially 
in the context of high out-of-pocket payments. 

controlling 

useful 

in 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

Estonia  has  a  Health  Technology  Assessment 
Centre that conducts health technology assessment. 
It was at first funded mainly from Structural Funds 
(01.02.2012-30.08.2015),  and it will in the future 
be getting its budget from the state. The authorities 
and  professional  associations  are  developing 

(131) Expenditure  on  pharmaceuticals  used  here  corresponds  to 
category HC.5.1 in the OECD System of Health Accounts. 
Note 
records 
pharmaceuticals  in  ambulatory  care  (pharmacies),  not  in 
hospitals. 

this  SHA-based  estimate  only 

that 

77 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

treatment  guidelines  to  harmonise  and  rationalise 
medical practices. 

Data  management  and 
prescription, e-medical records) 

E-health 

(e-

Digital  prescription  was  launched  in  2010  and  by 
prescriptions  were  written 
2012  most 
electronically.  Individuals  can  access  their  own 
medical data by using their electronic ID cards via 
the patient’s portal.  

Data  has  substantially  improved  in  recent  years. 
Information on activity and services is collected by 
the  EHIF  and  the  Ministry  of  Social  Affairs  on  a 
routine  yearly  basis.  Providers  are  obliged  to 
provide  annual  data  reports  according  to  national 
standards. This information is used for contracting 
purposes  and  allocation  of  funds.  The  Hospital 
Network  Development  Plan  is  used  to  make 
projections  of  hospital  activity  and  future  hospital 
capacity  needs  and  thus  hospital  licensing  and 
helped 
hospital 
adjusting/reducing  hospital  capacity  over 
the 
years). There are other plans for other services. 

regulation 

service 

(and 

Health  promotion  and  disease  prevention 
policies 

inequalities 

for  2009-2020  with 

reducing  socio-economic 

The  government  has  approved  the  Public  Health 
Development  Plan 
the 
objective  of  continuously  improving  the  health 
status  of  the  population:  increasing  average  life 
expectancy  at  birth,  increasing  healthy  life  years 
and 
in 
health.  This  plan  denotes  a  recent  much  stronger 
concern  with  health  promotion  and  disease 
prevention.  Total  and  public  expenditure  on 
prevention and public health as a % of GDP (0.2% 
and  0.1%  in  2015)  are  below  the  EU  average 
(respectively 0.3% and 0.3%). The same is true for 
public  expenditure  on  prevention  as  a  proportion 
of public current health expenditure (2.4% vs a EU 
average  of  3.2%)  However, 
(3.2%) 
expenditure on prevention and public health as a % 
of the total public expenditure on health is in fact 
slightly higher than the EU average in 2015.  

total 

Transparency and corruption 

The  Estonian  health  system  is  perceived  to  be 
transparent  and  featuring  little  corruption.  The 
latest  health  sector  corruption  survey  (University 

78 

of 

2% 

is  marginal; 

of Tartu, 2011) concluded that the role of informal 
payments 
patients 
acknowledged  having  paid  informally  to  obtain 
faster  access  to  care  and  about  3%  to  have  paid 
after  getting 
informal 
payments  do  not  appear  to  be  widespread  or 
significant  in  magnitude.  This  may  be  because  of 
the introduction of formal co-payments in 2002 or 
because of the generally low level of corruption ad 
informal payment practices. 

treatment.  Overall, 

the 

Recently 
reforms  

legislated  and/or  planned  policy 

In  order  to  improve  access  to  health  care,  the 
Estonian  government  has  legislated  additional 
funds to the EHIF starting from 2018. Along with 
these  funds,  EHIF  will  take  on  some  extra 
expenditures  which  were so  far financed  from the 
state  budget 
(ambulance  service,  HIV/AIDS 
treatment, dental care and others). However, these 
costs  amount  to  about  half  of  these  extra  funds. 
The remaining funds are allocated to reduce unmet 
need – to reduce delays. These extra funds amount 
to 15% increase of the EHIF budget in 2022. The 
base  for  calculating  the  extra  funds  are  the 
pensions  for  non-working  pensioners.  The  rate  is 
13%  (132),  which  is  the  same  as  the  healthcare 
proportion  of  the  social  tax  paid  by  the  working 
population.  

Challenges 

The  analysis  above  shows  that  a  wide  range  of 
reforms  have  been  implemented  over  the  years, 
many quite successfully (e.g. the development of a 
strong primary care system that patients can easily 
access and which can contribute to control cost and 
ensure  the  cost-effectiveness  of  the  systems;  the 
development  of  data  collection  and  monitoring  of 
inputs,  processes,  outputs  and  outcomes  use  for 
decision-making),  and  which  Estonia  should 
continue  to  pursue.  The  main  challenges  for  the 
Estonian health care system are as follows: 

•  To 

the 
improve,  as  acknowledged  by 
authorities,  the  basis  for  more  sustainable  and 
enhanced financing of health care in the future 
(e.g.  considering  additional  sources  of  general 
budget  funds),  with  a  better  balance  between 

(132) There is a phasing-in period from 2018-2021 when the rate 

is lower. 

 
                                                           
Health care systems 

2.8. Estonia 

care  services  (currently  the  only  services  to 
which uninsured individuals have access). 

•  To  continue  the  efforts  to  gather  and  make 
more  use  of  cost-effectiveness  information  in 
determining the basket of goods and the extent 
of cost-sharing. 

•  To continue to work on public health priorities 
defined in the 2009-2020 Plan and continue to 
enhance  health  promotion 
and  disease 
prevention activities, i.e. promoting healthy life 
styles  and  disease  screening  given  the  recent 
pattern  of  risk  factors  (diet,  smoking,  alcohol, 
obesity).
lack 

exercise, 

of 

resources and demand, between the number of 
contributors  and  the  number  of  beneficiaries 
and  which  can  improve  access  and  quality  of 
care  and  its  distribution  between  population 
groups  and  regional  areas.  If  more  resources 
are  brought  into  the  sector  it  is  important  that 
they  do  not  remain  fragmented  but  are  pooled 
the  strong  pooling 
together,  maintaining 
mechanisms in place today. 

•  To  define  a  comprehensive  human  resources 
strategy  to  ensure  a  balanced  skill-mix,  avoid 
staff  shortages  and  motivate  and  retain  staff 
within  the  sector  in  view  of  ageing  and 
migration. 

• 

Increasing insurance coverage to the uninsured 
population, while improving access, could also 
decrease  the  unnecessary  use  of  emergency 

79 

 
 
8
0

Table 2.8.1:  Statistical Annex – Estonia 

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2005

11

18.7

10.0

:

2006

14

19.5

10.9

19.4

2007

16

19.8

8.4

13.5

2008

17

18.3

-5.1

-5.0

2009

14

15.8

-14.6

6.8

2010

15

16.5

2.4

-2.7

2011

17

17.6

7.9

-0.6

2012

18

18.1

4.7

7.7

2013

19

17.9

2.3

4.7

2014

20

18.4

3.2

6.0

2015

20

18.8

1.9

9.2

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

5.6

5.1

0.5

5.6

5.0

0.7

7.0

6.5

0.5

6.7

6.3

0.4

6.2

5.8

0.3

6.3

5.8

0.5

6.5

6.0

0.5

6.7

6.2

0.5

7.1

6.5

0.6

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

1,016

1,037

1,113

1,103

1,153

1,281

1,390

1,495

1,650

2,745

2,895

2,975

3,305

4.4

3.9

795

0.53

78.2

14.9

95.9

22.2

5.2

4.6

962

0.67

92.8

11.7

95.6

20.5

5.6

5.1

885

0.50

79.5

11.4

95.6

20.3

5.2

4.8

857

0.36

77.7

13.2

95.6

21.9

4.8

4.5

901

0.34

78.1

14.1

92.9

21.6

0.51

78.5

13.2

93.7

21.5

0.45

77.2

13.7

93.6

22.6

0.45

77.3

13.1

93.9

22.6

0.54

76.7

13.3

94.0

22.8

5.0

4.5

5.0

4.6

5.2

4.7

5.5

4.9

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

1,006

1,073

1,157

1,265

2,153

2,263

2,324

2,609

5.0

4.7

0.3

618

4.1

3.8

503

0.25

81.5

14.5

94.3

20.5

5.4

4.9

0.5

803

4.1

3.6

615

0.48

76.6

15.0

95.0

25.4

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

1.4

78.2

67.6

52.4

48.3

136

5.4

1.4

78.6

67.6

53.9

49.6

128

4.4

1.3

78.9

67.5

54.9

49.8

105

5.0

1.3

79.5

68.9

57.5

53.1

90

5.0

1.3

80.3

70.0

59.2

55.0

79

3.6

1.3

80.8

70.9

58.2

54.2

74

3.3

1.3

81.3

71.4

57.9

54.3

255

2.5

1.3

81.5

71.4

57.2

53.1

252

3.6

1.3

81.7

72.8

57.1

53.9

240

2.1

1.3

81.9

72.4

57.1

53.2

235

2.7

1.3

82.2

73.2

56.2

53.8

224

2.5

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

1.7

0.1

1.0

1.2

0.1

0.1

0.2

1.5

0.1

0.8

0.5

0.1

0.1

0.2

1.5

0.1

1.1

1.2

0.2

0.1

0.1

1.4

0.1

0.8

0.5

0.1

0.1

0.1

1.5

0.1

1.2

1.1

0.2

0.1

0.1

1.4

0.1

1.0

0.5

0.1

0.1

0.1

1.8

0.1

1.3

1.3

0.2

0.2

0.1

1.7

0.1

1.1

0.5

0.1

0.2

0.1

1.8

0.1

1.8

1.3

0.2

0.2

0.1

1.8

0.1

1.4

0.7

0.1

0.1

0.1

1.7

0.1

1.8

1.3

0.2

0.2

0.1

1.7

0.1

1.2

0.7

0.1

0.1

0.1

1.5

0.1

1.7

1.2

0.2

0.2

0.1

1.5

0.1

1.2

0.6

0.1

0.1

0.1

1.5

0.1

1.7

1.2

0.2

0.2

0.1

1.5

0.1

1.2

0.6

0.1

0.1

0.1

1.5

0.1

1.8

1.2

0.2

0.2

0.1

1.5

0.1

1.2

0.6

0.1

0.1

0.1

1.5

0.2

1.9

1.2

0.2

0.2

0.1

1.5

0.2

1.3

0.6

0.1

0.1

0.1

1.6

0.2

2.0

1.2

0.2

0.2

0.1

1.6

0.2

1.3

0.6

0.1

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

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Table 2.8.2:  Statistical Annex - continued – Estonia 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

35.1%

1.9%

21.8%

25.4%

3.0%

2.5%

3.2%

39.5%

2.4%

21.5%

13.9%

1.8%

2.4%

4.5%

2005

0.22

0.4

0.7

0.0

:

:

13.1

2005

317

633

69

690

2005

6.3

18

2006

30.9%

1.8%

22.9%

24.2%

3.7%

2.7%

2.9%

38.6%

2.4%

22.6%

13.2%

1.7%

2.8%

3.6%

2006

0.37

0.4

0.7

0.1

15.9

27.8

13.4

2006

319

632

69

617

2006

6.4

18

2007

30.2%

2.0%

23.6%

21.8%

3.3%

2.7%

2.6%

36.2%

2.6%

24.5%

12.1%

1.6%

2.8%

3.4%

2007

0.52

0.4

1.1

0.2

:

:

14.7

2007

326

640

70

608

2007

6.6

18

2008

35.7%

2.5%

27.0%

25.2%

3.8%

3.2%

2.6%

36.5%

2.5%

24.6%

11.9%

1.8%

3.3%

2.9%

2008

0.82

0.6

1.5

0.2

18.0

26.2

14.2

2008

333

640

72

559

2008

6.6

18

2009

27.2%

2.0%

28.1%

20.0%

2.8%

3.2%

2.1%

34.5%

2.5%

26.5%

13.1%

1.6%

2.2%

2.7%

2009

0.75

0.6

1.5

0.2

:

:

11.9

2009

327

613

71

553

2009

6.3

17

2010

26.5%

1.9%

28.0%

20.5%

2.8%

3.5%

2.2%

34.1%

2.3%

25.4%

13.6%

1.9%

2.7%

2.9%

2010

0.82

0.6

1.6

0.2

16.9

26.2

11.4

2010

322

608

73

546

2010

6.1

17

2011

26.1%

1.9%

28.4%

19.9%

3.1%

3.3%

2.4%

33.6%

2.5%

25.7%

13.2%

1.8%

2.5%

3.1%

2011

0.97

0.6

1.6

0.2

..

:

11.6

2011

326

618

74

535

2011

6.4

17

2012

25.9%

1.9%

28.5%

20.1%

2.9%

3.6%

2.1%

33.1%

2.5%

26.2%

13.4%

1.8%

2.7%

2.7%

2012

0.98

0.7

1.7

0.2

19.0

26.0

12.1

2012

328

617

74

528

2012

6.3

17

2013

24.9%

2.0%

30.2%

19.3%

3.3%

3.0%

2.0%

32.2%

2.6%

27.0%

13.2%

2.2%

2.0%

2.4%

2013

1.14

0.7

1.9

0.2

:

:

11.9

2013

328

557

70

523

2013

6.4

17

2014

24.8%

2.7%

30.1%

18.7%

2.6%

3.1%

2.1%

32.1%

3.4%

27.0%

13.0%

1.3%

2.3%

2.6%

2014

1.14

0.5

2.0

0.2

19.7

22.1

11.1

2014

332

565

72

524

2014

6.3

17

3,886

4,814

5,916

6,061

5,921

6,080

6,852

8,044

7,021

7,862

69.0

6.0

12.2

2016

5.3

5.3

2016

1.3

71.0

5.9

14.2

2020

5.2

5.3

2020

1.3

71.9

7.9

16.2

2025

5.1

5.4

2025

1.3

70.1

7.8

16.8

2030

5.2

5.6

2030

1.3

68.2

7.7

25.3

2035

5.3

5.8

2035

1.3

70.8

7.6

25.8

2040

5.4

6.0

2040

1.3

71.0

7.7

28.2

2045

5.5

6.2

2045

1.3

69.1

7.9

31.8

2050

5.6

6.3

2050

1.3

69.4

7.5

29.0

2055

5.6

6.4

2055

1.2

69.1

7.6

31.7

2060

5.6

6.4

2060

1.2

2015

24.1%

2.9%

30.4%

18.3%

2.6%

3.2%

1.8%

31.4%

3.7%

27.2%

12.4%

1.2%

2.4%

2.4%

2015

1.22

0.5

1.7

0.2

:

:

10.3

2015

342

601

71

518

2015

6.4

:

:

67.0

7.6

:

2065

5.6

6.5

2065

1.2

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

5.6

6.4

2070

1.2

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Estonia

0.3

1.1

EU

0.9

1.6

Change 2016-2070, in %

Estonia

-10.3

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.9. FINLAND 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

Finland,  member  of  the  European  Union  since 
1995,  has  a  population  of  around  5.5  million 
inhabitants, which is slightly above 1% of the EU 
population in 2016 (133). It is expected to reach 5.6 
million  in  2070,  a  demographic  expansion  of  2%. 
With a GDP of around €210 billion, or 28,300 PPS 
per capita it is slightly below the EU average GDP 
per capita for the most recent year of 2015.  

increase  by  0.8  pps  of  GDP  by  2070,  slightly 
below  the  average  growth  expected  for  the  EU 
(0.9)  (137),  according  to  the  Reference  Scenario. 
When  taking  into  account  the  impact  of  non-
demographic  drivers  on  future  spending  growth 
(AWG  risk  scenario),  health  care  expenditure  is 
expected to increase by 1.4 pps of GDP from now 
until 2070 (EU value: 1.6). 

Finland does not appear to face fiscal sustainability 
risks  in  the  short  run.  There  are  low  fiscal 
sustainability  risks  in  the  medium  term,  but 
medium risks in the long term, primarily related to 
the projected ageing costs (138). 

Total and public expenditure on health as % of 
GDP 

Total expenditure (134) on health as a percentage of 
GDP  (9.9%  in  2015)  has  increased  over  the  last 
decade  (from  8.3%  in  2005),  below  the  EU 
average  (135)  of  9.9%.  Public  expenditure  has 
increased as well 6.3% in 2005 to 7.4% of GDP in 
2015.  It  is  also  below  the  EU  average  of  8%  in 
2015.  Looking  at  health  care  without  long-term 
care  (136)  reveals  a  similar  picture  with  public 
spending  being  below  the  EU  average  (6.1%  vs 
6.8%  in  2015).  According  to  the  authorities,  the 
main  factors  explaining  the  growth  of  health 
expenditure  are  the  increased  costs  of  specialised 
care and pharmaceuticals. 

When expressed in per capita terms, total spending 
on health at 3,216 PPS in Finland is slightly below 
the  EU  average  of  3,305  in  2015,  as  is  public 
spending on health care: 2,400 PPS vs. an average 
of 2,609 PPS in 2015.  

Expenditure projections and fiscal sustainability  

As  a  consequence  of  demographic  and  other 
changes,  health  care  expenditure  is  projected  to 

(133) According to Eurostat population projections.  
(134) Please note that these figures reflect current (from System 
of  Health  Accounts)  plus  capital  expenditure  (from  the 
COFOG  database)  in  contrast  to  OECD  and  EUROSTAT 
data series, which reflect only current expenditure. 

(135) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(136) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

Health status 

Life expectancy at birth (84.4 years for women and 
78.7  years  for  men  in  2015)  is  close  to  the 
respective EU averages (83.3 and 77.9 years of life 
expectancy  in  2015)  (139).  However,  healthy  life 
years, at 56.3 years for women and 59.4 years for 
men, were below the EU averages of 633 and 62.6 
in 2015. The infant mortality rate of 1.7‰ is lower 
than  the  EU  average  of  3.6‰  in  2015,  having 
gradually fallen over most of the last decade (from 
3‰ in 2005). 

As  for  the  lifestyle  of  the  Finnish  population,  the 
data indicates a fall in the proportion of the regular 
smokers (from 21.8% in 2005 to 17.4% on 2015), 
below  the  EU  average  of  20.9  in  2015).  Over  the 
same  period  the  proportion  of  the  obese  in  the 
population  has  increased  (from  14.1%  in  2005  to 
18.8% 
in  2015).  Alcohol  consumption  has 
decreased  since  2009,  when  it  was  10  litres  per 
capita,  to  8.8  in  2015  below  the  EU  average  of 
10.2.  

System characteristics  

Coverage 

Finnish  municipalities  and 
their  co-operation 
networks are required to provide social and health 

(137) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(138) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(139) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

82 

 
                                                           
                                                           
Health care systems 

2.9. Finland 

care  services,  including  essential  public  health 
services and actions, to their resident citizens.  

The provision of health care by the  municipalities 
is  complemented  by  the  Finnish  statutory  health 
insurance, which covers the entire population, and 
includes  both  medical  care  insurance  and  earned 
income insurance.  

tests  and 

KELA, the Social Insurance Institution of Finland 
is  in  charge  of  health  insurance.  This  insurance 
reimburses  patients  for 
treatments 
prescribed  by  private  doctors  and  dentists  as  well 
as  for  any  charges  paid  according  to  statutory 
reimbursement  rates.  Costs  in  excess  of  the 
statutory  reimbursement  rate  are  paid  by  patients. 
The  insurance  is  financed  44.9/55.1  from  taxation 
and  contributions.  Contributions  to  this  insurance 
are  deducted  from  the  taxable  income,  benefits 
and/or pension of the insured.  

Earned  income  insurance  covers  other  benefits 
such  as  allowances  for  sickness,  rehabilitation, 
children’s special care, and maternity/paternity. 

Administrative  organisation  and 
collection mechanism  

revenue 

From a financial point of view, the Finnish health 
care system has three main parts: municipal health 
care  services  (primary  and  specialised  health 
services), private  health services and occupational 
health services. 

integrated  but  decentralised 

An 
system  of 
municipal health care services, funded on the basis 
of  taxes  (central  and  local  taxes  and  for  a  small 
part client fees), provides full population coverage. 
On  the  basis  of  legal  provisions  (harmonised 
legislation  and  guidelines),  the  311  municipalities 
(in 2018, compared to 415 in 2008) are responsible 
for  providing  or  funding  a  wide  range  of  health 
services  (including  health  promotion,  disease 
prevention  and  rehabilitation)  for  their  residents 
(still 
the  majority  of 
in 
is  provided  by 
municipalities).  Primary  care 
individual  municipalities  or  by  groups  of 
municipalities  whereas  the  specialised  health  care 
is organised through federations of municipalities. 
is  coupled  with  a  compulsory  national 
This 
medical  insurance  (run  by  KELA,  the  Social 

than  10  000 

less 

Insurance  Institution)  covering  all  residents  (140), 
financed  through  the  state  (45%)  and  the  insured 
(55%). This covers part of patients' expenditure on 
outpatient drugs, transportation costs but also part 
of private health care (mainly outpatient visits and 
ambulatory  care).  Use  of  private  health  services 
represented  5.5%  of  total  health  expenditure  in 
employers  provide/buy 
2015. 
occupational  health  care  services  predominantly 
preventive  and  first  aid  care,  but  also  basic 
outpatient care for common illnesses especially in 
the  case  of 
larger  companies.  The  role  of 
compulsory occupational health care is significant, 
as 
total 
population.  Supplementary  private  health  care 
insurance is available but has only a minor role.  

it  covers  around  one 

third  of 

addition, 

the 

In 

Role  of  private  insurance  and  out  of  pocket 
co-payments  

Preventive and promotive services are mostly free 
of charge and used widely. However, users pay an 
out-of-pocket  fee  for  the  use  of  ambulatory  and 
hospital  services,  including  laboratory  tests  and 
scans.  The  maximum  fees  are  set  by  central 
government  every  other  year.  Users  are  further 
protected  by  an  annual  ceiling,  above  which  they 
are  able  to  use  of  all  municipal  health  services 
without further fees. 

services 

Most  municipal 
(primary, 
health 
outpatient  specialist  care,  hospital  day  case  and 
inpatient  care,  dental  care,  physiotherapy)  involve 
a  fee  at  the  point  of  use.  Children  and  those  who 
have  reached  an  upper  limit  for  out-of-pocket 
payments  are  exempted  from  cost-sharing.  Use  of 
child clinics, including vaccinations, and maternity 
services is free of charge. The occupational health 
care  is  free  of  charge  to  the  employee.  Under  the 
national  medical  health  insurance  the  cost-sharing 
applies to pharmaceuticals and many private health 
the  previous  paragraph). 
care  services 
Eyeglasses and contact lenses are, for example, not 
funded or provided by local or state authorities.  

(see 

for  pharmaceutical  outpatient 
Reimbursement 
prescriptions  is  calculated  as  a  percentage  of  the 
medicine's  reference  price.  Patients  enjoy  a  fixed 
deduction due to any travel expenses as well as the 

(140) This is a part of the national health insurance scheme that 
covers  both  the  medical  insurance  and  the  sickness  and 
parenthood allowances scheme. 

83 

 
                                                           
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

cost  of  prescribed  medicines.  Again,  an  annual 
ceiling is set on the maximum amount that patients 
pay for prescriptions and travel expenses. 

insurance  (to  cover 

11.4%  of  the  population  buys  supplementary 
private 
the  services  not 
covered  by  public  provision/  funding)  and  11.5% 
buys  complementary  health  insurance  to  cover 
cost-sharing.  If  cost-sharing  is  fully  covered  by 
private  insurance  it  may  lose  the  ability  to  reduce 
overconsumption  and/or  encourage  some  services 
more 
than  others,  although  complementary 
insurance is taken by a relatively small share of the 
population.  

hospital districts are further grouped into 5 tertiary 
care  regions  around  universities  with  medical 
schools.  Private  provision,  often  through  group 
practices, mostly concerns outpatient specialist and 
simple  ambulatory  services,  and  typically  takes 
place  in  urban  areas.  Private  physicians  can, 
however,  refer  patients  to  public  hospitals.  Of 
physicians, 70% work in the public and 30% in the 
private  sectors.  Of  all  physicians  working  in  the 
public sector, 24%  work also on a part time basis 
in  the  private  sector  outside  office  hours.  The 
proportion  of  GPs  who  work  in  the  public  health 
centres  and  have  a  private  practice  outside  office 
hours is 12%. 

In  2015,  private  expenditure  and  out-of-pocket 
expenditure  were  25%  and  19.9%  of  total  health 
expenditure  and  therefore  above  the  EU  average 
(21.6% and 15.9%).  

To  improve  access  and  reduce  the  waiting  times 
for primary care, legislation was introduced which 
establishes the right to immediate access to health 
centres  by  phone  or  a  visit  during  working  hours 
and  evaluation  of  the  person´s  health  care  needs 
within  3  working  days.  To  reduce  waiting  times 
for hospital surgery, which was seen as a problem 
in  Finland,  legislation  provides  that  a  non-urgent 
referral  must  be  assessed  within  3  weeks  and 
hospital  treatment  provided  within  6  months. 
When this is not possible, patients can be treated in 
another  hospital  district  or  in  the  private  sector  at 
the authorities' expenses.  In many areas there are 
phone  services  and  web  pages  in  place  to  help 
patients  access  the  system.  Waiting  times  have 
seen  a  reduction  since  these  systems  have  been 
implemented.  Some  hospital  districts  provide 
online  data  on  waiting  times.  In  addition,  the 
National Institute for Health and Welfare publishes 
general statistics on waiting times. 

Types of providers, referral systems and patient 
choice 

Primary  care  is  provided  by  general  practitioners 
(GPs)  in  municipal  public  health  centres  while 
outpatient  specialist  care  is  provided  in  outpatient 
hospital  departments.  In  larger  cities  the  public 
health  centres  also  provide  outpatient  specialist 
form 
services.  Federations  of  municipalities 
hospital districts (20 districts in total excluding the 
Åland  Island)  and  own  public  hospitals.  About 
89%  of  all  hospital  beds  are  public.  The  20 

The  number  of  licensed  physicians  per  100  000 
inhabitants in Finland is, at 321 in 2014, below but 
close to the EU average of 343 in that year. It has 
increased continuously since 2001. The number of 
general practitioners (GPs) per 100 000 inhabitants 
was  125  in  2015,  above  the  EU  average  of  78.3. 
The  number  of  nurses  per  100  000  inhabitants 
(1466  in  2014)  was  far  above  the  EU  average  of 
829. 

Authorities acknowledge shortages of staff in some 
specialties  and  in  some  geographic  areas.  A 
shortage  of  GPs  in  certain  municipalities  may 
explain  longer  waiting  times  to  see  a  GP.  Staff 
supply is regulated in terms of quotas for  medical 
students  but  not  in  terms  of  the  location  of 
physicians.  The  GP  shortage  has  been  addressed 
by redistribution of professional responsibilities in 
primary care between physicians and public health 
nurses. The effectiveness of this measure is unclear 
at this stage.  

Authorities have made some efforts to use primary 
care  vis-à-vis  specialist  and  hospital  care.  While 
residents  are  free  to  contact  a  GP,  there  is  in 
municipal health care a compulsory referral system 
from primary care to specialist doctors i.e. GPs act 
like  gatekeepers  to  specialist  and  hospital  care. 
However,  in  some  areas,  shortages  in  GPs  may 
have  led  to  perceived  long  waiting  times  for  GP 
visits  and  therefore  led  to  unnecessary  visits  to 
specialists or emergency departments.  

Choice  of  GP,  specialist  and  hospital  is  allowed 
but limited.  Increasing patient choice is, in fact, a 
priority of national authorities.  

84 

 
The  number  of  acute  care  beds  per  100  000 
inhabitants (305 in 2015) is below the EU average 
of  402  for  that  year.  It  has  consistently  decreased 
in recent times (372 in 2005) and stands as one of 
the  lowest  in  the  EU.  There  appears  to  be  no 
regulation 
in  hospital 
capacity  or  equipment  capacity.  Hospitals  have 
autonomy to recruit medical staff and other health 
professionals. Private hospitals are free to establish 
and  expand  their  capacity  in  compliance  with 
quality and safety requirements. 

terms  of 

increases 

in 

Treatment options, covered health services 

The Ministry of Social  Affairs and Health defines 
general policy guidelines and regulation, but there 
is not a defined basic benefit package. The Council 
for  Choices  in  Health  Care  at  the  Ministry  of 
Social 
provides 
and 
recommendations  on  which  treatments  and  other 
health  technologies  methods  are  included  in  the 
range  of  health  services  provided  by  public 
funding in Finland.  

Affairs 

Health 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Public  sector  physicians  (GPs  and  specialists)  are 
paid  a  salary.  The  pay  scale  for  medical  staff  and 
other  health  professionals  is  set  at  national  level. 
The labour unions negotiate  with the Commission 
for  Local  Authority  Employers  over  salaries.  The 
Government does not have a role in this procedure. 
Physicians  are  not  eligible  to  receive  bonuses 
regarding their activity or performance, although a 
small  share  of  the  salary  of  dentists  and  primary 
care physicians is paid following a fee-for-service 
principle.  Of  physicians  70%  work  in  the  public 
and  30%  in  the  private  sectors.  Physicians  who 
work in the public sector  may also practice in the 
private sector based on the approval of the (public) 
employer. Of all physicians  working in the public 
sector, 24% work also on a part time basis outside 
their  office  hours  in  the  private  sector.  The 
proportion  of  GPs  who  work  in  the  public  health 
centres  and  have  a  private  practice  outside  office 
hours is 12%. This is considered to be a measure to 
increase access.  

The municipalities remunerate the hospital districts 
for  their  services.  In  most  hospital  districts  some 
type  of  payment  per  case  basis  using  DRGs  is  in 

Health care systems 

2.9. Finland 

use. Hospital remuneration methods are negotiated 
at local level.  

looking  at  hospital  activity, 

inpatient 
When 
discharges  (16.9  per  100  inhabitants  in  2015)  are 
above the EU average (16.2) while the number of 
day case discharges, at 5,174 in 2015, is below the 
EU  average  of  7,635.  The  proportion  of  surgical 
day  case  discharges  amongst  all  procedures 
conducted was 23.2% in 2015, being below the EU 
average (32.3%). Acute average length of stay (9.4 
days in 2015) is above the EU average (7.6 days in 
2015). 

The market for pharmaceutical products 

to 

policies 

expenditure 

The  authorities  have  implemented  a  large  number 
of 
on 
control 
pharmaceuticals. As a new  method for controlling 
uncertainty linked to total costs, cost-effectiveness 
and  therapeutic  value  of  new  medicines,  Finland 
has 
into  use  a  so  called  conditional 
reimbursement for medicines, a Finnish model for 
risk  sharing  agreement.  The  provisions  on 
reimbursement  based  on  pilot 
conditional 
legislation will remain valid for a fixed term, to the 
end of year 2019. 

taken 

and 

is  based  partly  on  health 

Initial  price  is  based  on  clinical  performance, 
the  cost  of  existing 
economic  evaluation, 
treatments 
(EEA 
prices 
international 
countries). The government has used price cuts and 
there  is  a  positive  list  of  reimbursed  products 
which 
technology 
assessment  information  when  available.  Decisions 
on  reimbursement  are  temporary  in  nature,  which 
enables  the  reimbursement  to  be  adapted  to 
changes in the market. Generics are priced at -50% 
of  the  originators  price  and  biosimilars  at  -30%. 
rational  prescribing  of 
Authorities  promote 
physicians 
guidelines 
through 
complemented  with  monitoring  of  prescribing 
behaviour 
information 
education 
and 
and 
campaigns  on 
the  prescription  and  use  of 
medicines.  The  structure  of  co-payments  changed 
in  2006  so  that  the  co-payment  is  now  a  share  of 
the  medicine's cost rather than a fixed amount  for 
any "visit" to the pharmacy, which appears to have 
encouraged patients to buy excessive quantities of 
medicines.  There  is  an  explicit  generics  policy. 
Prescription by active element is in place although 
its application is rare. Nevertheless, pharmacies are 
the  prices  of 
obliged 

to  provide  advice  on 

treatment 

85 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

medicines  and  dispense  the  cheaper  product  and 
replace  the  prescription  by  a  generic  medicine  if 
available.  Generics  face  a  fast  track  registration 
and  lower  registration  fees.  Patients  aware  of  the 
generic  substitution  appear  to  request  cheaper 
medicines  and  electronic  systems  allow  doctors 
(and therefore the patients) to access the prices of 
medicines  when  prescribing  medicines.  Generic 
substitution is particularly important when patients 
have  to  incur  a  large  share  of  the  cost.  In  April 
2009,  reference  pricing  was 
introduced.  The 
reimbursement is based on the reference price that 
is  the  price  of  the  cheapest  substitutable  product 
plus  a  small  premium.  If  the  patient  chooses  a 
product  whose  retail  price  exceeds  the  reference 
price,  he/she  must  pay  the  share  above  the 
reference  price.  Both  generic  substitution  and 
reference  pricing  systems  have  had  notable 
pharmaceutical 
downward 
on 
expenditure.  Authorities  (through  KELA, 
the 
Social  Insurance  Institution)  monitor  the  general 
consumption  of  prescribed  medicines  closely  and 
evaluate 
impact  of  generic 
substitution. 

the  budgetary 

effects 

the 

Public pharmaceutical spending as a proportion of 
current health spending fell from 10.9% in 2005 to 
9.4% in 2015. It is below the EU average of 12.7% 
for that year.  

E-Health, Electronic Health Record 

The  coverage  of  electronic  patient  records  has 
been  100  %  in  Finland  for  many  years  now. 
Finland  has  also 
introduced  a  nationwide 
harmonised electronic patient record (Patient Data 
Repository),  an  electronic  prescription,  a  citizens’ 
health  portal  (My  Kanta  pages)  and  a  national 
medicine record (Pharmaceutical Database). These 
initiatives have been a part of the National Archive 
of Health Information –project (Kanta). 

The electronic prescription is in use by both public 
and  private  organisations  and  the  coverage  is  in 
public  organisations  nearly  100  %.  Electronic 
prescription  is  mandatory  as  of  1.1.2017.  All 
public  organisations  are  connected  to  the  Patient 
Data  Repository  and  private  organisations  are 
starting to participate in 2016. This allows sharing 
of data between  healthcare providers securely and 
with  patient  consent.  Citizen’s  health  portal 
enables  patients 
their  electronic 
prescriptions  and  health  records,  log  data,  give 

inspect 

to 

86 

information 

regularly  updated 

consent and denials and make advanced directives 
(e.g.  living  will).  The  national  medicine  record 
provides 
for 
physicians  and  pharmacies  about  e.g.  the  cost, 
reimbursement  eligibility  and  substitutability  of 
pharmaceuticals.  Modernisation  of  electronic 
health 
other 
health/hospital/patient  access  systems  is  moving 
forward.  Finland  also  has  a  national  eHealth  -
strategy  for  information  management  and  ICT-
development. 

systems 

record 

and 

Health  and  health-system 
information  and 
reporting  mechanisms/  Use  of  Health 
Technology  Assessments  and  cost-benefit 
analysis 

Finland has an extensive information management 
and  statistics  systems  and  comprehensive  data  is 
gathered  on  physician  and  hospital  activity  and 
quality  and  health  status.  Hospital  benchmarking 
data  is  available  allowing  for  costs  and  efficiency 
comparisons.  Existing  clinical  guidelines  and 
practice protocols are coupled with the monitoring 
of  physician  activity  and  feedback  to  physicians 
(for  example  on  their  prescription  behaviour)  to 
encourage  compliance  with 
those  guidelines. 
Through  surveys,  authorities  collect  information 
on  patient's  experience  and  satisfaction  with  the 
care obtained.  

The  Centre  for  Health  and  Social  Economics 
(CHESS)  at  the  National  Institute  for  Health  and 
Welfare undertakes  high-quality  health economics 
research  on  issues  relevant  for  health  policy. 
CHESS focuses on quality and efficiency of health 
services, financing and provision of health services 
and  evaluation  of  health  services  system.  The 
the 
Pharmaceuticals  Pricing  Board  confirms 
reimbursement 
of 
level 
(including 
reimbursement)  and  a  reasonable  wholesale  price 
outpatient 
pharmaceuticals, 
for 
prescription pharmaceuticals.  

including 

the 

The  Parliament,  the  Government  through  the 
Ministry  of  Health,  and  municipalities  set  public 
health  priorities  in  terms  of  outcomes  and  the 
reduction  of  health  inequalities.  For  example,  a 
shared  project  of  the  National  Institute  for  Health 
Institute  of 
and  Welfare  and 
Occupational  Health  (the  TEROKA  project)  aims 
aimed 
information  on  health 
inequalities  and  to  promote  the  reduction  of 

the  Finnish 

to  develop 

 
inequalities. As section 1 suggests there are indeed 
a  number  of  risk  factors  that  can  translate  into  an 
important  burden  of  disease  and  financial  costs. 
Authorities  have  strongly  emphasised  health 
promotion  and  disease  prevention  measures  in 
recent  years  as  well  as  emphasising  the  important 
contribution  other  policy  areas  can  make  to 
improve the health of the population ("Health in all 
Policies").  Recent  legislation  will  define  more 
explicitly the promotion and preventive services to 
be  provided  at  municipal  level.  Promotion  and 
prevention  are  seen  by  authorities  as  a  means  to 
ensure long-term fiscal sustainability of the health 
budget:  they  reduce  the  development  of  disease; 
the  need  for  care;  and,  the  consequent  need  for 
funding.  

Public expenditure on prevention and public health 
services as a % of GDP was above the EU average 
3.4% vs. 3.2% in 2015. This was also the case as a 
%  of  total  current  health  expenditure  (4%  vs.  the 
EU average of 3.1% in 2015).  

Recently 
reforms  

legislated  and/or  planned  policy 

On  April  5  2016 
the  Finnish  Government 
published  it’s  detailed  position,  which  will  guide 
the  drafting  of  legislation  on  three  interconnected 
reforms:  (1)  the  reform  of  the  organisation  of 
health  and  social  services,  (2)  the  reform  relating 
to  freedom  of  choice  and  multisource  financing, 
and  (3)  the  regional  government  reform,  i.e.  the 
establishment of 18 independent counties governed 
by elected county councils.  

The  goals  of  these  reforms  are  to  (1)  reduce  the 
currently forecasted public fiscal sustainability gap 
by  €3  billion  by  2030,  (2)  guarantee  equal  access 
to high quality services everywhere in the country 
and (3) reduce health inequities.  

The health and social reform  is based on a client-
centred integration of health and social services as 
the  key  measure  for  narrowing  health  and 
wellbeing  disparities,  improving  the  effectiveness 
of  the  services  in  an  equal  manner  and  bringing 
cost  savings.  A  single  strong  organiser,  county, 
will  be  responsible  for  services,  steering,  official 
activities,  evaluation  of  regional  impact,  cost-
effectiveness  and  quality  services  as  well  as 
supporting the  users’  freedom of choice. Freedom 
in  the  choice  of  choice  of  services,  will  enable 

Health care systems 

2.9. Finland 

users  themselves  to  make  choices  between  the 
providers. 

The county will have a single budget and a single 
financial  management  and  it  will  produce  the 
necessary  health  and  social  services  itself  or 
together  with  other  counties,  or  it  may  rely  on 
private or third sector in the provision of services. 
Counties  will  be 
the  central 
government  and  the  current  multisource  financing 
will  be  simplified  in  later  phases  of  the  reform. 
The  relevant  perspectives  of  European  Union  law 
and  the  realisation  of  fundamental  rights  will  be 
taken into account in the legislative drafting. 

financed  by 

Counties  will  ensure  that  the  organisation  and 
provision  of  services  are  genuinely  separated  and 
performed  by  different  organisations 
(legal 
persons).  Freedom  of  choice  will  significantly 
promote  competition  in  the  provision  of  services. 
Integration  of  information  systems  will  increase 
information  flows  between  different  providers. 
Consequently,  the  integration  of  service  chains 
will  improve.  Essential  public  health  functions, 
including health promotion and disease prevention, 
will be ensured.  

The decision entails a major shift of paradigm and 
will  require  additional  planning  to  that  already 
carried  out  at  earlier  phases  of 
the  reform 
preparations.  

introduced  Bills 

The  draft  laws  will  be  voted  in  the  parliament  in 
2019  after  the  constitutional  assessment.  The  new 
legislation  is  planned  to  come  into  force  in  2019. 
The new health and social care system itself, is due 
to  commence  on  1  January  2021.  In  preparation, 
the 
the  Government  has 
parliament  ranging  from  the  Counties  Act  to  the 
Freedom  of  Choice  legislation.  The  latter  is 
planned to come into force in stages during 2021-
2023.  An  election  of  the  county  councils  will 
follow 
the 
in  Spring  2019.  The  voting 
Parliament  is  expected  to  be  tight.  If  the  laws  are 
not  accepted  in  the  Parliament,  the  preparation  of 
the  reform  continues  during  the  next  electoral 
period. 

in 

to 

Successful and skilful change management will be 
a  prerequisite  for  achieving  the  targets  and  thus 
will  receive  particular  attention  during  the  reform 
implementation. 

87 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Challenges 

The  analysis  above  shows  that  a  wide  range  of 
reforms have been implemented over the years, to 
a  large  extent  successfully  (e.g.  to  reduce  waiting 
times,  to  improve  hospital  efficiency,  to  improve 
data  collection  and  monitoring, 
to  control 
pharmaceutical  expenditure),  and  which  Finland 
should continue to pursue. The main challenges for 
the Finnish health care system are as follows:  

•  To  ensure  greater  coherence  between 

the 
sources  of  financing  so  that  they  reinforce 
equity and efficiency in the system. 

medical interventions as is currently done with 
medicines.  

•  To  further  enhance  health  promotion  and 
disease  prevention  activities  i.e.  promoting 
healthy  life  styles  and  disease  screening  given 
the recent pattern of risk factors (diet, smoking, 
alcohol, obesity) in various settings (at work, in 
school).  

•  To tackle the increased waiting times found in 
distributing 
especially 

some 
by 
healthcare staff more efficiently. 

areas, 

•  To  ensure  consistency  in  the  provision  of 
care  by  different  municipalities, 
cost-

access 

equity 

and 

of 

health 
ensuring 
effectiveness.  

•  To 

track 

the  fiscal  sustainability  of 

the 
healthcare  system  and  ensure  that  the  medium 
and  long-term  risks  are  accounted  for.  All  the 
potential cost-drivers should be considered and 
dealt with. 

•  To  enhance  primary  care  provision  by 
increasing the numbers and spatial distribution 
of  GPs  and  nurses  and  by  rendering  referral 
system to specialist care more effective.  

•  To  consider  whether  it  is  worth  introducing 
some  element  of  performance  related  payment 
physicians'  remuneration  (e.g.  through  the  use 
of  mixed  payment  schemes)  to  encourage 
health  promotion,  disease  prevention  and 
disease management activities or the treatment 
of  vulnerable  populations 
increase 
outpatient output and render primary care more 
attractive.  More  generally,  to  ensure  sufficient 
numbers of staff in view of ageing of staff and 
population. 

and 

•  To  increase  hospital  efficiency  by  increasing 
the  use of day case surgery and increasing  the 
supply  of  follow-up  care  for  long-term  care 
patients so as to reduce the unnecessary use of 
acute  care  settings  for  long-term  care  patients. 
In  addition,  measures  pursued  in  recent  years 
should  be  consolidated  to  reduce  duplication 
and  improve  efficiency  and  quality  in  the 
and 
(e.g. 
hospital 
specialisation of hospitals within regions).  

concentration 

sector 

•  To  ensure  a  greater  use  of  health  technology 
to  determine  new  high-cost 
assessment 
equipment  capacity  as  well  as  the  benefit 
basket  and  the  cost-sharing  design  across 

88 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.9.1:  Statistical Annex – Finland 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

8
9

2005

164

29.7

2.4

:

2006

173

30.8

3.7

4.4

2007

187

32.7

4.7

2.2

2008

194

32.3

0.3

3.6

2009

181

28.9

-8.7

0.4

2010

187

29.6

2.5

2.1

2011

197

29.9

2.1

2.7

2012

200

29.1

-1.9

2.6

2013

203

28.0

-1.2

0.9

2014

205

27.7

-1.1

-1.3

2015

210

28.3

-0.2

-0.3

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

8.3

8.0

0.3

8.4

8.0

0.4

8.2

7.8

0.3

8.4

8.1

0.3

9.3

8.9

0.4

9.2

8.9

0.4

9.3

9.0

0.3

9.7

9.3

0.4

9.9

9.5

0.4

9.9

9.5

0.4

9.9

9.5

0.4

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

2,213

2,331

2,449

2,614

2,674

2,739

2,887

3,048

3,155

3,167

3,216

2,745

2,895

2,975

3,305

6.3

6.1

6.3

6.0

6.1

5.9

6.3

6.0

7.0

6.6

6.9

6.6

7.0

6.7

7.4

7.0

7.5

7.1

7.5

7.1

7.4

7.0

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

1,689

1,759

1,844

1,967

2,016

2,051

2,179

2,321

2,401

2,404

2,400

2,153

2,263

2,324

2,609

0.26

76.3

14.1

100.0

19.2

0.31

75.5

14.3

100.0

19.7

0.29

75.3

15.0

100.0

19.8

0.29

75.2

14.8

100.0

19.6

0.35

75.4

14.5

100.0

19.4

0.31

74.9

14.7

100.0

20.0

0.31

75.5

15.0

100.0

19.4

0.38

76.2

14.8

100.0

18.7

0.41

76.1

14.4

100.0

19.0

0.41

75.9

14.1

100.0

19.0

0.34

74.6

12.4

100.0

19.9

2005

2006

2007

2008

2009

2010

2011

2012

5.2

82.5

75.6

52.5

51.7

62

3.0

5.3

83.1

75.9

52.8

53.2

60

2.8

5.3

83.1

76.0

58.0

56.8

57

2.7

5.3

83.3

76.5

59.5

58.6

54

2.6

5.3

83.5

76.6

58.6

58.2

54

2.6

5.4

83.5

76.9

57.9

58.5

51

2.3

5.4

83.8

77.3

58.3

57.7

130

2.4

5.4

83.7

77.7

56.2

57.3

125

2.4

2013

5.4

84.1

78.0

:

:

118

1.8

2014

2015

5.5

84.1

78.4

57.5

58.7

114

2.2

5.5

84.4

78.7

56.3

59.4

111

1.7

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.1

0.1

2.3

1.3

0.2

0.3

0.2

1.9

0.1

1.7

0.7

:

0.2

0.2

2.0

0.1

2.4

1.2

0.2

0.3

0.2

1.8

0.1

1.7

0.6

:

0.2

0.2

1.9

0.1

2.3

1.2

0.2

0.3

0.2

1.7

0.1

1.7

0.6

:

0.2

0.2

2.0

0.1

2.4

1.2

0.2

0.3

0.2

1.8

0.1

1.7

0.6

:

0.2

0.2

2.2

0.1

2.7

1.3

0.2

0.3

0.2

2.0

0.1

1.9

0.7

:

0.2

0.2

2.2

0.1

2.7

1.2

0.2

0.3

0.2

2.0

0.1

1.9

0.7

:

0.2

0.1

2.3

0.2

2.7

1.2

0.2

0.3

0.1

2.0

0.1

1.9

0.6

:

0.2

0.1

2.3

0.2

2.8

1.2

0.2

0.3

0.2

2.1

0.1

2.0

0.7

:

0.2

0.1

2.4

0.2

2.9

1.2

0.2

0.3

0.2

2.2

0.2

2.1

0.6

:

0.2

0.1

2.4

0.2

3.0

1.2

0.2

0.3

0.2

2.2

0.1

2.1

0.6

:

0.2

0.1

2.3

0.2

3.2

1.2

0.2

0.4

0.1

2.0

0.2

2.3

0.7

:

0.2

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
e
a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

2
.
9
.

l

i

F
n
a
n
d

 
 
 
 
 
 
 
 
 
 
 
9
0

Table 2.9.2:  Statistical Annex - continued – Finland 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

26.1%

1.4%

28.7%

16.1%

2.6%

3.6%

2.4%

31.5%

1.6%

28.2%

10.9%

:

2.8%

3.0%

2005

1.47

:

1.5

0.1

14.1

21.8

10.0

2005

263

1257

101

690

2005

4.3

20

2006

25.0%

1.6%

29.8%

14.6%

2.8%

3.5%

2.5%

30.2%

1.8%

28.9%

10.7%

:

3.0%

3.0%

2006

1.52

:

1.5

0.1

14.3

21.4

10.2

2006

268

1315

102

617

2006

4.3

20

2007

24.4%

1.5%

29.6%

14.7%

2.7%

3.8%

2.2%

29.6%

1.7%

28.7%

10.4%

:

3.2%

2.7%

2007

1.53

2.0

1.7

:

14.9

20.6

10.5

2007

269

1340

101

608

2007

4.2

19

2008

24.8%

1.5%

29.7%

14.6%

2.5%

3.6%

2.1%

30.0%

1.8%

28.5%

10.6%

:

3.1%

2.6%

2008

1.56

:

:

:

15.7

20.4

10.3

2008

272

1314

103

559

2008

4.3

19

2009

24.6%

1.5%

30.2%

14.1%

2.5%

3.4%

1.9%

29.7%

1.8%

29.0%

10.4%

:

2.9%

2.3%

2009

1.57

2.3

2.0

0.2

14.9

18.6

10.0

2009

283

1356

102

553

2009

4.2

18

2010

24.8%

1.6%

30.6%

13.5%

2.6%

3.3%

1.8%

29.9%

1.8%

29.3%

9.9%

:

2.7%

2.1%

2010

1.86

2.4

2.1

0.2

15.6

19.0

9.7

2010

299

1386

119

546

2010

4.3

18

2011

25.3%

1.7%

29.6%

13.0%

2.5%

3.2%

1.6%

30.5%

1.9%

27.8%

9.6%

:

2.7%

1.9%

2011

2.02

2.1

2.1

0.2

16.6

17.8

9.8

2011

299

1408

123

535

2011

4.2

18

5,552

5,403

5,429

5,434

5,332

5,473

5,547

:

7.1

21.6

2016

6.1

6.1

2016

5.5

:

7.2

21.6

2020

6.2

6.3

2020

5.6

:

13.1

22.2

2025

6.4

6.5

2025

5.6

:

12.6

22.4

2030

6.5

6.6

2030

5.7

:

12.7

22.4

2035

6.6

6.8

2035

5.7

:

11.8

23.2

2040

6.6

7.0

2040

5.7

:

11.4

23.6

2045

6.7

7.1

2045

5.7

2012

25.2%

1.7%

29.8%

12.6%

2.3%

3.3%

1.6%

30.1%

2.0%

28.1%

9.3%

:

2.6%

1.9%

2012

2.16

2.0

2.2

0.2

15.8

17.0

9.2

2012

307

1420

122

528

2012

4.2

:

:

:

11.2

:

2050

6.7

7.2

2050

5.7

2015

23.8%

1.8%

33.5%

12.6%

2.3%

4.0%

0.8%

28.7%

2.3%

32.6%

9.4%

:

3.4%

0.9%

2015

2.59

1.5

2.2

0.3

18.8

17.4

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2015

2009

2011

2013

2015

2013

25.4%

1.8%

30.9%

12.4%

2.2%

3.4%

1.6%

30.7%

2.1%

29.5%

8.8%

:

2.7%

1.8%

2013

2.21

1.9

2.2

0.2

15.7

15.8

9.0

2013

315

1443

126

523

2013

4.2

17

2014

25.1%

1.8%

31.4%

12.3%

2.3%

3.4%

1.6%

30.3%

2.0%

30.0%

9.0%

:

2.7%

1.8%

2014

2.33

2.0

2.1

0.2

17.8

15.4

8.8

2014

321

1466

131

524

2014

4.2

17

:

:

125

518

2015

4.3

17

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

5,323

5,240

5,174

6,362

6,584

76.4

7.8

29.1

:

10.8

23.5

2055

6.7

7.2

2055

5.7

:

10.6

23.4

2060

6.7

7.3

2060

5.7

:

9.4

23.2

2065

6.8

7.4

2065

5.6

77.1

8.0

28.0

2070

6.9

7.5

2070

5.6

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Finland

0.8

1.4

EU

0.9

1.6

Change 2016-2070, in %

Finland

2.5

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.10. FRANCE 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

France  has  a  population  of  almost  66.8  million 
inhabitants, which is expected to grow by 15% up 
to  77  million  by  2070,  above  the  EU  overall 
growth of 2%. With a GDP of more than €2,194 bn 
in  2015,  or  29,200  PPS  per  capita,  it  is  slightly 
below the EU average GDP per capita of €29,600 
PPS.  

Total and public expenditure on health as % of 
GDP 

Total expenditure (141) on health as a percentage of 
GDP  (11.7%  in  2015)  has  increased  over  the  last 
decade (from 10.6% in 2005) and is above the EU 
average  (142)  of  10.2%.  Public  expenditure  has 
increased  as  well:  from  8.4%  in  2003  to  9%  of 
GDP  in  2015,  above  the  EU  average  of  8%. 
Looking at health care without long-term care (143) 
reveals  a  similar  picture  with  public  spending 
being  above  the  EU  average  (7.7%  vs  6.8%  in 
2015). 

When expressed in per capita terms, total spending 
on  health  at  3451  PPS  in  France  is  above  the  EU 
average of 3305 in 2015. So is public spending on 
health care: 2647 PPS vs. an  EU average of 2609 
PPS in 2015.  

Expenditure projections and fiscal sustainability  

As a consequence of demographic changes, health 
care expenditure is projected to increase by 0.5 pps 
of GDP, in line with the average growth expected 
for the EU (144), according to the "AWG reference 

(141) Please note that these figures reflect current (from System 
of  Health  Accounts)  plus  capital  expenditure  (from  the 
COFOG  database)  in  contrast  to  OECD  and  EUROSTAT 
data series, which reflect only current expenditure. 

(142) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(143) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

(144) I.e. considering the "reference scenario" of the projections 
Report: 
2018 

(see 
https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf ). 

Ageing 

The 

scenario". When taking into account the impact of 
future  spending 
non-demographic  drivers  on 
growth 
scenario),  health  care 
expenditure  is  expected  to  increase  by  1.2  pps  of 
GDP  from  now  until  2070  (both  below  the  EU 
average). 

(AWG 

risk 

France  faces  low  fiscal  sustainability  risks  in  the 
short run. There are high risks for the country from 
debt  sustainability  analysis  in  the  medium  term, 
but  the  contribution  of  health  care  and  long-term 
care  is  relatively  small.  Finally,  according  to  the 
new  risk  classification  methodology  of  the  2018 
Fiscal  Sustainability  Report,  long-term  risks  are 
medium (145). 

Health status 

Life expectancy at birth (85.5 years for women and 
79.2 years for men in 2015) and healthy life years 
(64.6 years for women and 62.6 years for men) are 
above  the  respective  EU  averages  (83.3  and  77.9 
years of life expectancy in 2015, 63.3 and 62.6 in 
2015  for  the  healthy  life  years)  (146).  An  infant 
mortality  rate  of  3.7‰  is  slightly  above  the  EU 
average of 3.6‰ in 2015. 

System characteristics  

Coverage 

The  French  system  is  a  social  health  insurance 
system in which all legal residents have to register 
with the public health insurance program (sickness 
insurance funds) and provides universal population 
coverage. The universal coverage is given, first, on 
the  professional/  occupational  basis  and  secondly, 
since 2000, on the basis of residence.  

The system is based on the principles of solidarity 
and  the  guarantee  of  financial  protection  against 
life's  contingencies  for  everyone.  The  basic 
(though  comprehensive  in  scope)  social  health 
insurance  system  had  three  dominant  schemes  – 
the  general  health 
the 
agricultural  scheme  and  the  national  insurance 
fund for self-employed non-agricultural workers – 

insurance 

scheme, 

(145) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(146) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

91 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

brought  together  under  the  National  Union  of 
Sickness Insurance Funds (UNCAM) since 2004.  

and 

contributions 

These  funds  are  not  allowed  to  define  the  benefit 
basket,  the  level  of  coverage  or  premiums,  and 
risk-equalisation  is  in  place.  In  addition  to  the 
basic  social  insurance  scheme  (financed  by  social 
taxation),  more 
security 
vulnerable  households  (i.e.  with  a  yearly  income 
below €8,645 for a single person in 2015, €15,560 
for  a  3-person  household)  (147)  benefit  from  free 
complementary 
– 
sickness 
"Complementary  Universal  Health  Coverage" 
(CMUC),  an  effort  by  authorities  to  improve 
access  to  health  insurance  and  therefore  to  health 
care by those  more  vulnerable groups. In order to 
avoid a threshold effect, if the income exceeds the 
threshold  to  the  limit  of  35%,  the  government 
finances a part of the premium paid by the insured 
for complementary insurance.  

insurance 

More and more people are also covered by private 
voluntary health insurance. 96% of the population 
is  covered  by  complementary  (to  cover  for 
for  public  goods  and 
patients'  cost-sharing 
services) and supplementary (to cover the services 
not  covered  by  public  provision/ 
funding) 
voluntary  health  insurance  by  individual  initiative 
(57%) or in the context of employment (43%).  

Administrative  organisation  and 
collection mechanism  

revenue 

The Parliament and the central government set the 
level  of  taxes  and  social  contributions  financing 
basic health insurance. The Parliament also sets the 
total public budget for health and by type of care. 
resource 
The  central  government  determines 
allocation  across  the  regions  and  the  payment 
methods  of  hospitals.  Fees  are  defined 
in 
agreements  negotiated  between  public  health 
insurance  funds  and  physicians  unions.  While  the 
State  plays  the  steering  role  in  administering  the 
system, some decentralisation has been introduced 
during  the  1990's  to  give  more  responsibilities  to 
regional  authorities  in  the  planning  and  financial 
resource allocation for hospitals.  

This  system 
involves  a  strong  collaboration 
between the entities of the system. The legitimacy 
of  the  social  partners  in  the  management  of  the 

(147) See the official website of the CMU fund: www.cmu.fr. 

92 

state 

intervention.  However, 

health insurance funds and their role with regard to 
the  role  of  the  state  was,  for  example,  one  of  the 
questions  that  have  been  raised  often  in  the  past. 
Over  time,  the  balance  tends  to  shift  towards 
increasing 
the 
division  of  responsibilities  between  the  central 
government  and  the  regions  remains  unclear  in 
certain  areas  and  could,  therefore,  benefit  from 
further  clarification  to  avoid  conflict  relations 
between 
the  health 
insurance  funds  and  improve  the  efficiency  in 
running the health sector.  

the  state  authorities  and 

The number of actors involved in decision making 
may  partly  explain  why  public  expenditure  on 
health  administration  and  health  insurance  as  a 
percentage  of  GDP  (0.34%  and  as  a  %  of  current 
health expenditure (3.9%) is above the EU average 
(respectively  0.26%  and  3.4%),  amongst 
the 
highest in the Union in 2015. This shows that there 
is perhaps scope to reduce administrative costs and 
improve  the  general  management  of  the  sector 
despite  current  efforts.  The  setting  up  of  the 
Regional  Health  Agency  (ARS),  in  2010,  can 
certainly  contribute  to  enhance  the  efficiency  in 
running  the  health  sector.  For  instance,  the  ARS 
aims  at  improving  care  coordination  between 
outpatient and inpatient care and at optimising the 
regional health care supply. 

In  France,  a  non-mandatory  national  health  care 
spending  target  (ONDAM)  is  voted  each  year  by 
the Parliament as part of the social security budget 
law  (Loi  de  financement  de  la  sécurité  sociale  – 
LFSS).  Compliance  with  this  target  has  been  met 
for the 8th year in a row in 2017 and, according to 
the  warning  committee’s  report  of  15th  October 
2018, the 2018 target should be met.  

These  measures 

This  is  mostly  explained  by  restrained  growth  in 
outpatient  care  spending,  in  particular  reductions 
in  pharmaceutical  prices  (detailed  in  the  Lois  de 
financement  de  la  Sécurité  sociale  -  LFSS)  and 
to  promote  generic  and  biosimilar 
measures 
medicines. 
the 
implementation  of  incentive  payments  for  general 
practitioners,  specialists  and  pharmacists  in  2012 
(Rémunération  sur  objectifs  de  santé  publique  – 
ROSP)  with  prescribing  targets,  renewed  and 
strengthened ever since. Patients were also given a 
larger  incentive  to  accept  the  substitution  for 
generic  drugs  with 
the  “tiers  payant  contre 
générique”  measure:  patients  have  to  wait  to  be 

include 

 
                                                           
reimbursed  the  cost  of  their  prescription  from  the 
Social  Insurance  if  they  do  not  wish  to  be 
dispensed the generic. In parallel, the development 
of ambulatory care was promoted.   

and 

tracking 

Although the ONDAM is  not a budgetary ceiling, 
several  monitoring 
levers, 
strengthened  recently  (especially  after  the  2010 
Briet  report)  are  used  to  ensure  it  continues  to  be 
respected.  First,  spending  is  monitored  closely  by 
an  independent  “warning  committee”,  composed 
of  3  experts  whose  role  is  to  give,  three  times  a 
year, an opinion on progress towards the target and 
on  the  risks  of  overshooting.  Second,  there  has 
been a gradual reduction of the  warning threshold 
(amount  above  which  the  government  must  take 
corrective measures to ensure compliance with the 
target) from 0.75% of the target in 2010 to 0.7% in 
2011, then to 0.6% in 2012 and finally to 0.5% in 
2013.  Finally, 
late  2010,  a  monitoring 
committee  co-chaired  by  the  ministers  of  Health 
and  Budget  was  implemented.  This  committee  is 
assisted  by  a  statistical  group 
in  charge  of 
reviewing  the  data  monthly  in  order  to  come  up 
with  propositions  to  curb  spending  and  ensure 
compliance  with 
target.  The  committee 
overviews the implementation of the spending cuts 
decided  along  with  the  level  of  the  target.  It  is  in 
charge of monitoring the regulation strategy in the 
case  of  an  overshooting  of  the  target  and  of 
preparing 
the 
following year. 

the  construction  of 

target 

the 

the 

in 

Role  of  private  insurance  and  out  of  pocket 
co-payments  

and 

care 

primary 

Cost-sharing  applies  to  most  goods  and  services, 
specialist 
especially 
consultations,  laboratory  tests,  pharmaceuticals, 
eyeglasses  and  contact  lenses,  dental  care  and 
dental  prostheses.  Pregnant  women,  those  with 
certain  severe  medical  conditions,  those  with  an 
income below a defined threshold, those on social 
assistance,  and  victims  of  accidents  at  work  are 
exempted from cost-sharing. The private voluntary 
complementary health insurance increases the rate 
of 
the  discrepancy 
between the actual amount paid by patients and the 
amount  they  are  reimbursed  by  their  social  health 
insurance fund. Voluntary insurance decreases this 
discrepancy  to  greatest  extent  for  prostheses, 
drugs,  optical  and  dental  care.  In  doing  so, 
the 
complementary  health 

reimbursement, 

insurance 

reducing 

reduces 

Health care systems 

2.10. France 

a 

and 

ticket, 

implemented 

ability of cost-sharing to control overconsumption 
as it renders users less cost-aware. As a result, the 
authorities 
a 
“deductible”:  the  patient  has  to  pay  €1  for  each 
physician  visit ( 148)  and  each  biomedical  analysis, 
€0.50  per  drug  box,  €0.50  on  each  paramedical 
procedure and €2 for each medical transport. In the 
same  time,  government  encourages  with  fiscal 
incentive  “responsible  contracts”  that  don’t  cover 
the  deductible  part  in  order  to  limit  health  sector 
inflation.  As  a  result  the  deductible  is  usually  not 
covered by complementary health insurance. 

Private  expenditure  (patient  co-financing  and 
voluntary  private  health  insurance)  represented 
around  23.3%  of  the  total  health  expenditure  in 
2015,  i.e.  a  small  increase  since  2003  (22%), 
slightly  above  the  EU  average  (21.6%  in  2015). 
Out-of-pocket  spending  accounts  for  a  small  part 
of  private  expenditure  (6.8%  of  total  health 
spending which is a small share in the EU context 
– EU average of 15.9% in 2015) and having fallen 
consistently since 2011.  

Types of providers, referral systems and patient 
choice 

The  French  system  is  strongly  characterised  by 
freedom  of  choice  and  unrestricted  access  for 
patient, and by free practice of professionals on the 
basis of accreditation. The primary and secondary 
health  care  delivery  relies  then  on  an  easily 
accessible  combination  of  public  and  private 
supply. Providers are organised in two groups: the 
health  institutions  that  include  hospitals,  nursing 
homes and laboratories, which provide most of the 
inpatient  care  and  employ  mainly  salaried  health 
self-
professionals 
employed 
general 
practitioners  (GPs),  specialists,  dentists,  nurses, 
and  pharmacists  who  provide  outpatient  care. 
is  provided  by  self-employed 
Primary  care 
physicians  and  other  professionals  mostly 
in 
private  individual  practices.  This  is  also  the  case 
for 
although 
sometimes  these  also  work  in  private  clinics.  Day 
case  and  inpatient  care  is  provided  in  hospitals. 
Hospitals  are  organised  in  three  categories:  the 

the  generally 
such 

( 149);  and 
professionals 

specialist  outpatient 

services, 

as 

(148) Children under 18, pregnant women between the 6th month 
and 12 days after delivery, and those with an income below 
a defined threshold  are exempted. 

(149) The net salary of a full-time employed doctor in hospital is 

very close to the one earned by a self-employed GP. 

93 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

public  sector,  the  non-profit  and  profit-making 
private sector, the latter is mainly concentrated on 
surgical procedures.  

In  2015,  the  number  of  practising  physicians  per 
100  000  inhabitants  was  312  (slightly  below  the 
EU  average  of  344).  The  number  of  general 
practitioners was 154, far above the EU average of 
78.3.  Finally,  the  number  of  practising  nurses  per 
100 000 in 2015 (940) was above the average EU 
number (825). 

It should be noted that there are differences in the 
supply of physicians across regions as, while total 
supply  is  regulated,  the  location  of  physicians  is 
not.  The  numerus  clausus  system  was  introduced 
in  1971  in  order  to  regulate  access  to  health 
professions.  Indeed,  a  ministerial  decree  sets 
annually  the  number  of  places  available  for  each 
health qualification and research units. This policy 
has resulted in the stabilisation of doctors' numbers 
but  some  specialities,  such  as  anaesthesiology, 
gynaecology  or  obstetrics  have  been  reported  to 
need  more  professionals.  The  same  problem, 
which  might  become  more  severe  in  the  near 
future,  concerns  other  specialities  and  nurses 
working  in  hospitals.  On  the  one  hand,  specific 
incentives  could  be  developed  to  promote  and 
encourage  staff  to  work  in  some  specialities 
currently 
the  other  hand,  
geographical  disparities  could  be  reduced.  More 
generally,  the  human  resources  strategy  needs  to 
tackle staff and population ageing in the future. In 
this  view,  some  financial  incentives  have  been 
granted  since  2006  to  physicians  who  settle  in 
areas where there is a lack of supply of physicians.  

in  shortage.  On 

lack  of  coordination  between  primary, 
The 
specialist  and  hospital  care  has  been  one  major 
problem  of  the  health  care  system,  potentially 
leading  to  unnecessary  use  of  specialist  and 
hospital  care  and  the  duplication  of  procedures 
resulting  in  higher  expenditure.  To  improve  the 
situation, referring GP and provider networks were 
implemented  as  from  July  2005.  The  patient 
chooses and registers with a general practitioner at 
the social health fund. The patient is free to change 
general practitioners but has to report any change. 
If  necessary,  the  GP  plays  the  role  of  gatekeeper 
and  sends  his  patient  to  a  specialist  who  will 
report,  with  the  authorisation  of  the  patient,  any 
relevant information to the GP in order to follow-

94 

to 

applied 

financial 

penalties 

up and coordinate the care (150). The patient has to 
face 
the 
reimbursement  rate  by  the  national  sickness  fund, 
if  he/she  doesn't  designate  his/her  preferred  GP 
and does follow a referral procedure. Around 90% 
of the insured patients have designated a preferred 
doctor  so  far.  Patients  are  also  free  to  choose  a 
specialist and a hospital.  

put 

plans 

the  health  fund  where  he 

Each  patient  has  his  own  medical  card  called 
"Carte Vitale" which transmits all the transactions 
to 
is  registered.  
prescriptions, 
to 
However, 
reimbursements  and  information  on  the  health 
status  on  the  card  have  not  been  implemented. 
Therefore, 
it  does  not  contain  any  medical 
for  care 
information  and  cannot  be  used 
coordination.  Since  2011,  a  new  individualised 
medical  record  (Dossier  medical  personnalisé, 
DMP) has also put in place aiming to improve care 
coordination.  

The  central  government  evaluates  via  the  High 
Authority  for  Health  (HAS)  the  best  medical 
life-long 
practices  and  promotes  compulsory 
medical  education. 
sets  a  package  of 
It 
recommendations and targets after consulting with 
funds  and  professionals  such  as 
for  drug 
prescriptions  (generics,  right  prescription)  which 
each  physician  is  advised  to  follow.  Penalties 
could  be 
the 
recommendations is frequent, serious or costly for 
the  health  system.  Such  procedures  are  likely  to 
have  a  positive  effect  on  doctors'  prescribing 
behaviour  and  efforts  should  continue  in  that 
direction. 

if  non-compliance 

issued 

to 

France  has  a  number  of  acute  care  beds  per 
100,000 inhabitants (407 in 2015) close to the EU 
average  in  that  year  (402).  These  results  reflect 
efforts  made  during  the  1980's  and  1990's  to 
reduce the number of hospitals beds as well as the 
average hospital length of stay (see further below).  

are 

pharmaceuticals 

Finally, 
exclusively 
distributed  by  approximately  23,000  pharmacies 
and  their  establishment  is  regulated  by  a  numerus 
clausus 
the 
population and a distance factor.  

into  account 

the  size  of 

taking 

(150) Gynaecology,  ophthalmology,  stomatology  and  psychiatry 

are out of that procedure. 

 
                                                           
Treatment options, covered health services 

There  is  a  common  basket  of  services  of  the 
National Health System that has to be delivered to 
the whole population covered. 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Two payment systems have been implemented, the 
first  one  is  a  reimbursement  system  (ambulatory 
care)  and  the  second  one  is  a  third-party  payer 
system  where  the  patient  pays  only  the  co-
insurance  or  the  co-payment  (inpatient  care  and 
pharmaceuticals).  

Outpatient  primary  and  specialist  care  doctors  are 
generally  self-employed  and  paid  on  a  fee-for-
service basis paid by the patient at the consultation 
and  partly  reimbursed  at  a  later  stage  by  their 
social  health  insurance.  The  fees  are  fixed  and 
negotiated  between  physicians'  unions  and  the 
public  health  insurance  funds  under  contracts 
signed  for  every  four  or  five  years.  Medical 
practitioners  and  clinics,  which  are  not  under 
contract,  have  to  display  their  prices.  Almost  no 
reimbursement  is  given  by  the  statutory  health 
insurance  to  patients  visiting  professionals  not 
under contract. 

Hospital  inpatient  doctors  are  mostly  salaried 
employees  of  the  hospitals,  with  the  salary  scale 
defined  at  central  level.  For  hospital  day  care  or 
is 
inpatient  care,  a  third-party  payer  system 
generally  used  whereby  the  patient  pays  only  the 
co-insurance or the co-payment.  

The  amount  paid  by  the  patient  and  not  taken  in 
charge  by  the  compulsory  insurance  is  called 
"ticket modérateur". An average of 70% of the cost 
of a visit to a GP is thereby refunded, from 80% to 
95% for a surgery, 95% for childbirth, 70% for x-
rays,  dental  care  and  60%  for  nursing  at  home 
among  others.  Under  certain  conditions  such  as 
some  chronic  disease  or  care  requiring  hospital 
stay of at least 30 days ( 151) or beneficiaries of the 
CMUC,  individuals  could  be  entitled  to  a  100% 
reimbursement  of  medical  and  hospital  costs. 
Hospitals are remunerated on a payment per case/ 

(151) Although it should be noted that the 100% reimbursement 
in this case is only applied from the 31st day and patients 
pay a 20% “ticket modérateur” the first 30 days. 

Health care systems 

2.10. France 

DRG basis (152). Hospitals are legally autonomous 
and  manage  their  own  budgets.  Since  2009,  they 
have autonomy to recruit their own medical staff.  

are 

that 

care 

alternative 

The  number  of  inpatient  discharges  is  below  the 
EU  average  (15.4  vs.  16.2  per  100  inhabitants  in 
2015) but this is related to many policies that have 
been put in place in order to encourage methods of 
providing 
to 
hospitalisation  such  as  day  care  surgery  or 
hospitalisation  at  home.  Among  others,  extension 
of  hospital's  capacity  via  a  theoretical  exchange 
rate  of  one  acute  bed  for  two  "non-acute"  beds  is 
possible. Day cases as % of all hospital discharges 
are, at 40.7%, well above the EU average (32.3.% 
in 2015). This share has increased gradually since 
2009.  

Hospital average length of stay (10.1 days in 2014) 
has  fallen  since  2007  but  is  higher  than  the  EU 
average of 7.7 days in 2014.  

The market for pharmaceutical products 

The  central  government  regulates  the  production 
and  distribution  of  pharmaceuticals  and  any  drug 
must  obtain  a  formal  authorisation  to  be  sold. 
International  price  reference  is  used  and  based  on 
manufacturing  price  in  DE,  ES,  IT,  and  UK.  The 
initial  price 
the  clinical 
is  also  based  on 
performance and cost of existing treatments.  

About  4900  pharmaceuticals  are  reimbursable  in 
France,  which  represents  approximately  one  half 
of  the  drug  presentations  available.  The  list  of 
reimbursable  drugs  is  established  by  ministerial 
ordinance  and  will  contain  only  drugs  having  a 
sufficient  medical  service  rendered  (SMR)  (153). 
The  amount  reimbursed  will  depend  on  various 
criteria  such  as  the  effectiveness,  the  side  effects, 
the place in the therapeutic process, the seriousness 
of the condition, the properties of the drug and its 
importance  for  public  health.  According  to  the 
SMR, the reimbursement rate for prescribed drugs 
is  chosen  between  four  rates  (100%,  65%,  30%, 
and  15%).  In  order  to  control  final  spending  on 
reimbursable products, the central government sets 
the prices on producer's side, after bargaining with 

(152) The  OECD  score  for  remuneration  incentives  to  raise  the 
volume of care in France is about 4.5 out of 6 as a result of 
the  use  of  activity  related  payment  elements  in  physician 
and hospital remuneration. 

(153) For a period of five years before revaluation. 

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the  drug's  committee  and  the  laboratory  involved. 
In  order  to  promote  the  use  of  generic  drugs,  the 
pharmacists  have  been  financially  encouraged  to 
offer  their  clients  generic  drugs  where  this  is 
possible. In such cases, an equivalent profit margin 
is guaranteed.  

Generics  also  face  a  fast-track  registration  and 
automatic  price  setting  (60%  of  the  price  of  the 
brand  name  drug).  Authorities  promote  rational 
prescribing  of  physicians  through  prescription 
guidelines,  complemented  with  monitoring  of 
prescribing behaviour and feedback, and education 
and information campaigns on the prescription and 
use of medicines. They also promote education and 
information  campaigns  for  patients.  Physicians 
receive feedback on their prescription behaviour in 
comparison with that of colleagues and in relation 
to  some  sort  of  national  contract/  priorities 
established  between  the  doctors  and  the  social 
health  insurance  funds.  Doctors  are  visited  by 
delegates  of  the  social  insurance,  who  provide 
them with information on rational prescribing.  

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

Quality of care, especially in  hospitals, is a  major 
matter of concern to public French authorities. To 
improve  it,  from  1996,  the  central  government 
decided  that  all  health  care  institutions  must  be 
accredited  to  provide  treatment  by  the  Haute 
Autorité de Santé (HAS). An evaluation procedure 
is then done on several dimensions such as quality 
of  care,  information  given  to  the  patient,  medical 
records,  general  management  and  risk  prevention 
strategies.  The  HAS  publishes  afterward 
the 
performance 
reviews.  Perhaps 
accreditation 
monitoring in the sector could be further improved 
by  publishing  more  routine  and  comparable 
information on the activity and quality of providers 
(clinical  outcomes,  use  of  appropriate  processes, 
patients'  satisfaction  and  patient  experience), 
which  can  support  choice  of  provider  while  help 
identifying  good  practices 
for 
improvement through peer reviews for example. 

areas 

and 

Health  technology  assessment  information  has 
been  used  to  define  guidelines  and  determine 
coverage  of  new  procedures,  new  medicines  and 
new 
of 
equipment, 
reimbursement  of  new  procedures  and  new 
medicines, and to develop guidelines for high-cost 

high-cost 

level 

the 

equipment. The benefits package is defined on the 
basis of clinical effectiveness. 

E-Health, Electronic Health Record 

The  government  has  the  ambition  to  develop  E-
Health. The implementation of a medical personal 
data  folder  has  been  ongoing  for  years  but  will 
enter a second phase now. 

The government is opening administrative data on 
reimbursements  to  researchers.  Related  to  patient 
privacy, it can sometimes be merged with medical 
data.  That  should 
improve  medical  products 
surveillance.   

Health  promotion  and  disease  prevention 
policies 

the  parliament, 

The Ministry of Health, on the basis of the overall 
is 
framework  established  by 
responsible for defining priority areas for national 
programmes  in  the  field  of  health  promotion  and 
disease  prevention.  The  main  priorities  include 
cancer,  pain  control  and  anti-smoking  campaigns. 
Public health objectives are set in terms of process, 
outcomes  and  the  reduction  of  health  inequalities. 
Public expenditure on prevention and public health 
services  as  a  %  of  GDP  (0.2%)  is  below  the  EU 
average  of  0.3%  in  2015,  and  as  a  percentage  of 
public  current  health  expenditure  (1.6%)  it  is  also 
below the EU average of (3.2%).  

that 

As  for  the  lifestyle  of  the  French  population,  the 
data  suggests 
the  proportion  of  regular 
smokers  has  decreased  slightly  (from  26.2%  in 
2008 to 22.4% in 2014), above the EU average of 
20.9%.  Over  the  recent  past  the  proportion  of  the 
obese  in  the  population  has  also  increased  (from 
9.4%  in  2001  to  14.7%  in  2014),  while  alcohol 
consumption  shows  a  reduction  from  13.5  litres 
per capita in 2003 to 11.5 litres in 2014 (still above 
the EU average of 10.2). 

Recently 
reforms 

legislated  and/or  planned  policy 

Recent policy response 

The  success  in  not  overshooting  the  planned 
expenditure increase in 2013 led the government to 
propose a reduction of the national health spending 
target  for  2014  by  €800  million  (the  2014  target 

96 

 
initially set at €179.1 billion was brought down to 
€178.3  billion)  in  the  rectified  social  security 
budget  bill.  Furthermore,  it  was  decided  that  €10 
billion would be achieved through health insurance 
savings,  and  the  national  health  target  budget 
increase would be set at respectively 2.1%, 1.75% 
and  1.75%  for  the  2015-2017  time  period.  These 
the  higher  planned 
to 
economies 
expenditure  were  expected  to  stem  from  the 
implementation of the national healthcare strategy, 
which  promotes  greater  efficiency  in  expenditure 
through structural reforms such as the streamlining 
of  treatments,  development  of  outpatient  care, 
improving  the  share  of  generic  drugs  consumed 
and  reducing  their  prices  (along  with  other  drug 
policies). 

relative 

The new government has a plurennial management 
of the national health spending and has thereby set 
a maximum target of annual 2.3% of growth of this 
spending  during  the  five  year  presidential  term 
2017-2022.  This  has  since  then  been  further 
increased  up  to  2.5  %  in  the  draft  budgetary  plan 
for 2019. 

has 

also 

new 

government 

The 
recently 
implemented  a  set  of  reforms.  First  of  all, 
prevention (see challenges section below) is at the 
core  of  the  ministry  of  health’s  strategy  for  the 
next  five  years:  on  January  2018,  11  instead  of  3 
vaccines  were  made compulsory, price of tobacco 
will  increase  significantly  over  the  government 
term,  and  other  behavioral  taxes  are  being  set 
(taxes  on  added  sugar  in  beverages,  etc.).  Among 
others,  one  can  also  enumerate  the  main  reforms 
on  daily-basis  prevention  announced  on  March 
2018: possibility to give a vaccine shot against the 
flu  for  the  dispensary  pharmacist,  free  uterus 
cancer  screening  organised  nationwide,  increased 
size  for  the  preventive  logo  on  alcohol  bottles 
“forbidden  to  pregnant  women”,  free  “condom 
card”  for  people  under  25  years  old,  campaign  to 
identify teenagers’ hearing disorders, prevention of 
obesity from the earliest age, etc. 

In order to reinforce access to health services, the 
plan«  renforcer  l’accès  aux  soins  »  was  set  into 
motion in October 2017:  rebalancing the  medical 
(the  numer  of  pluridisciplinary 
demography 
santé 
medical 
pluridisciplinaires”)  will  double  in  the  next  five 
years, in order to make some zones more attractive 
to professionals, it will be easier for physicians in 

(“maisons 

centers 

de 

Health care systems 

2.10. France 

medically  under-staffed  to  cumulate  a  job  and 
retirement,  etc.  A  ministerial  committee  made  up 
of professionals and patients  will gather every  six 
month to monitor its implementation. 

in 

the 

consists 

four-year-plan 

the  careers  and 

Another  structural  reform  has  recently  been 
announced  in  September  2018.  The  “Ma  santé 
a  deep 
2022” 
transformation  of  the  French  Health  System  in 
order to have a patient-focused and quality-driven 
improve  primary  care  access  by 
system, 
to 
reorganising 
relations  between  hospital, 
ambulatory  and  medico-social  services,  and  to 
rethink 
tuition  of  health 
professionals.  Some  of  the  main  measures  are: 
deployment 
“Communautés 
professionnelles  territoriales  de  santé  (CPTS)” 
which  allows  liberal  professionals  to  practice  in  a 
coordinated  way;  financing  of  medical  assistants 
that  will  allow  to  free  up  medical  time  for 
physicians ; creation of 600 primary care hospitals 
("Hopitaux de proximité"); reforming care grading 
the  2 
in 
competitive  examinations  during 
the  medical 
doctor  studies  (to  be  replaced  with  a  more 
progressive  process  that  will  more  take  into 
account medical capacities of the students). 

the  hospital  system; 

removal  of 

1000 

of 

Some other important reforms are:  

−  a  “sanitary  service”  for  medical  students,  in 
order  to  increase  prevention  and  access  to 
healthcare. 

−  The  agreement  “100%  santé”  signed  in  June 
2018  with  health  professionals  will  provide 
“zero  out-of-pocket  spending”  on  glasses, 
hearing  aids  and  dentures  to  patients.  In  those 
three  areas,  the  patients  will  be  provided 
devices  that  are  quality  compliant  and  without 
out-of-pocket  spending  after  coverage  by  the 
health 
compulsory 
insurance. This deal will be put into application 
gradually  until 
in 
January 2021. 

implementation 

complementary 

its  full 

and 

Recent policy changes adopted 

From  January  2016  collective  complementary 
insurance  is  compulsory  for  all  employees  of  the 
private sector. 

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European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

if patients' financial contributions have already 
been  implemented,  it  may  also  be  worth 
exploring 
further 
adjusted  to  encourage  the  use  of  more  cost-
effective interventions. 

if  cost-sharing  can  be 

•  To 

continue 

generic 
pharmaceuticals by extending reference pricing 
schemes.  

promote 

to 

•  To continue to improve the general governance 
of  the  system,  through  strategies  to  rationalise 
administrative  procedures,  therefore  enhancing 
the  global  system's  efficiency  and  quality. 
Possible areas include: increasing the financial 
responsibility 
clarifying 
the 
responsibilities  of  the  various  actors  in  the 
system,  and  improving  accountability,  perhaps 
through  greater  use  of  systems  of  rewards  and 
fines.  

funds, 

of 

•  To  improve  data  collection  and  comparability 
in  order  to  evaluate  more  thoroughly  the 
activity and quality of providers and the overall 
system. Possible indicators include preventable 
hospitalisations,  readmission  rates,  mortality 
post-hospital,  complication  during  and  post 
operation, prescription mistakes (recommended 
by  OECD).  Public  comparisons  and  peer 
reviews  can  help  providers  identify  areas  for 
improvement and good practices. 

•  To  enhance  health  promotion  and  disease 
prevention activities, i.e. promoting healthy life 
styles. 

regulations  and 

New 
for 
"responsible  contracts"  have  been  implemented  in 
order 
to 
complementary insurance coverage.  

limit  health  price 

inflation  due 

incentives 

fiscal 

to 

The  “Loi  de  modernisation  de  notre  système  de 
santé”  has  been  promulgated  in  January  2016.  It 
the  offer  by  care  providers:  for 
rationalises 
hospitals with the GHT (“groupements hospitaliers 
de 
territoire”)  and  for  ambulatory  care  and 
coordination between inpatient and outpatient care 
(“Communautés  professionnelles  territoriales  de 
santé”).  Health  care  accessibility  has  also  been 
improved  by  the  direct  payment  to  doctors  (“tiers 
payant“)  of  the  reimbursement  of  social  security 
funds. 

Challenges 

continue 

to  pursue.  For 

The  analysis  above  has  shown  that  a  range  of 
reforms has been implemented in recent years to a 
large  extent  successfully,  which  France 
very 
should 
example, 
improvements  in  access  to  health  insurance  for 
those  most  vulnerable,  improvements  in  hospital 
efficiency, 
and 
monitoring  and  better  control  of  pharmaceutical 
expenditure,  greater  use  of  primary  care  and 
improvements  in  care  coordination  from  primary 
to  secondary  care.  The  main  challenges  for  the 
French health care system are as follows:  

collection 

improved 

data 

•  To  reinforce  human  resources  strategies  to 
avoid a shortage of physicians in the future as a 
result  of  staff  and  population  ageing.  This  can 
be  done  by  pushing  up  numerus  clausus 
ceilings  according  to  projected  needs.  To 
to  doctors 
improve  geographical  access 
especially  between  urban  and  rural  areas 
through  incentives  system  directed  at  doctors, 
especially primary care staff. 

•  To  continue  efforts 

to 

implement  cost-
containment  policies  in  a  system  characterised 
by  fee-for-service  payment  of  doctors  and 
unrestricted  freedom  of  choice  for  patients. 
These  include  continuing  to  encourage  a  more 
rational  and  coordinated  use  of  care  through 
greater use of primary care and more effective 
referrals  from  family  doctors  to  steer  demand 
to other types of care and organise appropriate 
and  cost-effective  channels  of  treatment.  Even 

98 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.10.1:  Statistical Annex – France 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

9
9

2005

1,772

28.2

0.8

:

2005

10.6

10.0

0.6

2006

1,853

28.6

1.7

2.2

2006

10.7

10.1

0.6

2007

1,946

29.2

1.7

0.8

2007

10.6

10.0

0.6

2008

1,996

28.1

-0.4

1.3

2008

10.7

10.1

0.6

2009

1,939

26.7

-3.4

3.0

2009

11.4

10.8

0.6

2010

1,998

27.5

1.5

0.7

2010

11.4

10.7

0.6

2011

2,059

28.0

1.6

2.1

2011

11.4

10.7

0.7

2012

2,087

27.9

-0.3

0.4

2012

11.5

10.8

0.7

2013

2,115

28.2

0.1

0.6

2013

11.5

10.9

0.6

2014

2,148

28.6

0.4

1.9

2014

11.7

11.1

0.7

2015

2,194

29.2

0.6

0.2

2015

11.7

11.0

0.7

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

2,679

2,797

2,891

2,999

3,089

3,144

3,238

3,288

3,332

3,417

3,451

2,745

2,895

2,975

3,305

8.6

8.3

8.3

7.9

8.1

7.8

8.2

7.9

8.8

8.5

8.7

8.4

8.7

8.4

8.8

8.5

8.9

8.6

9.0

8.7

9.0

8.7

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

2,179

2,171

2,230

2,288

2,370

2,404

2,472

2,526

2,561

2,630

2,647

2,153

2,263

2,324

2,609

0.36

81.3

14.7

99.9

7.4

0.36

77.6

14.6

99.9

7.4

0.31

77.1

14.3

99.9

7.4

0.30

76.3

14.3

99.9

7.8

0.30

76.7

14.2

100.9

7.6

0.30

76.5

14.3

101.9

7.5

0.33

76.3

14.3

99.9

7.5

0.35

76.8

14.2

99.9

7.4

0.29

76.9

14.4

99.9

7.1

0.31

77.0

14.1

99.9

6.9

0.27

76.7

14.1

99.9

6.8

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

62.8

83.8

76.7

64.6

62.3

46

3.8

63.2

84.5

77.3

64.4

62.8

43

3.8

63.6

84.8

77.6

64.4

62.8

40

3.8

64.0

84.8

77.8

64.5

62.8

40

3.8

64.4

85.0

78.0

63.5

62.8

39

3.9

64.7

85.3

78.2

63.4

61.8

37

3.6

65.0

85.7

78.7

63.6

62.7

84

3.5

65.3

85.4

78.7

63.8

62.6

82

3.5

65.6

85.6

79.0

64.4

63.0

80

3.6

65.9

86.0

79.5

64.2

63.4

78

3.5

66.5

85.5

79.2

64.6

62.6

78

3.7

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

3.4

0.6

1.8

1.8

0.5

0.2

0.7

3.1

0.6

1.1

1.3

0.2

0.2

0.4

3.1

0.4

1.8

1.7

0.5

0.2

0.6

2.9

0.4

1.2

1.2

0.2

0.2

0.4

3.0

0.4

1.8

1.7

0.5

0.2

0.6

2.9

0.4

1.1

1.2

0.2

0.2

0.4

3.0

0.4

1.9

1.7

0.5

0.2

0.6

2.8

0.4

1.2

1.2

0.2

0.2

0.4

3.2

0.4

2.0

1.8

0.5

0.3

0.7

3.0

0.4

1.3

1.2

0.2

0.2

0.4

3.2

0.4

1.9

1.8

0.5

0.2

0.6

3.0

0.4

1.2

1.2

0.2

0.2

0.4

3.2

0.4

2.0

1.7

0.5

0.2

0.7

2.9

0.4

1.3

1.2

0.2

0.2

0.4

3.2

0.4

2.0

1.7

0.6

0.2

0.7

3.0

0.4

1.3

1.2

0.2

0.2

0.4

3.2

0.4

2.0

1.6

0.6

0.2

0.7

3.0

0.4

1.3

1.1

0.2

0.2

0.4

3.2

0.5

2.1

1.7

0.6

0.2

0.7

3.0

0.4

1.4

1.2

0.2

0.1

0.4

3.2

0.5

2.1

1.6

0.6

0.2

0.7

3.0

0.4

1.4

1.2

0.2

0.1

0.3

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
e
a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

2
.
1
0
.

F
r
a
n
c
e

 
 
 
 
 
 
 
 
 
 
 
1
0
0

Table 2.10.2:  Statistical Annex - continued – France 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

2005

33.6%

6.2%

17.9%

18.4%

4.5%

2.3%

6.9%

37.8%

7.0%

13.6%

15.6%

1.8%

1.9%

5.1%

2005

0.48

:

1.0

0.0

..

:

12.2

2005

:

785

165

690

2006

30.8%

4.0%

18.0%

17.3%

4.5%

2.2%

6.1%

36.8%

4.7%

14.5%

15.4%

2.0%

1.9%

4.4%

2006

0.52

:

1.0

0.1

10.5

25.9

12.4

2006

:

804

164

617

2007

30.5%

3.8%

18.0%

17.2%

4.6%

2.2%

6.0%

36.4%

4.6%

14.5%

15.4%

2.2%

2.0%

4.5%

2007

0.55

:

1.0

0.1

..

:

12.2

2007

:

791

163

608

2008

29.8%

3.7%

18.4%

17.0%

4.8%

2.3%

6.0%

35.7%

4.4%

15.1%

14.8%

2.2%

2.0%

4.6%

2008

0.61

:

1.1

0.1

12.2

26.2

11.9

2008

:

819

162

559

2009

29.7%

3.7%

18.0%

16.7%

4.7%

2.5%

6.0%

35.5%

4.4%

14.7%

14.4%

2.1%

2.2%

4.5%

2009

0.64

:

1.1

0.1

..

:

11.8

2009

:

847

160

553

2010

29.7%

3.7%

18.0%

16.3%

4.9%

2.1%

6.0%

35.4%

4.4%

14.7%

14.3%

2.3%

1.9%

4.4%

2010

0.70

:

1.2

0.1

12.9

23.3

11.7

2010

:

876

159

546

2011

29.4%

3.8%

18.3%

16.0%

5.0%

2.1%

6.1%

35.1%

4.5%

14.9%

14.2%

2.4%

1.8%

4.3%

2011

0.75

:

1.3

0.1

..

:

11.8

2011

307

901

156

535

2012

29.4%

3.9%

18.4%

15.6%

5.2%

2.0%

6.0%

35.1%

4.6%

15.0%

13.7%

2.4%

1.8%

4.3%

2012

0.87

:

1.4

0.1

14.5

24.1

11.5

2012

308

910

156

528

2013

29.5%

3.9%

18.6%

15.0%

5.2%

2.0%

6.1%

35.0%

4.5%

15.3%

13.3%

2.4%

1.7%

4.2%

2013

0.94

:

1.5

0.1

:

:

11.1

2013

310

940

155

523

2014

29.3%

4.1%

18.7%

15.0%

5.3%

2.0%

6.1%

34.7%

4.7%

15.5%

13.5%

2.5%

1.6%

4.0%

2014

1.09

:

1.5

0.2

14.7

22.4

11.5

2014

311

:

155

524

2015

29.5%

4.1%

18.7%

14.7%

5.4%

1.9%

6.0%

34.8%

4.7%

15.6%

13.2%

2.6%

1.6%

3.9%

2015

1.25

:

1.7

0.2

:

:

:

2015

312

:

154

518

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

330

835

78

408

338

825

78

407

2013

6.2

16

344

833

78

402

2015

6.3

16

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

7.0

16

6.8

16

6.8

16

6.7

16

6.7

16

6.7

16

6.8

16

6.7

16

6.4

16

6.3

15

:

15

6.2

17

6.2

16

9,629

10,205

9,378

9,287

9,158

9,297

9,541

9,731

9,982

10,265

10,563

6,362

6,584

7,143

7,635

74.0

5.9

37.0

74.0

5.9

38.6

73.9

11.2

36.8

74.2

10.9

36.8

74.4

10.5

36.3

75.0

10.2

36.9

75.0

10.1

37.6

75.0

10.1

38.2

75.8

10.1

39.0

75.1

10.1

39.8

:

:

40.7

77.1

8.0

28.0

76.4

7.8

29.1

76.5

7.7

30.9

76.8

7.6

32.3

Projected public expenditure on healthcare as % of GDP*

2016

2020

2025

2030

2035

2040

2045

2050

2055

2060

2065

2070

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

7.9

7.9

8.0

8.1

8.1

8.3

8.2

8.5

8.3

8.6

8.4

8.8

8.4

8.9

8.4

9.0

8.4

9.1

8.4

9.1

8.3

9.1

8.3

9.1

Population projections

Population projections until 2070 (millions)

2016

66.7

2020

67.8

2025

69.2

2030

70.5

2035

71.8

2040

72.9

2045

73.7

2050

74.4

2055

74.9

2060

75.5

2065

76.2

2070

76.9

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

Change 2016-2070, in pps.

France

0.5

1.2

EU

0.9

1.6

Change 2016-2070, in %

France

15.4

EU

2.0

r

E
u
o
p
e
a
n
C
o
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m

i
s
s
i
o
n

i

J
o
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p
o
r
t
o
n
H
e
a

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C
a
e
a
n
d
L
o
n
g

r

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T
e
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C
a
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y
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m

r

s
a
n
d
F
i
s
c
a

l

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u
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t
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i

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-

C
o
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D
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c
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e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2.11. GERMANY 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

GDP per capita in PPS is at 33,200 and above the 
EU average of 29,600 PPS in 2015. Germany has a 
population of 81.2  million inhabitants. During  the 
coming  decennia  the  population  will  steadily 
decrease, from 82.1 million inhabitants in 2016 to 
79.3 million inhabitants in 2070, depending on the 
migration rate. Thus, Germany is facing a decrease 
of  its  population  by  3%,  while  the  EU  average 
population is estimated to increase by 2%.  

Total and public expenditure on health as % of 
GDP 

Total expenditure on health was one of the highest 
in the EU at 11.2% of GDP in 2015 (EU: 10.2%). 
Total  public  spending  on  health  was  at  9.4%  of 
GDP  (EU:  8.0%).  Looking  at  health  care  without 
long-term  care (154)  reveals  a  similar  picture  with 
public spending above the EU average (DE: 8.1% 
vs. EU: 6.8% in 2015). Spending relative to GDP 
was quite constant between 2003 and 2008, with a 
sharp increase due to falling GDP in 2009, and has 
stayed  on  this  level  in  2015.  In  2015,  16.0%  of 
total  government  expenditure  was  channelled 
towards  health  spending  (EU:  15.0%).  In  per 
capita terms, total (3,981 PPS) and public spending 
(3,365  PPS)  are  well  above  the  respective  EU 
averages (3,305 PPS and 2,609 PPS) (155).  

Expenditure projections and fiscal sustainability  

As a consequence of population ageing, health care 
expenditure for the insured in the Statutory Health 
Insurance  is  projected  to  increase  by  0.7  pps  of 
GDP (156),  below 
level 
expected  for  the  EU  (0.9  pps  of  GDP),  according 

the  average  growth 

(154) To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(155) Note  that  these  PPS  figures  reflect  current  plus  capital 
health expenditure in contrast to Eurostat data series, which 
reflect only current expenditure. 

(156) Due  to  some  institutional  specificities,  the  projections  for 
Germany include solely expenditure of the Statutory Health 
Insurance Funds and the State, and exclude expenditure of 
the  mandatory  Private  Health  Insurance  Funds.  Thus,  the 
projections  for  Germany  cover  approx.  87%  of  the 
population insured at the Statutory Health Insurance. 

to  the  "AWG  reference  scenario"  (157).  When 
taking into account the impact of non-demographic 
drivers  on  future  spending  growth  (AWG  risk 
scenario),  health  care  expenditure  for  the  insured 
in  the  Statutory  Health  Insurance  is  expected  to 
increase  by  1.5  pps  of  GDP  from  now  until  2070 
care 
(EU:  1.6).  Overall,  projected  health 
is  expected 
increase 
to 
expenditure 
budgetary 
fiscal 
pressure.  However, 
sustainability risks appear over the long run as the 
favourable 
initial  budgetary  position  would 
mitigate  the  projected  increase  in  age-related 
expenditure (158). 

to  add 
no 

Health status  

Life expectancy at birth is 78.3 years for men and 
83.1 years for women, being one of the highest in 
the  EU  (EU:  77.9  for  men  and  83.3  for  women). 
Healthy  life  years  are  also  above  the  EU  average 
(65.3  vs.  62.6  years  and  67.5  vs.  63.3  years) 
Amenable  mortality  rates,  i.e.  deaths  that  should 
not  occur  with  timely  and  effective  care,  are  well 
below EU average.  Infant mortality is at the level 
of 3.3‰ (EU: 3.6‰). 

System characteristics  

financing, 

collection 
System 
mechanism,  coverage  and  role  of  private 
insurance and out of pocket co-payments 

revenue 

in 

the  SHI 

The German health care system provides universal 
coverage.  Insurance  is  compulsory  and  provided 
by  either  statutory  (SHI)  (around  90%  of  the 
population) or private health insurance (PHI). The 
membership 
for 
employees  with  gross  income  not  exceeding  a 
legally  defined  threshold,  covering  in  most  cases 
also  the  spouses  and  children  of  the  insured 
without  additional  contributions.  High-earners 
with  a  monthly  income  exceeding  a  specified 
threshold,  the  self-employed  and  civil  servants 
have to contribute towards a private insurance.  

is  mandatory 

SHI  provides  a  standardised  benefits  package. 
Premiums  are  income  dependent  but  do  not 

(157) The 

2018 

Ageing 

Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(158) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

101 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

dependent  on  individual  health  risks.  In  contrast, 
PHI  premiums  depend  on  the  individuals’  health 
risks  and  not  on  income.  The  benefit  package  is 
based on an insurance contract and co-insurance of 
family  members  requires  additional  premiums. 
Once  covered  by  PHI,  the  possibility  to  switch 
back to SHI is restricted. 

(Gesundheitsfonds) 

SHI  is  predominately  financed  through  labour-
income-dependent contributions accompanied by a 
complementary government subsidy. Since 2009, a 
National  Health  Fund 
is 
responsible  for  pooling  contributions  paid  at  a 
uniform rate set by the Federal government. From 
January  2015  on,  the  uniform  contribution  rate  is 
set  at  14.6%  (7.3%  and  7.3%  paid  by  employers 
fund), 
(pensioners)  and  employees 
respectively.  Yet,  the  SHIs  may  charge  additional 
surcharges  if  expenses  do  not  cover  expenditures. 
The introduction of additional surcharges increases 
competition  between  SHIs  (see  explanation  of  the 
SHI health financing reform below). 

(pension 

The  collected  contributions  are  pooled  and 
complemented  by  a  federal  tax  subsidy.  They  are 
allocated  then  to  the  individual  sickness  funds  in 
the  form  of:  (i)  a  uniform  basic  lump-sum  per 
person  insured,  (ii)  payments  adjusted  for  risk, 
gender,  invalidity,  age  and  morbidity  from  80 
chronic  and  serious  illnesses;  and  (iii)  additional 
funds  to  cover  other  standard  expenditure  (e.g. 
administrative costs).  

are 

public 

non-profit 

In  2018,  the  SHI  was  composed  of  110  sickness 
funds,  which 
law 
corporations  and  financially  and  organisationally 
independent bodies. The number of SHI funds has 
decreased  from  over  1,123  in  1992,  mainly  as  a 
result  of  reforms  aimed  at  strengthening  the 
competition  among  health-care  insurers.  There  is 
an obligation for sickness funds to insure anybody 
to  SHI.  A  risk  adjustment 
who 
mechanism redistributes funds across SHI funds to 
better reflect actual morbidity costs.  

is  entitled 

In  2015,  the  SHI  bore  58%  of  total  health 
expenditure.  Other  social  insurance  schemes  bore 
another  10.6%,  the  PHI  8.39%,  public  authorities 
4.6%  and  employers  4.2%.  Private  out-of-pocket 
total  health 
payments  amount 
expenditures  (EU:  15.9%).  Private  expenditure 
with  16.5%  was  below  the  EU  average  of  21.6%. 
Since  2004,  patients  need  to  provide  certain  co-

to  12.5%  of 

102 

payments  limited  to  2%  of  an  annual  household 
income, respectively to 1%  for the chronically ill. 
The  quarterly  fee  paid  by  patients  for  medical 
treatment  (Praxisgebühr)  was  abolished  at  the 
beginning  of  2013,  after  having  been  assessed  as 
ineffective. 

The  health  reform  (GKV-Finanzstruktur-  und 
Qualitätsweiterentwicklungsgesetz), that came into 
force  in  January  2015,  promotes  a  quality-based 
competition among health funds. Its main elements 
are  the  following.  The  general  contribution  rate 
was  decreased  from  15.5%  in  2010  to  14.6%, 
while  freezing  the  contribution  rate  paid  by 
employers  at  7.3%.  The  0.9%  employee’s 
contribution surcharge was abolished. Health funds 
received  greater  financial  autonomy  due  to  the 
lowering  of  the  uniform  contribution  rate  and  the 
introduction  of  health  insurance  fund-specific, 
income-related  surcharges  to  cover  expenditures 
exceeding risk-adjusted allocations. A full revenue 
compensation  scheme  for 
income-related 
surcharges  was  introduced  to  avoid  incentivising 
risk selection. 

the 

Administrative organisation 

The responsibility for the system is shared between 
national  and  regional  level  (Länder).  At  the 
national level the legal framework for both tiers of 
the  insurance  system  is  set.  The  Länder  are 
responsible  for  organising  medical  education, 
planning inpatient capacities  and financing capital 
investments  in  hospitals.  Large  sections  of  the 
German  health  care  system  are  shaped  through 
contracts  between  the  SHI-funds  and  various 
health care providers.  

A  special  feature  in  the  regulation  of  medical 
services  of  the  German  health  care  system  is  the 
important  role,  alongside  that  of  the  legislature, 
played  by  the  self-governing  bodies  of  service 
providers  and  health  insurance  funds.  In  the 
statutory  health 
the  major 
decision-making  body 
the  Federal  Joint 
Committee  (G-BA).  It  is  formed  by  the  national 
associations  of  doctors  and  dentists,  the  German 
Hospital  Federation  and  the  National  Association 
of  Health  Insurance  Funds.  Thus,  the  G-BA 
determines the benefit catalogue of the SHI as well 
as on binding collective regulations on the quality 
of health care services. 

insurance  system 
is 

 
Treatment options, covered health services 

prescription 

drugs,  medical 
and  palliative 

SHI  covers  preventive  services,  inpatient  and 
outpatient hospital care, physician services, mental 
health  care,  dental  care,  optometry,  physical 
aids, 
therapy, 
rehabilitation,  hospice 
care, 
pregnancy  care,  maternal  leave  and  sick  leave 
compensation.  SHI  preventive  services  include 
regular  dental  check-ups,  child  check-ups,  basic 
immunisations,  check-ups  for  chronic  diseases, 
and  cancer  screening  at  certain  ages.  All 
prescription drugs - including newly licensed ones 
-  are  covered  unless  explicitly  excluded  by  law 
lifestyle  drugs)  or  pending 
(mainly  so-called 
evaluation.  While 
the 
the  broad  contents  of 
benefits  package  are  legally  defined,  specifics  are 
decided upon by the Federal Joint Committee.  

Types of providers, referral systems and patient 
choice   

Primary  care  is  provided  by  private  for-profit 
physicians, most of whom run individual practices, 
and  about  25%  share  a  practice.  The  majority  of 
doctors are accredited for SHI. They can also take 
private  patients  and  charge  them  higher  prices. 
Traditionally, the German health-care system does 
not have a gate-keeping system and the patients are 
free  to  choose  any  doctor  under  a  contract  with 
their  sickness  fund.  SHI  operates  with  collective 
contracts  covering  provision  by  all  doctors  of  a 
certain  region.  There  is  no  affiliation  to  a  single 
sickness fund. Additionally, there is also the option 
for  selective  contracts  for  a  range  of  services  or 
specific  care  models.  More  recently,  patients  are 
encouraged to choose a family doctor. 

The  number  of  physicians  has  grown  constantly 
over  the  recent  decade:  from  340  per  100,000 
inhabitants in 2005 to 414 in 2015, well above the 
EU average of 344. Over the same period of time, 
the  number  of  general  practitioners  has  stayed 
nearly  constant  at  66  per  100,000  between  2005 
and  2015  (EU:  78).  The  number  of  nurses  is  at 
1,334  per  100,000  in  2015,  remaining  well  above 
the  EU  average  of  833.  Total  and  public 
expenditure  on  outpatient  care  as  a  %  of  current 
health expenditure were at the EU average (around 
22%).  

Germany  has  the  highest  per-capita  hospital  beds 
for  curative  (acute)  care  in  the  EU:  611  beds  per 

Health care systems 

2.11. Germany 

100,000 inhabitants in Germany in 2015 compared 
to  402  in  the  EU.    Obviously,  access  to  inpatient 
care  is  high.  This  is  despite  a  constant  decline  of 
hospital  bed  capacity  in  the  past,  driven  by  a 
decrease  in  the  average  length  of  stay,  which  still 
remains above the EU average.  

inhabitants 

Contrary  to  the  general  trend  in  the  EU,  the 
number  of  hospital  inpatient  discharges    is  rising 
from  21.3  in  2005  to  24.9  in  2015  per  100 
inhabitants (EU: 16.2 in 2015). At  the  same time, 
the  level  of  day  case  discharges  is  very  low  with 
in 
677  discharges  per  100,000 
Germany, versus 7,635 discharges in the EU. The 
low  number  of  day  case  discharges 
is  a 
consequence  of  the  disintegrated  system  of  care, 
which basically limits the room  for providing day 
case 
in  German  hospitals.  Public 
inpatient care accounts  for roughly 31% of public 
expenditure  on  health  in  Germany  compared  to 
32% in the EU. High expenditure levels may be a 
sign  of  a  modern  hospital  system  providing  high-
quality  services.  They  may,  also,  reflect  hospital 
centrism,  an  overprovision  of  inpatient  services,  a 
focus on costly high-technology treatments and an 
undervaluation  of 
(cheaper)  ambulatory  care 
services (at the same level of quality of care). 

treatments 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Physicians and other health professionals  working 
in  hospitals  or  institutions  for  nursing  care  or 
rehabilitation  are  paid  salaries.  Public  and  non-
profit  providers  usually  pay  public  service  tariffs 
to 
their  employees,  while  private,  for-profit 
providers  may  pay  lower  or  higher  wages  or 
additional  payments  to  their  employees.  Services 
provided by the ambulatory care providers, as well 
as  by  private  physicians,  dentists,  pharmacists, 
midwifes and other health professionals are subject 
to predetermined price schemes or price ranges. 

Medical  billing  is  based  on  the  standard  schedule 
of fees (Einheitlicher Bewertungsmaßstab - EBM). 
It is the fee schedule that applies to outpatient care 
and,  in  the  form  of  fees-for-service  or  flat  rates, 
comprises  all  services  that  outpatient  doctors  can 
bill  for  reimbursement  by  the  statutory  health 
insurance funds. Patients covered by PHI pay out-
of-pocket  on  a  fee-for-service  basis.  Doctors  may 
charge higher fees for private patients – based on a 
medical fee schedule for private patients. 

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Hospital  expenditures  are  financed  using  two 
different  mechanisms.  Investment  is  financed  by 
the  regions  (Länder),  mainly  through  regional 
taxes,  while  recurrent  expenditure  (thus,  mainly 
cost  of  care)  is  reimbursed  by  the  SHI-funds  and 
PHI. Recurrent expenditures of acute hospitals are 
reimbursed  by  the  SHI-funds  according  to  the 
Diagnosis-Related  Group  (DRG)  system,  with 
some exceptions. 

The market for pharmaceutical products 

therapeutic  substitutes. 

Until  2011,  prices  of  medicines  were  mainly 
internal  reference  pricing  for 
determined  by 
generics  and 
Internal 
reference  prices  are  price 
limits  on  certain 
pharmaceutical  substance  groups.  The  G-BA 
specifies  the  groups  of  active  ingredients.  The 
National  Association  of  Health  Insurance  Funds 
sets  the  reference  prices,  considering  that  enough 
medicines are available at that price. Patients have 
to  bear  the  price  difference  for  any  drug  whose 
price  exceeds  the  reference  level.  This  sets  strong 
incentives to producers not to set prices above the 
reference  price.  In  contrast,  prices  of  newly 
invented  drugs  were  unilaterally  set  by 
the 
producer.  

(AMNOG) 

the  Reform  of 

the  Market  for 
Since  2011, 
Pharmaceutical  Products 
obliges 
producers  to  verify  the  additional  therapeutic 
benefit of new patented medicines. If an additional 
benefit  is  proven,  the  National  Association  of 
Statutory  Health  Insurance  Funds  negotiates  the 
price  for  the  medicine  with  the  pharmaceutical 
company.  If  an  additional  benefit  is  not  proven, 
new  active  pharmaceutical  ingredients  are  subject 
to reference pricing. If this is not possible the price 
must  not  be  higher  than  the  price  of  the  therapy 
standard.  

AMNOG aims at ensuring fair prices that balance 
the interests of both, the statutory health insurance 
as  well  as  the  pharmaceutical  companies.  As  a 
further  cost-containment  measure, 
the  SHI-
Amendment  Law  (in  force  since  August  2010) 
introduced  a  mandatory  discount  of  16%  on 
pharmaceuticals 
freeze  of  prices  of 
pharmaceuticals until 2013. With the 13th and 14th 
SGB V-Amendment Law (in force since December 
2013 respectively April 2014) the price freeze was 
extended  until  2017  and  while  the  mandatory 
discount of 16 % ran out by the end of 2013, there 

and 

104 

is still a remaining mandatory discount of 7 % (16 
%  for  generics).  With  the  Pharmaceutical  Care 
Strengthening  Act  (AMVSG)  the  price  freeze  was 
extended  until  2022,  though  from  2018  onwards 
price  increases  in  line  with  inflation  will  be 
allowed. However, the prize freeze does not apply 
for  medicines  that  have  been  subject  to  internal 
is  not  relevant  for 
it 
price  referencing  and 
medicines  that  have  a  negotiated  price  after  the 
AMNOG-procedure.  

Pricing  policies  are  supplemented  by  financial 
incentives  and  the  monitoring  of  prescription 
patterns  of  physicians  vis-à-vis  prescription 
guidelines and prescription targets. 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

factors 

(HTA) 

in  maintaining 

Health  Technology  Assessment 
is 
increasingly  used  in  Germany  to  inform  health-
care  decision-making.  Quality  and  efficiency  are 
two  deciding 
the 
performance of the German health care system. To 
achieve  this  aim,  it  is  important  to  examine 
objectively  the  advantages  and  disadvantages  of 
the 
medical  services 
responsibility  of 
the 
for  Health  Technology 
German  Agency 
Assessment  (DAHTA),  which  runs 
the  HTA 
information  system  and  the  Institute  for  Quality 
and Efficiency in Health Care (IQWiG). IQWiG is 
an independent scientific institute that investigates 
the benefits and harms of medical interventions for 
patients.  

for  patients.  This 
is 
two  German  Institutes: 

eHealth (e-prescription, e-medical records) 

One of the  most important eHealth projects in the 
German  health  care  system  is  the  adoption  of  an 
eHealth  card  and  a  telematics  infrastructure.  The 
eHealth  card  is  meant  to  contribute  to  better 
medical care provision, to improve communication 
among  all  of  the  parties  involved  and  ensure 
greater efficiency in health care processes. To this 
end,  the  application  possibilities  for  the  eHealth 
card are to be expanded step by step,  whereas the 
eHealth  card  has  been  distributed  to  the  ca.  70 
million publicly insured persons in Germany.  

A  new  act  on  eHealth,  which  came  into  force  in 
December 2015, accelerated the deployment of the 
applications  of  the  eHealth  card,  setting  clear 

 
to 

further  specifications 

deadlines  and 
the 
entrusted  company  (Gematik).  In  addition,  the  act 
on eHealth set out further incentives with regard to 
telemedicine as well as supporting interoperability. 
Gematik  is  responsible  for  the  national  telematics 
infrastructure  and  the  applications  of  the  eHealth 
card and supported by the self-administration. The 
act on eHealth also supported Gematik´s continued 
work to support interoperability at EU-level.  

As  set  out  in  the  act  on  eHealth,  from  the  end  of 
2018  onwards  patients  in  Germany  can  choose  to 
have  the  relevant  emergency  data  stored  on  their 
health  card.  Also  an  electronic  medication  plan  is 
planned to be available by end of 2018, including a 
verification  of  drug  treatment  safety  among  care 
implementation  of  Electronic 
providers.  The 
Patient  Health  Records  will  follow  and  should  be 
completed  by  2021.    They  will  be  managed  by 
health professionals, but also patients  will be able 
to store data and access the information  stored by 
health  professionals.  The  design  of  the  German 
telematics  infrastructure  fulfils  the  highest  safety 
standards:  there  are  clear  rights  of  access  and  the 
accessing  of  data  by  physicians  is  recorded. 
Medical  data  is  encrypted.  At  all  times,  patients 
have  control  over  their  data  and  decide  whether 
and which medical data may be stored and who is 
entitled to read them.  

Health  and  health-system 
reporting mechanisms 

information  and 

The planning of measures on health care provision 
is  based  on  a  range  of  information  and  research 
made  available  by  various  actors  at  the  federal, 
state  and  corporatist  levels.  For  example,  the 
Federal  Association  of  Sickness  Funds  and  the 
Federal Association of SHI Physicians are obliged 
by  law  to  provide  and  publish  statistics  on  their 
financial performance and activities and about the 
structure  of  their  membership.  Additionally,  these 
and  other  stakeholders  are 
financing  health 
services  research,  health  policy  research  and 
publish  related  reports  and  statistics.  A  large 
number  of  health  statistics  is  published  by  the 
Federal Statistical Office. An Advisory Council on 
the Assessment of Developments in the Healthcare 
System  reports  every  two  years  to  the  Federal 
Ministry of Health on current developments in the 
health care system. 

Health care systems 

2.11. Germany 

Health  promotion  and  disease  prevention 
policies 

Preventive 

Total  and  public  expenditure  on  prevention  and 
public health services as a % of total current health 
expenditure  were  at  EU  average  in  2015.  The 
German 
Act 
(Präventionsgesetz)  has  given  a  further  boost  on 
to 
health  prevention.  SHI-funds  are  obliged 
provide  more  disease  prevention  and  health 
promotion  activities  especially  in  the  settings  and 
spend  more  money  in  this  sector  (See  section  on 
recently legislated reforms). 

Health 

Care 

Transparency and corruption 

is 

fulfil 

incumbent  on 
and 

The  task  of  supervising  whether  doctors,  dentists, 
their 
pharmacists  and  psychotherapists 
the 
professional  obligations 
specific  professional  organisations 
the 
professional  disciplinary  tribunals.  Professional 
obligations  include  the  observance  of  specific 
prohibitions 
inadmissible  business 
relations and forms of cooperation, or relations that 
are prone to corruption, with other benefit and care 
providers.  Statutory  disclosure  obligations  apply, 
for  example,  to  fees  and  remuneration  received 
within the framework of surveys and observational 
non-interventional 
the  context  of 
medicinal products supply.  

regarding 

trials 

in 

and/or 

associations 

The  health  insurance  funds,  together  with  the 
outpatient  doctors' 
the 
associations  of  the  other  care  providers,  are 
responsible  for  verifying  the  observance  of  the 
rules applicable in the statutory health care system 
regarding  the  cost-effectiveness  of  care  provision 
and  the  mathematically  and  factually  accurate 
settlement  of  claims  for  benefits  and  services  by 
offices 
the 
responsible  for  combating  misconduct 
the 
in 
statutory  health  insurance  have  been  set  up  at  all 
health  insurance  funds  and  outpatient  doctors' 
associations  as  well  as  their  associations  at  Land 
and federal level.  

Furthermore, 

providers. 

care 

the  Act 

to  Combat  Corruption 

In  2016, 
in 
Healthcare entered into force, whereby active and 
passive  bribery  in  the  health  care  sector  were 
added  as  criminal  offences  to  the  Criminal  Code 
(sections 299a, 299b). This goes back to a decision 
by the Federal Supreme Court from 2012 that had 
identified criminal liability loopholes in regards to 

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the  application  of  the  bribery  provisions  in  the 
to  healthcare  professionals, 
Criminal  Code 
specifically  doctors  working 
the  field  of 
in 
statutory health insurance. 

Recently 
reforms 

legislated  and/or  planned  policy 

The increase in the elderly population will result in 
a  greater  need  for  health  and  long-term  care 
benefits.  The  federal  government  addresses  these 
challenges  in  its  recent  reforms  to  the  health  care 
system  and  has  implemented  several  structural 
health  care  reforms  to  strengthen  competition  in 
the  health  care  system  in  order  to  improve 
efficiency  in  health  care  provision.  A  sustainable 
funding  for  health  care  provision  was  emphasised 
in particular as part of this process.  

The  Reform  of  the  Market  for  Pharmaceutical 
Products  (AMNOG)  in  2011  was  a  far-reaching 
structural reform that aimed at curbing expenditure 
growth  of  medicines.  The  AMNOG  obliges 
producers  to  verify  the  additional  therapeutic 
benefit  of  new  patented  medicines.  The  AMNOG 
also allows for the possibility of price negotiations 
for  patented  medicines  instead  of  unilateral  price 
setting by the producers. 

The  Health  Financing  Reform  (Act  on  the  further 
development  of  the  Statutory  Health  Insurance 
System's  Financial  Structure  and  Quality),  which 
came into force in January 2015, promotes quality-
based  competition  among  providers  and  health 
funds.  Health  funds  received  greater  financial 
autonomy  due  to  the  lowering  of  the  uniform 
contribution  rate  and  the  introduction  of  health 
insurance fund-specific, income-related surcharges 
to  cover  expenditures  exceeding  risk-adjusted 
allocations.  The  idea  behind  the  surcharges  is  to 
foster  competition  among  statutory  health  funds. 
Through  increasing  the  financial  autonomy  of 
health  funds  and  by  implementing  a  consistent 
quality  focus  in  health  care  provision,  the  cost-
effectiveness  of  public  spending  should  be 
improved. At the same time,  freezing the share of 
employers'  health  insurance  contributions  at  7.3% 
aimed  at  containing  wage  related  costs. The  latter 
measure,  however,  will  be  reversed  as  of  January 
2019 (GKV-GEK). 

The  establishment  of  an  Institute  for  Quality 
Assurance  and  Transparency  in  the  healthcare 

106 

sector  (IQTIG),  as  specified  in  the  Act  to  Further 
Develop the Financial Structure and Quality of the 
Statutory  Health  Insurance  System,  strengthens 
competition  in  terms  of  quality  in  the  statutory 
health insurance system. The aim is for patients to 
have  a  set  of  transparent  criteria  which  they  can 
use  to  ascertain  which  specific  hospitals  offer  the 
best  quality  for  a  specific  treatment,  for  instance. 
Higher quality in hospital care, should translated in 
fewer  complications  and  re-admissions  and  will 
lead,  in  the  medium  to  long  term,  to  a  more 
efficient  use  of 
to  greater 
sustainability in the German health care system. 

resources  and 

goals 

resources. 

Representatives of the federal government and the 
Länder  agreed  for  structural  reform  measures  in 
the hospital sector that came into force in January 
2016  (KHSG  –  Krankenhausstrukturgesetz).  The 
aim  was  to  boost  the  efficiency  of  hospital  care  – 
ranging  from  nationwide  care  provision  to  high-
end  medical care – by improving the efficient  use 
of 
included 
Important 
strengthening  the  quality  of  care  as  a  criterion, 
when  it  comes  to  hospital  planning  and  the 
remuneration  of  services,  and  establishing  a 
promotion  programme  for  nursing  homes.  A 
structural  fund  was  set  up  to  finance  measures  to 
improve  existing  care  structures.  To  this  end,  a 
one-time  disbursement  of  500  million  euros  was 
made  from  the  liquidity  reserve  of  the  national 
health fund. This money was supposed to be used 
to finance projects proposed by the Länder, if the 
latter  contribute  to  an  equal  amount.  Thus,  a 
maximum  of  1  billion  euros  funding    was  made 
available  in  order  to  promote  the  reduction  of 
excess  capacity  and 
transformation  and 
the 
concentration  of  hospital  capacities.  Presumably, 
all of the available funds will be used until the end 
of 2018.  

In  addition  to  that  a  legislation  is  planned  which 
focusses  on  the  further  improvement  of  hospital 
care.  This  legislation  is  supposed  to  enter  into 
force  in  the  year  2019  and  contains  for  example 
measures  to  improve  the  reconciliation  of  work 
and  family  and  financing  measures  in  order  to 
improve the current staff situation in hospital care. 
Furthermore, the above mentioned  structural fund 
will  be  continued  for  four  more  years  with  a 
disbursement  of  one  billion  euros  per  year.  Such 
amount is to be contributed by the liquidity reserve 
of the national health fund and the Länder in equal 
shares.  Finally,  the  German  federal  government 

 
recently  submitted  draft  legislation  providing  for 
minimum  nurse  to  patient  ratios  in  selected  fields 
of  hospital  services  in  order  to  improve  patient 
services  and  working 
security,  quality  of 
conditions in the hospitals. 

as 

centres, 

child  day-care 

The  federal  government  introduced  a  "Preventive 
Health  Care  Act"  that  entered  into  force  in  July 
2015.  At  the  core  of  this  law  is  the  strengthening 
of prevention and health promotion in the settings, 
such 
schools, 
workplaces,  neighbourhoods  or  in  long-term  care 
facilities. The intention is to achieve this through a 
much  better  fine-tuning  of  efforts  undertaken  by 
persons  responsible  for  these  settings  at  federal, 
regional  (Land)  and  municipal  level.  Expenditure 
by  the  health  insurance  funds  on  prevention  and 
health  promotion  is  to  be  almost  doubled.  The 
additional  expenditure  shall  be  offset  in  the 
medium  and  long  term  by  cost  savings  achieved 
through  avoided  costs  of  diseases.  Additionally, 
early  detection  screening  among  children,  young 
persons  and  adults  will  continue  to  be  developed 
and  important  measures  shall  be  taken  to  close 
vaccination gaps. 

the  Act 

introduced 

In  order  to  ensure  a  needs-based,  universal  and 
easily  accessible  supply  of  medical  care,  the 
to 
federal  government 
Strengthen Care Provision in the Statutory Health 
Insurance  System  (Care  Provision  Strengthening 
Act)  that  came  into  force  in  July  2015.  The 
primary objective of this law is to ensure a proper 
supply  of  physicians  both  in  the  cities  and  in  the 
rural  areas.  The  role  of  family  doctors  is  to  be 
strengthened.  The  strain  on  doctors  is  to  be 
reduced  by  allowing  them  to  delegate  selected 
to  qualified  non-physician 
medical 
personnel, 
for  example,  practice  assistants. 
Moreover,  in  the  future,  hospitals  in  underserved 
areas  will  be  able  to  assume  more  responsibility 
for  medical  care.  In  order  to  promote  innovative 
care 
inter-sectoral 
cooperation  among  health  care  providers  and  to 
stimulate  research  on  health  care  provision,  an 
innovation  fund  has  been  set  up  at  the  Federal 
Joint  Committee,  endowed  with  EUR  300  million 
annually – initially from 2016 to 2019. 

structures, 

facilitate 

services 

to 

The coalition agreement from February 2018 calls 
for  further  amendments  to  improve  the  access  to 
healthcare  with  action  focusing  on  minimising 

Health care systems 

2.11. Germany 

waiting times for outpatient care appointments and 
on improving outpatient medical care.  

the 

introduced  by 

Telemedicine and digital technologies can provide 
vital  support 
the  supply  of 
in  organising 
healthcare.  In  order  to  make  these  advantages 
available nationwide as soon as possible a new act 
federal 
on  eHealth  was 
government  and  came  into  force  in  December 
2015. The act on eHealth contains an overall plan 
to  accelerate  the  deployment  of  the  telematics 
infrastructure  and  the  applications  to  the  eHealth 
emergency  data, 
electronic 
Card 
medication  plan  and  electronic  health  records  as 
well as to set out further incentives with regard to 
telemedicine.  Digital  technologies  are  meant  to 
to  better  medical  care  provision, 
contribute 
improve 
all  parties 
among 
communication 
involved  and  ensure  greater  efficiency  in  health 
care processes (See above the section on eHealth: 
e-prescription, e-medical records). 

such 

as 

Further legal adaptations to the eHealth framework 
are  foreseen  in  2018,  so  that  patients  will  be  able 
to  access  eHealth  applications  via  their  mobile 
phones  and  health  insurances  will  be  obliged  to 
introduce Electronic Health Records by 2021 at the 
latest.   

Challenges 

to 

The  analysis  above  shows  that  a  wide  range  of 
promising reforms has been implemented in recent 
years 
sustainability, 
efficiency and quality of health care provision. The 
main challenges for the German health system are 
as follows: 

strengthen 

financial 

spending, 

promoting 

•  To continue increasing the efficiency of health 
care 
and 
integrated care against the background of rising 
the  coming 
health  care  expenditure  over 
decades,  due  to  population  ageing  and  non-
demographic factors. 

quality 

•  To  improve  further  the  coordination  among 
care  providers  and  to  reduce  inter-sectorial 
borders  between  inpatient  and  outpatient  care 
and  to  promote  new  models  of  health  care 
delivery. 

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•  To  promote  further  telemedicine  and  digital 
technologies  in  the  health  care  sector  for  a 
better  medical  care  provision,  for  improving 
the  parties 
communication  among  all  of 
involved  and  to  ensure  greater  efficiency  in 
health care processes. 

•  To  enhance  primary  care  provision  through 
promoting  the  number  and  the  use  of  GPs' 
services. 

•  To  extend  the  possibilities  of  hospitals  to 
provide ambulatory and day  care as  well as to 
transfer  more  health  care  services  into  the 
ambulatory  sector  in  order  to  reduce  the 
number of inpatient care treatments. 

•  To 

further 
and 

of 
promote 
modernisation 
among 
hospitals and to stimulate the further reduction 
of excess capacities. 

the 
specialisation 

process 

•  To  strengthen  further 

the  role  of  health 
promotion and disease prevention in the overall 
health  care  system  as  well  as  in  society  in 
general. 

108 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.11.1:  Statistical Annex – Germany 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

1
0
9

EU- latest national data

2005

2,301

29.1

0.9

:

2005

10.8

10.3

0.5

2006

2,393

30.2

3.9

2.3

2006

10.6

10.1

0.5

2007

2,513

31.5

3.5

1.9

2007

10.5

10.0

0.5

2008

2,562

31.3

1.4

3.5

2008

10.7

10.2

0.5

2009

2,460

28.9

-5.3

4.0

2009

11.8

11.2

0.6

2010

2,580

30.5

4.3

2.6

2010

11.6

11.0

0.5

2011

2,703

31.9

3.7

0.9

2011

11.3

10.8

0.5

2012

2,758

32.1

0.3

0.5

2012

11.3

10.8

0.5

2013

2,826

31.7

0.2

-0.8

2013

11.2

11.0

0.2

2014

2,932

32.6

1.5

2.8

2014

11.3

11.1

0.3

2015

3,044

33.2

0.9

-0.2

2015

11.2

11.2

0.0

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,866

2,936

3,041

3,169

3,351

3,466

3,603

3,678

3,723

3,900

3,981

2,745

2,895

7.9

7.8

7.7

7.7

7.6

7.6

7.8

7.8

9.4

9.3

9.2

9.2

9.0

9.0

9.0

9.0

9.2

9.2

9.3

9.3

9.4

9.4

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,084

2,131

2,212

2,304

2,668

2,768

2,875

2,940

3,075

3,223

3,365

2,153

2,263

2,324

2,609

0.02

72.7

14.3

99.8

14.2

0.01

72.6

14.7

99.8

14.3

0.02

72.7

15.2

99.8

14.2

0.02

72.7

15.5

99.9

14.0

0.01

79.6

15.2

99.9

13.8

0.02

79.9

14.9

99.9

13.9

0.03

79.8

15.4

99.9

13.9

0.03

79.9

16.1

99.9

13.9

0.03

82.6

16.4

100.0

13.2

0.03

82.6

15.9

100.0

12.7

0.02

84.5

16.0

100.0

12.5

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

82.5

82.0

76.7

54.8

54.5

60

3.9

82.4

82.4

77.2

58.3

58.7

56

3.8

82.3

82.7

77.4

58.6

59.0

52

3.9

82.2

82.7

77.6

57.7

56.4

51

3.5

82.0

82.8

77.8

58.1

57.1

50

3.5

81.8

83.0

78.0

58.7

57.9

47

3.4

80.2

83.1

77.9

58.7

57.9

120

3.6

80.3

83.1

78.1

57.9

57.4

118

3.3

80.5

83.1

78.4

57.0

57.8

118

3.3

80.8

83.6

78.7

56.5

56.4

113

3.2

81.2

83.1

78.3

67.5

65.3

116

3.3

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.9

0.1

2.3

1.6

0.5

0.3

0.6

2.6

0.1

1.6

1.2

0.3

0.3

0.4

2.8

0.1

2.3

1.5

0.5

0.3

0.6

2.5

0.1

1.6

1.1

0.3

0.3

0.4

2.7

0.1

2.3

1.5

0.5

0.3

0.5

2.4

0.1

1.6

1.2

0.3

0.3

0.4

2.8

0.1

2.3

1.6

0.5

0.4

0.5

2.5

0.1

1.6

1.2

0.3

0.3

0.4

3.1

0.1

2.5

1.7

0.6

0.4

0.6

2.9

0.1

2.0

1.4

0.3

0.4

0.6

3.0

0.1

2.5

1.7

0.6

0.4

0.6

2.9

0.1

2.0

1.4

0.3

0.3

0.6

3.0

0.1

2.5

1.5

0.6

0.3

0.6

2.9

0.1

2.0

1.3

0.3

0.3

0.5

3.0

0.1

2.5

1.5

0.6

0.3

0.6

2.9

0.1

2.0

1.2

0.3

0.3

0.5

3.0

0.1

2.5

1.5

0.6

0.3

0.5

2.9

0.1

2.1

1.3

0.3

0.3

0.5

3.1

0.1

2.5

1.6

0.6

0.3

0.5

2.9

0.1

2.1

1.3

0.3

0.3

0.5

3.1

0.1

2.5

1.6

0.6

0.3

0.5

2.9

0.1

2.1

1.3

0.3

0.3

0.5

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
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1
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Table 2.11.2:  Statistical Annex - continued – Germany 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

27.8%

0.8%

22.5%

15.4%

5.1%

3.1%

5.5%

32.7%

1.0%

20.5%

14.9%

3.4%

3.6%

5.4%

2006

27.8%

0.9%

22.5%

15.0%

5.2%

3.2%

5.4%

32.7%

1.2%

20.6%

14.8%

3.5%

3.8%

5.2%

2007

27.3%

1.0%

22.5%

15.3%

5.2%

3.4%

5.2%

32.0%

1.3%

20.5%

15.3%

3.4%

4.1%

5.0%

2008

27.1%

1.0%

22.7%

15.3%

5.1%

3.4%

5.2%

31.7%

1.3%

20.5%

15.3%

3.5%

4.1%

5.0%

2009

27.3%

1.0%

22.6%

15.2%

5.1%

3.4%

5.2%

31.2%

1.2%

21.8%

15.2%

3.3%

3.7%

5.9%

2005

2006

2007

2008

2009

:

0.7

3.0

:

13.6

23.2

11.7

2005

340

1116

67

690

2005

8.1

21

591

76.0

8.8

:

2016

7.4

7.4

2016

82.1

:

0.8

2.9

:

:

:

11.8

2006

344

1128

66

617

2006

7.9

21

576

77.0

8.7

2.6

2020

7.5

7.6

2020

83.8

:

0.8

3.0

:

:

:

11.5

2007

349

1150

66

608

2007

8.1

22

578

78.7

10.1

2.5

2025

7.6

7.8

2025

84.4

:

:

3.1

:

15.8

22.8

11.4

2008

354

1174

65

559

2008

8.6

23

596

79.1

9.8

2.6

2030

7.7

8.0

2030

84.6

:

:

3.1

:

14.7

21.9

11.2

2009

362

1204

65

553

2009

9.2

23

613

79.2

9.7

2.6

2035

7.8

8.2

2035

84.5

2010

27.5%

1.0%

22.6%

15.0%

5.2%

3.2%

5.3%

31.4%

1.2%

21.7%

14.8%

3.3%

3.5%

6.0%

2010

2.70

:

3.2

:

:

:

11.2

2010

371

1214

66

546

2010

9.9

23

629

79.0

9.5

2.6

2040

8.0

8.5

2040

84.1

2011

27.8%

0.9%

22.8%

14.2%

5.2%

3.1%

5.2%

31.8%

1.1%

21.9%

14.1%

3.4%

3.4%

5.9%

2011

2.83

:

3.3

:

:

:

11.2

2011

380

1229

66

535

2011

9.7

24

647

79.0

9.3

2.7

2045

8.1

8.7

2045

83.5

2012

27.8%

0.9%

22.8%

14.1%

5.4%

3.1%

5.1%

32.0%

1.1%

21.8%

13.8%

3.3%

3.3%

5.8%

2012

2.81

:

3.3

:

:

:

11.2

2012

387

1238

65

528

2012

9.7

24

655

79.2

9.2

2.6

2050

8.2

8.8

2050

82.7

2013

27.6%

1.0%

22.6%

14.0%

5.5%

2.9%

4.9%

31.6%

1.2%

22.3%

13.7%

3.4%

3.2%

5.5%

2013

2.87

:

3.3

:

15.7

20.9

10.9

2013

400

1290

66

523

2013

9.9

24

656

79.3

9.1

2.6

2055

8.1

8.9

2055

81.8

2014

27.6%

1.0%

22.4%

14.4%

5.5%

3.0%

4.7%

31.5%

1.2%

22.0%

14.3%

3.7%

3.2%

5.3%

2014

3.05

:

3.5

:

16.4

:

11.0

2014

411

1324

67

524

2014

9.9

25

676

79.7

9.0

2.6

2060

8.1

8.8

2060

80.8

2015

27.4%

1.0%

22.3%

14.3%

5.5%

3.0%

4.8%

31.1%

1.2%

21.9%

14.2%

3.6%

3.2%

5.2%

2015

3.36

:

3.5

:

:

:

:

2015

414

1334

66

518

2015

10.0

25

677

79.8

9.0

2.7

2065

8.1

8.9

2065

80.0

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

8.1

8.9

2070

79.3

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Germany

0.7

1.5

EU

0.9

1.6

Change 2016-2070, in %

Germany

-3.5

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.12. GREECE 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

In  2015,  Greece  had  a  GDP  per  capita  of  21,158 
PPS,  below  the  EU  average  of  29,610.  While  the 
economic effects of the crisis cannot be considered 
fully resolved yet, there are signs that the economy 
is improving. Greece is now experiencing a period 
of  steady  growth.  Real  GDP  is  expected  to  grow 
by 2% in 2018, strengthening to 2.2 % of GDP in 
2019  and  2.3%  in  2020 (159).  Growth  in  2019  is 
expected  to  be  supported  by  the  budget  for  2019, 
which  includes  discretionary  measures  to  reach  a 
primary  surplus  of  3.5%  of  GDP  in  line  with 
agreed targets (160). 

Population  was estimated at  10.8 million in 2016. 
According to Eurostat projections, total population 
in Greece is projected to decrease to 7.7 million in 
2070,  with  a  28.7%  decrease,  which  goes  in  the 
opposite direction of the EU as a whole, projected 
to increase on average by 2.0%. 

GDP  (2015),  showed  a  wider  gap  from  the  EU 
average of 7.8% (163).   

When  expressed  in  per  capita  terms,  also  total 
spending  on  health,  at  1449  PPS  in  Greece  was 
below  the  EU  average  of  3305  in  2015.  Public 
spending on health care in the same year was 858 
PPS  vs.  an  EU  average  of  2609  PPS.  Looking  at 
health care without long-term care (164) reduces the 
gap  relative  to  the  EU  average  (4.7%  vs  6.8%  in 
2015).In  all  these  cases,  after  a  steady  decrease 
from  2009  onwards  until  2014,  expenditure 
recorded an increase in 2015. 

Expenditure 
sustainability(165) 

projections 

and 

fiscal 

As a consequence of demographic changes, health 
care expenditure is projected to increase by 1.2 pps 
of  GDP,  above  the  average  growth  expected  for 
the  EU  (0.9)  according  to  the  "AWG  Reference 
Scenario". When taking into account the impact of 
non-demographic  drivers  on 
future  spending 
growth 
risk  scenario"),  health  care 
expenditure  is  expected  to  increase  by  2.0  pps  of 
GDP from now until 2070 (EU1.6) (166). 

("AWG 

Total and public expenditure on health as % of 
GDP 

Health status 

Total expenditure (161) on health as a percentage of 
GDP, at 8.4%, was below the EU average (162) of 
10.2%  in  2015.  Public  expenditure,  at  5.0%  of 

(159) The  growth  forecast  reflects  a  fiscal  package  that  is 
projected to deliver a primary surplus of 3.5 % of GDP in 
2019.  That  forecast  is  different  from  the  Commission's 
2018  autumn  forecast,  which  was  based  on  a  no-policy 
change assumption given that the final package was not yet 
finalised  at  the  time  of  its  cut-off  date.  The  forecast  for 
2020  continues  to  build  on  the  achievement  of  the  fiscal 
target. 

(160) European  Commission  –DG  ECFIN  (2018),  Enhanced 
Surveillance  Report  -  Greece,  November  2018,  European 
Economy Institutional Paper 090, November 2018. 

(161) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(162) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

Life expectancy at birth (83.7 years for women and 
78.5 years for men in 2015) is above the respective 
EU  averages  (83.3  and  77.9  years  of 
life 
expectancy)  (167)  and  overall  it  has  increased 

(163) Figures  concerning  the  share  of  public  expenditure  on 
health in  Greece  and  their interpretation  should be  treated 
with  caution  as  the  statistics  typically  do  not  reflect  the 
actual value of the public provision of goods and services, 
which  largely  exceeds  the  legislated  expenditure  ceilings 
captured  by  the  statistics  due  to  the  extensive  use  of 
payback  mechanisms  that  cover  a  large  share  of  EOPYY 
outpatient public spending. 

(164) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

(165) Greece has just completed the third adjustment programme 
monitored by the EU, the IMF and the ECB. The medium-  
and  long-term  fiscal  sustainability  indicators  S1  and  S2 
point  to  remaining  challenges  to  ensure  future  fiscal 
(2018),  Fiscal 
sustainability 
(European  Commission 
(2018) 
Sustainability 
https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_1.pdf). 
2018 

(166) The 

Ageing 

Report 

Report 

at 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(167) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 

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slightly  since  the  beginning  of  the  crisis.  Healthy 
life  years,  at  64.1  years  for  women  and  63.9  for 
men were above the EU averages of 63.3 and 62.6 
in  2015,  but  they  have  fallen  slightly  since  2005. 
The infant mortality rate of 4‰ was above the EU 
average  of  3.6‰  in  2015,  slightly  increased  since 
2005,  though  with  slight  fluctuations  during  the 
past  decade.  Amenable  mortality  in  2015  well 
matched  the  EU  average  of  127  per  100  000 
inhabitants. 

As  for  the  lifestyle  of  the  Greek  population,  the 
proportion  of  regular  smokers,  recorded  in  2014 
(latest available figure) at 27.3% of the population, 
was above the EU average of 20.9% for 2015 (168) 
and amongst the highest recorded in the EU though 
a marked decrease has taken place during the past 
decade  from  a  value  of  40%  in  2006.  Alcohol 
consumption,  at  7.5  litres  per  capita  in  2014,  was 
lower than the EU average of 10.2 in 2015.  

System characteristics  

financing, 

System 
population  coverage  and 
insurance and out-of-pocket payments  

collection, 
role  of  private 

revenue 

A  mixed  system  in  terms  of  funding  and  service 
delivery  operates  in  Greece.  A  national  health 
service funded by taxation goes hand in hand with 
a  social  health  insurance  system.  A  universal 
health  system  (ESY)  financed  on  the  basis  of 
taxation  was  introduced  in  the  early  1980s.  The 
mandate  of  ESY  is  to  provide  both  primary  and 
secondary  care.  However,  the  actual  provision  of 
services  was  characterised  by  an  underdeveloped 
primary  care  which  resulted  in  exposing  the 
population to high private expenditure. In terms of 
provision, public provision via ESY facilities goes 
in parallel with private provision with a very large 
number and type of private providers contracted by 
EOPYY.  Private  provision  expanded  rapidly  until 
the  eruption  of  the  crisis  (total  health  expenditure 
stood at about 9%  for  much  of the second  half of 
the 2000s, and roughly about 40% of it was private 
spending  –  mostly  out-of-pocket  payments,  as 
private insurance remained limited).  

Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

(168) The EU average value is recorded for 2009. 

112 

Four  decades  after  its  establishment,  the  system 
had  not  developed  into  a  typical  fully-fledged 
national  health  service  despite  the  legal  reforms 
introduced over the 1990s and 2000s. Until the end 
of  2011,  a  highly  fragmented  (multiple  funds), 
occupation-based 
system 
purchased  goods  and  services  in  parallel  and  in 
supplement to the National Health Service.  

insurance 

health 

and  OAEE 

(self-employed) 

(farmers),  OPAD 

Until 
the  2011  reform,  when  EOPYY  (“the 
National  Health  Services  Organisation”)  initiated 
its activity, the employed population  was enrolled 
in  one  of  the  large  number  of  occupation  based 
health insurance funds (the four biggest being IKA 
(civil 
(employees),  OGA 
servants) 
and 
the  population). 
comprising  about  80%  of 
Contribution  rates  varied  across  funds  and  each 
fund  provided  its  own  package  of  health  services 
and  goods.  There  was  no 
risk-adjustment 
mechanism  across  funds  to  account  for  socio-
economic  differences  and  differences  in  health 
conditions  of 
fund's  members.  The 
multiplicity  of  funding  and  the  fragmentation  in 
the system did not contribute to ensuring good care 
coordination  or  defining  effective  care  paths  and 
referral  systems,  and  were  instead  a  significant 
challenge  to  equity,  efficiency  and  effectiveness 
(unequal  access  to  services,  unnecessary  use  of 
specialists  and 
rising  pharmaceutical 
expenditure).  This  was  reflected  in  a  diversity  of 
service  coverage  by  social 
funds 
enhanced by the different ability of funds to access 
private services.  

insurance 

rapidly 

each 

The  crisis  showed  that  the  coverage  available  to 
the unemployed for health care benefits offered by 
social security funds was uneven across funds and 
largely temporary in the case of some professions. 
While  some  groups  continued  to  have  coverage 
two  years  after  becoming  unemployed  (e.g.  those 
insured  with  IKA),  certain  groups  lost  coverage 
immediately  (e.g.  many  of  the  self-employed 
professions).  The  coverage  for  those  who  became 
uninsured  or  those  who  could  not  afford  their 
health  insurance  fees  was  limited  to  very  low 
incomes  (only  those  whose  family  income  was 
below  €6,000  and  held  the  so-called  poverty 
booklet  had  access  to  the  whole  range  of  health 
care services for free).  

Many  Greek  citizens  lost  their  employment  status 
and  therefore  the  insurance  status,  losing  their 

 
                                                                                   
access  to  medicines,  diagnostic  tests  and  non-
emergency primary and secondary care. Preventive 
care such as vaccination, emergency care and care 
reportedly 
to  chronic  diseases  was 
provided  to  everyone.  Whether  in  practice  access 
was  provided 
to  uninsured  persons  anyway, 
notably in terms of primary and hospital care under 
ESY, is unclear (169). 

instead 

of 

the 

economic 

The  economic  and  sovereign  crisis  made  health 
system  reform  a  key  priority  and  a  major 
requirement 
adjustment 
programme.  The  merging  of  all  public  health 
insurance  funds 
into  a  unified  health  fund 
(EOPYY),  initiated  with  Law  3918  of  2011  (and 
subsequent 
legislation),  constitutes  a  major 
development  in  health  insurance  with  the  aim  to 
equalise contribution rates and health care benefits 
across  occupational  groups,  for  those  employed 
and  their  dependents.  EOPYY  became  the  fully-
fledge purchaser of health and services, while ESY 
and private providers provide the necessary health 
goods  and  services.  While  the  implementation  of 
EOPYY  has  been  an  improvement  so  far,  some 
challenges remain, notably the effective allocation 
of  assets  to  EOPYY,  the  persistence  of  arrears  in 
their payments to public and private providers and 
the  collection  of  contributions  and  the  lack  of  a 
comprehensive  primary  care  network  and  service. 
As signalled by a density of GPs that is lower than 
half that of the EU average (32 vs. 78 per 100 000 
inhabitants  in  2015)  (170),  the  primary  health  care 
sector has been historically been underdeveloped.  

In  addition 
the  authorities  consolidated  and 
strengthened existing policies to ensure a coherent 
and universal coverage of all residents and citizens 
independent  of  their  occupational  status.  In  the 
recent  past,  the  Greek  government  had  passed 
several  Ministerial  Decrees  to  grant  access  to  the 
uninsured to primary health care (December 2013), 
secondary care and diagnostics (July 2014) as well 
as pharmaceuticals (July 2014). 

to 

Due 
government 

reported  administrative  hurdles, 

did 

not 

proceed  with 

the 
full 

(169) According to several reports, the uninsured did continue to 
receive  care  unofficially  from  different  health  care 
providers  especially  NHS  (ESY)  providers,  but  this  was 
left  to  the  discretionary  decision  of  providers  and  not 
necessarily done in a systematic manner.  

(170) See  section  "Coverage  of  services,  types  of  providers, 

referral systems and patient choice". 

Health care systems 

2.12. Greece 

implementation and the establishment of universal 
coverage  required  additional 
legal  provisions. 
Reportedly,  up  to  2016,  over  2,000,000  people 
were  still  estimated  to  have  no  health  care 
coverage  due  to  unemployment  (of  the  individual 
or of the household head upon whom they depend) 
or  due  to  discontinued  payment  of  contributions. 
Whereas  it  seems  that  uninsured  did  receive  free 
hospital  care,  although  not  full,  it  is  extremely 
difficult  to  estimate  the  real  level  of  access  at  the 
time  (171). The  actual  implementation  of  universal 
coverage  was  thus  granted  by  the  "Social  Bill"  of 
February  2016,  which  consolidated  and  improved 
previous provisions, tackling the issue of universal 
coverage,  addressing  the  existing  administrative 
shortcomings  (172)  and  extending  coverage  to 
refugees  and  other  vulnerable  groups  in  response 
to recent migration flows. 

The share of private expenditure on health in total 
health  expenditure  (40.7%  in  2015)  is  far  higher 
than  the  EU  average  of  21.6%  for  the  same  year. 
Most is out-of-pocket for private care or for private 
providers  with  a  contract  with  EOPYY.  Out-of-
pocket  expenditure  constitutes  about  35.5%  of 
total  current  health  expenditure,  far  above  the  EU 
average  (15.9%  in  2015).  Though  with  some 
fluctuations  over  the  last  decade,  the  value  is 
relatively  similar  to  the  one  prior  to  the  crisis  in 
2005  (34.8%).  To  a  large  extent,  this  is  due  to 
overconsumption and to higher than average prices 
of  healthcare  goods  and  services.  To  tackle  the 
first  issue,  several  measures  to  monitor,  control 
and  sanction,  where  appropriate,  the  behaviour  of 
providers  were  introduced  over  the  years.  In 
parallel, some co-payments were revised upwards. 
Hospital care is delivered  free of charge in public 
hospitals of the National Health System (ESY). As 
for  contracted  private  clinics  the  amount  patients 
contribute  depends  on  the  reimbursement  system 
(173). For private clinics not contracted by EOPYY, 
full charges apply.  

(171) Recent  figures  provided  by  the  OECD  report  a  level  of 

coverage of 86% in 2015. 

(172) For  instance  removing  the  obligation  for  a  committee  to 
reportedly  hindering 

assess  eligibility,  which  was 
implementation in many cases.  
(173) When  Diagnosis-related  Groups 

(Κλειστό 
Ενοποιημένο  Νοσήλειο-  KEN)  apply,  insured  pay  a  30% 
contribution.  When  daily  fees  apply,  they  pay  a  10% 
contribution 
http://www.missoc.org/missoc/informationbase/comparativ

(DRGs) 

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A  15%  co-payment  for  clinical  tests  when  using 
private providers contracted by EOPYY, in tandem 
with  25%  co-payment  for  a  range  of  prosthetic 
devices,  orthopaedic  materials  and  respiratory 
devices,  and  a  ceiling  on  consumables,  such  as 
diabetic  test  strips,  injection  needles  etc.  Cost-
sharing also applies to pharmaceuticals (a share of 
the price of either 0%, 10% or 25%) depending on 
severity  of  condition  with  exemptions  for  chronic 
conditions  and 
those  with  a  chronic 
condition (174) that opt for generics.  

for 

At  the  same  time  existing  exemptions  from  user 
charges  for  some  groups  have  been  rationalised 
(e.g. for the chronically ill persons exemptions are 
strictly related to their chronic illness). 

In 

EOPYY  and  ESY  are  also  funded  form  the  State 
general  budget.  The  budget  for  ESY  is  defined 
annually in Parliament when the general Budget is 
recent  years,  authorities  have 
approved. 
tightened the monitoring over the budget execution 
of both ESY and EOPYY. The information system 
has  been  strengthened  and  financial  flows  are 
regularly followed up on both an accrual and cash 
basis. 

There  are  also  seven  Regional  Health  Authorities 
and  their  role  vis-à-vis  the  administrative  regions 
is under evaluation. Nevertheless, decision-making 
remains  highly  centralised  (which  may  actually 
have  helped  with  the  implementation  of  cost 
containment policies in recent times). 

Despite  the  increase  registered  in  co-payment 
rates, parallel measures adopted to lower prices of 
goods, such as pharmaceuticals ( 175), and services, 
have  lowered  the  basis  on  which  the  patients 
participation is calculated. However for policies to 
realise  the  full  potential  in  terms  of  containing 
costs 
joint  effort  of  all 
the 
stakeholders is essential. 

for  patients, 

Administrative  organisation  and 
collection mechanism  

revenue 

specifying 

The  Ministry  of  Health  develops  the  national 
health  policy  strategy,  defining  public  health  and 
policy  priorities, 
regulatory 
framework,  defining  the  system  organigram  and 
providing  the  overall  management  of  the  health 
care  system  as  a  whole.  The  Ministry  of  Health 
through  ESY  provides  goods  and  services  to 
residents and citizens of Greece. 

the 

EOPYY, 
Services 
the  National  Health 
Organisation purchases the goods and services for 
its  insurees.  At  the  moment  the  Social  Security 
health-related 
Funds 
contributions  from those insured and submit them 
to  EOPYY.  EOPYY  then  commissions  providers 
of health care, both public and private. 

continue 

collect 

to 

etables/missocdatabase/comparativeTablesSearchResultTre
e.jsp, accessed 8 March 2016. 

(174) For  the  category  entitled  to  10%  copayment,  this  is 
currently not paid if the patient chooses a generic drug. 
(175) See  section  "Coverage  of  services,  types  of  providers, 

referral systems and patient choice". 

114 

EPY  is  the  centralised  purchasing  agency  for  the 
Ministry  of  Health  and  tenders  for  and  purchases 
centrally  medicines  and  medical  devices.  The 
National  Agency  for  Pharmaceuticals  (EOF)  is  in 
charge  of  developing  and  implementing  pricing 
and reimbursement policies, clinical and economic 
evaluation. IDIKA, the IT agency for the Ministry 
of  Labour  maintains  the  e-health  prescription 
system  and  monitoring  prescription  together  with 
EOPYY who receives the data on a daily basis. 

Coverage  of  services,  types  of  providers, 
referral systems and patient choice 

ESY  comprises  primary  and  secondary  specialist 
and  hospital  care  through  a  network  of  public 
facilities.  In  some  rural  areas  it  is  the  main 
provider  of  care.  In  Greece  a  mixed  system  of 
service  delivery  by  public  and  private  providers 
exists  and  there  are  a  range  of  public  and  private 
care  providers.  Public  providers  include  the  ESY 
health  centres  plus  the  former  health  centres  of 
IKA that  have come  under EOPYY and that  have 
now  been  moved  under  ESY  and  the  outpatient 
and  inpatient  departments  of  public  hospitals  and 
public  laboratories.  Private  providers  either  under 
a  contract  with  EOPYY  or  paid  out-of-pocket  by 
the patients include a large variety of laboratories, 
diagnostic centres and hospitals from small to very 
large  companies.  EOPYY  defines  the  services 
included  in  the  statutory  provision.  The  services 
provided  by  ESY  are  not  necessary  explicitly 
defined.  

Poor coordination between primary and secondary 
care  is  a  major  predicament  of  health  care  in 

 
                                                                                   
referral/gate  keeping 

Greece.  The  re-modelling  of  the  primary  health 
care system and of EOPYY aimed to help set up an 
effective 
system.  The 
amalgamation  of  most  health  insurance  funds 
under  a  single  organisation 
(EOPYY)  also 
constituted  a  significant  step  towards  improving 
primary care organisation and provision. Similarly, 
the transformation of EOPYY into a commissioner 
of health care rather than a provider means that its 
former hybrid form as a funding agency (for both 
primary  and  hospital  care)  but  also  a  provider  of 
primary  care  services,  as  well  as  a  contractor  of 
services  to  and  buyer  of  services  from  private 
providers  –  has  been  rationalised.  In  2014,  all 
primary  health  care  centres  of  public  nature  have 
been  grouped  under  the  common  label  of  PEDY 
(National Primary Healthcare Network). De  facto, 
primary care provision has remained inadequate as 
PEDY provided primary care was not sufficient to 
cover the population's needs. This led to access to 
primary  care  through  EOPYY's  contracted  private 
providers, for those who could afford it and to low-
quality  service  and 
for 
vulnerable groups. Addressing this shortcoming is 
a current policy priority and the implementation of 
a  comprehensive  network  of  primary  health  care 
over 
is  currently  ongoing.  The 
authorities  are  rolling-out  a  system  of  primary 
of 
health 
multidisciplinary 
family 
doctors,  who  will  be  the  first  point  of  contact 
between  patients  and  the  health  care  system,  with 
compulsory patient registration and gatekeeping.   

teams  built  around 

long  waiting 

territory 

creation 

based 

care 

lists 

the 

the 

on 

The  number  of  practising  physicians  per  100  000 
inhabitants ( 176) (632 in 2015) is largely above the 
EU  average  (344  in  2015)  and  has  continuously 
increased  since  2005  (506),  both  before  and  after 
the crisis. Data on the physician skill-mix indicates 
that the number of GPs per 100 000 inhabitants (32 
in 2015) is lower than half of the EU average (78), 
which is low but more than twice as high its level a 
decade  ago  (14  in  2005).  This  represents  part  of 
the  authorities'  effort  to  improve  primary  care 
provision. The number of nurses (321 in 2015) per 
100  000  inhabitants  is  itself  far  below  the  EU 
average  (833  in  2015). The  reported  figures  point 
at  an  oversupply  of  doctors  and  undersupply  of 

(176) OECD  data:  no  data  series  available  for  the  variable 
"practicing  physicians" due  to technical  issues. Physicians 
licensed to practice is used here as a proxy. 

Health care systems 

2.12. Greece 

inefficient 

nurses,  which 
allocation of resources. 

is 

indicative  of  an 

In  2015  Greece  had  360  acute  care  hospital  beds 
per  100  000  inhabitants  slightly  lower  than  its 
2005 value of 386), and below the EU average of 
402 for the same year. Greece displays higher than 
average rates of MRI units (2.43 vs EU 1.5 for the 
latest  recorded  value  in  2013),  angiography  units 
(1.1  vs  EU  0.9  in  2013)  and  CT  scanners  (3.5  vs 
EU 2.1 in 2013) per 100,000 inhabitants. 

Purchasing,  contracting  and 
mechanisms 

remuneration 

Remuneration  is  defined  by  the  government.  All 
ESY doctors in primary or secondary care are paid 
on  a  salary  basis  and  directly  by  the  Ministry  of 
Finance.  Hospitals  are  allocated  resources  setting 
the  budget  on 
the  basis  of  historical  and 
prospective  costs,  but  the  authorities  plan  to 
develop  a  Diagnosis-Related  Group  (DRG)(177) 
system  to  be  used  for  hospital  remuneration.  In 
addition  to  the  transfers  from  the  Government, 
hospitals  generate  their  own  revenue,  though  a 
very limited share of the total (178), through special 
services  (e.g.  individual  private  rooms)  and  from 
privately insured patients in the so-called afternoon 
practice. 

There has also been some progress in establishing 
a DRG-based hospital payment system in order to 
ensure  effective  reimbursement  of  hospitals.  The 
first  step  was  to  develop  KEN-DRGs  in  2011,  to 
define  standard  patient  cases  and  calculate  the 
respective  hospital  costs  and  use  these  to  bill 
EOPYY,  private  insurance  companies  and  private 
patients.  Work  is  still  on-going  but  progress  is 
currently uncertain. 

Doctors  in  private  practices  are  paid  a  fee  for 
service  in  the  case  of  most  diagnostics  and 
outpatient  consultations  and  on  the  basis  of  a 
"DRG-KEN"  costing  structure  in  the  case  of 
private hospitals. 

(177) Κλειστά Ενοποιημένα Νοσήλια (KEN) in Greek. 
(178) The share is estimated not to exceed 10%. 

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The  market  for  pharmaceutical  products,  the 
use  of  Health  Technology  Assessment  and 
cost-benefit analysis 

Major  developments  in  this  area  embrace  higher 
control  over  medical  prescriptions  (e-prescribing 
and  e-diagnosis  systems),  the  development  of 
rules 
clinical  protocols,  new  pricing 
for 
in  procurement 
pharmaceuticals  and  changes 
processes. 

in 

A  new  pricing  and 
regulation  system  was 
introduced in 2010. The price of drugs is set on the 
basis  of  the  average  price  of  the  three  lowest-
priced  markets 
the  EU.  A  drug-pricing 
observatory  was  established  for  this  purpose  and 
about  12,000  pharmaceutical  products  started 
being  re-priced  on  the  basis  of  the  new  system  (a 
price list is set two times yearly) ( 179). A number of 
drugs were also eliminated from the “positive list” 
of  drugs  (reimbursed  drugs).  Yet  the  pricing 
mechanism  still  requires  adjustments  so  as  to 
become more transparent and to reduce the number 
of  complaints  and  potential  confusion  caused  by 
several revisions of the same list. 

and 

Increasing  the  market  share  of  generics  and 
regulating their prices are also major objectives of 
past 
current  Greek  governments.  E-
prescription  and  prescription  by  active  substance 
(INN  -  International  Non-proprietary  Name)  are 
now  compulsory.  The  pharmacist  is  obliged  to 
dispense  the  generic  with  the  lowest  price,  but, 
according to evidence, this is not happening. If the 
patient chooses the branded name instead, s/he has 
to pay 50% of the difference between the reference 
price and the actual price of the branded medicine 
(while  lately  the  Ministry  of  Health  raised  this 
charge to the full price difference). Very recently, 
further  legislation  amended  this  mechanism  to 
limit the patients' participation to 20 euros. 

The market penetration of generics remains limited 
(180),  though  their  share  has  recently  increased 
following  ad-hoc  measures  adopted  by 
the 
authorities,  such  as  eliminating  any  charge  to  the 
patient  in  case  of  a  difference  between  the 
reimbursement  price  and  the  actual  price  for 
generics, 
the  elimination  of  co-payments  on 
generics  for  patients  suffering  from  chronic 

(179) This may become only once per year starting from 2019. 
(180) The  Role  of  Generic  Medicines  in  Sustaining  Healthcare 

Systems: A European Perspective, IMS (2015). 

116 

conditions and the introduction of an incentive for 
pharmacists  proportional  to  the  share  of  non-
generics 
electronic 
dispensed.  Combining 
prescription  with  compulsory  use  of  prescription 
guidelines/protocols  for  physicians  drawing  upon 
the  IDC10  (International  Statistical  Classification 
of  Diseases  and  Related  Health  Problems)  is 
another component of the on-going reform. This is 
attempted initially for the expensive medicines and 
those  most  widely  used.  Only  over  2018,  twenty 
new  therapeutic  protocols  have  been  added  to  the 
e-systems. 

The  rationalisation  of  expenditure  observed  for 
pharmaceuticals has mostly concerned outpatients, 
while  hospital  drug  expenditure  has  been  rising 
(largely  due  to  the  transfer  of  dispensing  of 
expensive  drugs  to  hospital  pharmacies).  The 
introduction  of  an  expenditure  ceiling  for  hospital 
pharmaceuticals  was  therefore  deemed  necessary 
during  the  last  programme,  to  ensure  expenditure 
was  kept  under  control.  In  parallel,  centralised 
tenders  and  international  e-auction  procedures  for 
hospital  procurements  were  launched,  but  remain 
limited. 

Given  the  fact  that  drugs  expenditure  increased 
exceptionally  fast  during  the  2000s  reaching  the 
highest level in the EU  with  2% of GDP in 2009, 
rationalising  and  containing  of  pharmaceuticals 
expenditure  has  been  a  top  priority  and  has  been 
carried  out  successfully  in  recent  years,  reaching 
the  level  of  1.2%  of  GDP  in  2016  (notably,  still 
above the EU average of 0.8% of GDP for public 
outpatient  expenditure).  Significant  cost-savings 
have so far been achieved through the introduction 
of e-prescribing and e-referral systems (initially on 
a  pilot  basis,  but  made  progressively  compulsory 
for  all  outpatient  medical  acts  under  ESY  and 
and 
EOPYY  – 
including  drugs, 
diagnostics).  Accompanying  measures 
include: 
compulsory prescription guidelines and therapeutic 
protocols,  incentives  and  obligations  (for  medical 
staff) to use generics, the regular revision of drugs’ 
prices,  the  reduction  of  the  profit  margin  for 
clawback 
pharmacies, 
(outpatient  and  inpatient),  which  has  preserved 
from  otherwise  stricter 
prices  and  volumes 
necessary  downwards 
the 
“positive list” of drugs is periodically revised. The 
past introduction of many high-cost drugs into the 
positive  list  without  a  proper  assessment  of  cost-
effectiveness  led  to  an  increase  in  pharmaceutical 

revisions.  Also, 

automatic 

referrals 

and 

the 

 
                                                           
its 

inception, 

spending countering the effect of regulated prices. 
The need to rationalise the criteria for introduction 
led the authorities to the creation of a committee in 
charge  of  health  technology  assessment  (HTA)  to 
evaluate  the  introduction  of  new  drugs  into  the 
list  based  on  cost-effectiveness  and 
positive 
affordability  criteria.  Since 
the 
committee  has  formulated  the  assessment  jointly 
with  the  application  of  an  external  reference 
criterion.  As  a  further  step,  the  authorities  have 
worked  on  legislation  to  establish  a  full-fledged 
HTA  agency  with  the  aim  to  exclusively  use  the 
for 
internal  HTA  assessment  as  criterion 
introduction  once  the  capacity  building  has  been 
completed.  Co-payments  (for  pharmaceuticals, 
tests  and  use  of  private  clinics) 
diagnostic 
too,  while  exemptions  have  been 
increased 
drastically reduced. 

through 

Prescription  patterns  by  EOPYY  doctors  are 
the  web-based 
closely  monitored 
application used for e-prescription and e-diagnosis. 
Hence,  real  time  information  is  available,  on  the 
basis of which detailed auditing on pharmaceutical 
prescription  and  expenditure  is  carried  out  (on 
volume  and  value,  use  of  generics  and  off-patient 
drugs,  on  rebate  etc.).  Individual  prescription 
behaviour, 
is  also 
monitored  and  assessed  (every  month),  and  in  the 
case  of  non-compliance  with  guidelines,  penalties 
could  be  imposed  on  physicians.  Nevertheless, 
despite 
innovations,  major 
stumbling  blocks  remain  in  performance  terms, 
due  to  resistance  from  main  stakeholders,  in 
particular doctors and pharmacists.  

in  comparison 

significant 

to  peers, 

these 

E-health  (e-prescription,  e-medical  records) 
and information and reporting mechanisms 

that 

includes 

prescription 

Greece  has  an  e-prescription  system,  run  by 
HDIKA 
for 
pharmaceuticals,  referrals  and  diagnostics.  A 
prescriptions’  processing  unit  in  EOPYY  collects 
all  the  data  of  prescribing,  both  the  electronic 
prescriptions  and  handwritten  and  scanned  ones 
and  has  developed  a  Business  Intelligence  system 
producing  both  fixed  reports  as  well  as  reports 
generated ad-hoc. 

In  addition,  a  personal  health  insurance  file  is 
being  developed, 
all 
hospitalisations,  health  services,  materials  and 
diagnoses  of  a  patient.  The  data  are  computerised 

containing  data 

for 

Health care systems 

2.12. Greece 

and  the  coverage  is  national.  This  will  be  further 
enhanced  by  adding  information  on  laboratory 
exams  recorder  by  diagnostic  centres.  EOPYY 
recently  introduced  registries  for  certain  diseases 
(hepatitis  C,  chronic  myeloid 
leukaemia  and 
multiple sclerosis) with the goal to expand it in the 
future.  Each  registry  lays  down  who  is  suffering 
from  a  particular  disease,  what  medication  is 
prescribed  and  how  far  advanced  the  disease  is. 
The registry can help to check how money is spent 
also  how  much  money  is  spent.  It  will  enable 
authorities  to  assess  whether  the  money  is  being 
correctly spent and make forecasts on future costs, 
which supports negotiations. 

These  tools  can  help  improving  monitoring  and 
control  of  prescription  and  consumption  of 
services and goods and will render a future referral 
system  and  care  coordination  more  effective, 
reducing  the  use  of  unnecessary  pharmaceutical, 
specialist and hospital emergency care.  

Health  promotion  and  disease  prevention 
policies 

In 2015, public and total expenditure on prevention 
and  public  health  services  as  a  %  of  GDP  were 
lower  than  the  EU  average  (0.1%  and  0.1%  vs. 
0.3%  and  0.3%  in  the  same  year)  which  also 
characterised 
total 
expenditure  on  prevention  and  public  health 
services  as  a  share  of  current  health  expenditure 
(public and total, respectively) are, similarly, both 
below the EU average (2% vs. 3.2% and 1.3% vs. 
3.1% respectively in 2015). 

recent  years.  Public  and 

Transparency and corruption 

to 

In past years, there have been reports of corruption 
in  the  system  ( 181),  in  the  form  of  bribery  in 
medical  service  delivery  (informal  payments  to 
jump  queues, 
obtain  better  services  or 
incorrect/undue  charges,  collaboration  between 
physicians  and  pharmaceutical  companies,  and 
prolongation  of  hospitalisation),  procurement 
corruption  (favouring  of  specific  providers  and 
putting  obstacles  to  competition)  and  misuse  of 
(high)  level  position.  It  is  important  to  assess  to 
the  measures  addressing  public 
what  extent 

(181) European  Commission 

(2017),  "Updated  Study  on 
Corruption  in  the  Healthcare  Sector",  Directorate-General 
Home Affairs. 

117 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

procurement adopted so far have positive effects in 
this  field  and  to  design  further  improvements  to 
completely eliminate corruption.  

Furthermore,  although  there  has  been  important 
progress  in  safeguarding  the  independence  of 
hospital  managers  the  last  years,  the  system  has 
isolating  political 
succeeded 
not 
interventions from decision making. 

fully 

in 

Recently 
reforms  

legislated  and/or  planned  policy 

In  recent  years,  the  authorities  have  taken  several 
steps to improve health care delivery in Greece.  

contribution 
population 

The  creation  of  EOPYY  was  an  important  step  in 
improving  equity  in  financing  and  access  to  care. 
rates 
With  EOPYY, 
across 
professions 
groups  were 
and 
harmonised considerably (only those previously in 
OGA  continued  paying  a  lower  amount  and  had 
access  to  a  more  limited  set  of  benefits).  The 
programme  also  included  the  introduction  of 
centralised  tendering  of  specific  hospital  supplies, 
which  has  led  to  significant  savings,  as  the 
differences  in  prices  paid  by  different  hospitals 
have  been  eroded.  However,  the  proportion  of 
purchasing  that  is  conducted  through  centralised 
tendering is still relatively low, indicating there is 
still  scope 
in 
efficiency.  

to  achieve 

increases 

further 

reduce 

fraud  and  waste. 

Many  of  the  measures  adopted  so  far  have  also 
helped 
Improved 
budgeting  and  transparency,  regular  monitoring 
and  e-prescription  have  made  it  easier  to  detect 
reforms  can  be 
irregular  behaviour.  More 
undertaken  in  this  direction,  such  as  electronic 
queuing  systems  for  referrals  to  secondary  care, 
which should result from the referral system of the 
new  primary  health  care,  network,  increases  in 
centralised  tendering  and,  as  mentioned  in  the 
paragraphs above, the introduction of DRGs.  

Under the programmes, the Greek government has 
undertaken  measures  yielding  substantial  savings 
on  pharmaceuticals  in  line  with  best  international 
practice:  

•  Setting up of an electronic prescription system 
and  monitoring  of 
the 

to 
prescription  behaviour,  as  well  as 

control 

enable 

118 

implementation  of  electronic  prescription 
guidelines.  

•  Pricing based on the three-lowest EU prices. 

•  Establishment  of  an  evidence-based  positive 
list of drugs that are reimbursed by EOPYY. 

•  Promotion  of  generic  medicines  and  reduction 
INN 

fraud  by 

of  over-prescription  and 
prescribing. 

•  Establishment of an annual expenditure ceiling 
and  claw  back  system  to  enable  control  of 
expenditure  on  pharmaceuticals  (inpatient  and 
outpatient) all of which have been extended up 
to 2022.  

•  Establishment  of  pharmaceutical  co-payments 
from  25%  to  10%,  while  setting  up  a  list  of 
exemptions to ensure access. 

– 

of 

Health 

•  Establishment 
Technology 
(Επιτροπή 
Assessment 
Committee 
the 
Τεχνολογιών  Υγείας).  The  aim  of 
Committee  is  to  deal  with  the  bargaining  of 
prices  for  the  new,  innovative  and  expensive 
medicines,  in  this  way,  the  access  of  the 
patients  to  new  and  innovative  treatments  will 
be  ensured  with  low  budgetary  cost  for  the 
health system. 

•  Set-up of the committee for the pre-approval of 
high-cost  drugs  and  the  expansion  of  patient 
registries. 

result  of 

reforms,  public 
the  above 
As  a 
reimbursed  expenditure  on  pharmaceuticals  has 
gone from above 5bn at the start of the programme 
to  a  budgetary  cost  of  about  2bn  in  2014  and  is 
legislated to remain at this level until 2022. 

There  were  also  several  measures  to  rationalise 
public  spending  on  private  services  delivered  by 
private providers contracted by the EOPYY. Based 
on  observed  and  projected  expenditure  trends,  the 
authorities  developed  several tools  to  improve  the 
monitoring  of  irregular  behaviour  by  providers, 
typically  supply-induced  demand  of  diagnostics 
and  not 
and/or  other  medical 
infrequently,  fake  expenditure  submissions  for 
the 
is 
reimbursement.  This 

also  due 

treatments 

to 

 
improvements  in  the  auditing  procedures,  which 
are  expected  to  eventually  be  applied  ex-ante  (as 
pre-approval).  Though 
there  have  also  been 
attempts  to  regulate  the  reimbursed  tariffs  of 
diagnostic  tests,  there  seems  to  still  be  scope  for 
improvement  in  this  area.  Another  new  policy 
introduced by EOPYY relates to the new rules on 
recording 
reimbursement, 
expenditure slippages in items directly reimbursed 
to  patients.  EOPYY  will  reimburse  the  providers 
directly  instead  of  reimbursing  the  patient  (which 
was  the  previous  practice).  The  patient  no  longer 
has  to  pay  in  advance  and  EOPYY  has  greater 
control on expenditure by regulating tariffs.  

following 

adopted 

Expenditure  ceilings,  binding  up  until  2022,  also 
apply  to  almost  the  entire  budget  of  EOPYY  and 
include  all  expenditure  on  diagnostics  and  private 
clinics. 

an 

systems 

inefficient 

procurement 

combined  with 

Until  recently,  public  hospitals  faced  significant 
deficits. These deficits were addressed periodically 
through  ad-hoc  state  subsidies  derived  from 
taxation  revenues  and  often  resulted  in  payment 
arrears  to  providers.  The  reasons  were  manifold 
and included delays in payment by SSFs combined 
with  low  statutory  fees  paid  by  SSFs  for  hospital 
services,  in  comparison  to  actual  per  diem  costs, 
but  also  poor  IT  systems,  poor  budgeting  and 
accounting 
poor 
monitoring  which  led  to  a  lack  in  transparency  of 
financial and care activities carried by hospitals. In 
of 
addition, 
pharmaceuticals  and  medical  supplies  led  to  high 
prices  and  large  variations  in  the  prices  paid  by 
different  hospitals.  More  generally,  a  proper 
incentive 
to  deliver  cost-effective 
services and stay  within their budgets  was absent. 
Such  incentives  common  in  other  Member  States 
include  a  mix  payment  system  and  performance 
assessment  mechanisms.  More  recently,  improved 
IT  and  modern  accounting  systems  have  been 
established 
been 
introduced  in  addition  to  cash  accounting),  with 
balance  sheets  for  all  hospitals,  unpublished  for 
several  years,  now  regularly  published  online. 
Hospital  funding  and  funding  flows  from  various 
sources  are  now  transparent  and  monitored  on  a 
regular  basis  and  arrears  have  been  significantly 
reduced.  However  the  resources  available  do  not 
seem  to  be  allocated  efficiently.  There  is  one 
general  budget  for  the  healthcare  sector,  but  this 
budget is not divided between hospitals or between 

accounting 

structure 

(accrual 

has 

Health care systems 

2.12. Greece 

specific  departments  within  a  hospital,  e.g. 
cardiology.  Reportedly,  it  is  not  transparent  how 
the  money  is  spent  and  the  system  does  not  yet 
the  money 
provide  any 
efficiently. A physician does not have a budget to 
manage  but  he  is  free  to  choose  how  much  to 
spend  on  items  such  as  equipment  or  devices  and 
the costs will be covered by the hospital ( 182). 

incentives 

to  spend 

Performance  indicators  have  been  introduced  in 
order  to  assess  the  performance  of  hospitals  and 
identify specific challenges, but they don't seem to 
be  published  regularly  and  to  shape  hospital 
policies.  Centralised  purchasing  had  been 
Procurement 
introduced  with 

the  Health 

Commission (Επιτροπή Προμηθειών Υγείας-ΕΠY) 
even  if  at  slow  speed  with  important  savings, 
sometimes  reaching  more  than  50%  in  price 
reduction  paid  for  some  medicines  and  medical 

supplies.  However,  the  work  of  ΕΠΥ  has  been 
discontinued and existing tenders were left on hold 
until  the  recent  adoption  of  legislation  to  re-
engineer centralised procurement in health care. 

The  replacement  of  ΕΠΥ  by  the  National  Health 
Authority  (Εθνική  Κεντρική  Αρχή  Προμηθειών 
Υγείας - ΕΚΑΠΥ)) took place recently. The aim of 
the new authority is to centralise the purchasing of 
health supplies and to improve on the pre-existing 
system,  in  order  to  achieve  economies  of  scale  in 
the  short  term.  The  new  body  in  charge  of 
centralised  procurement  EKAPY  has  recently 
approved  the  Operational  Plan  for  the  next  two 
years  (until  2019),  with  the  goal  to  increase  the 
share of items procured centrally to be 30% of the 
total value of hospital expenditure. 

recently 

concluded 

Greece  has 
the  ESM 
programme monitored by the EU, the IMF and the 
ECB. The commitments have been fulfilled by the 
authorities  and  policies  are  being  developed 
accordingly  to  meet  the  agreed  targets  under  the 
Enhanced  Surveillance  procedure  linked  with  the 
reform  work 
intrinsically 
medium/long-term and exceeded the horizon of the 
programme, such as the implementation of primary 
health  care,  centralised  procurement,  and  several 

that  are 

streams 

(182) European  Commission 

(2017),  "Updated  Study  on 
Corruption  in  the  Healthcare  Sector",  Directorate-General 
Home Affairs. 

119 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

other  measure  to  enhance  the  cost-effectiveness 
and the modernisation of the health care system. 

The most relevant reform of the health care system 
has  probably  been  the  introduction  of  universal 
coverage in Greece, a defining trait of modern EU 
health  care  systems  that  addressed  and  solved  the 
post-crisis  coverage  gap  of  at  least  two  million 
uninsured  people  and  established  the  right  to 
health  care  coverage  for  all  Greek  citizens. 
Recently,  legislation  was  passed  to  resolve  the 
hurdles  of  the  pre-existing  legislation  on  the 
coverage  of  uninsured  Greek  citizens  and  to 
accommodate  the  incoming  flows  of  migrants. 
This 
to 
legislation  contained  other  measures 
improve  the  functioning  of  the  healthcare  sector, 
such as a human resource strategy to increase staff 
and  re-qualify  the  existing  one  to  support  the 
development of a primary health care network over 
the territory.  

In  general,  policies  have  being  developed  to 
support  the  goals  of  greater  generics  penetration, 
more  rational  prescribing  patterns,  rationalisation 
of  healthcare  expenditure,  promotion  of  higher 
transparency  in  the  system,  elimination  of  waste, 
greater transparency and elimination of corruption. 
In practice though, progress is slow and uncertain 
the  authorities  strongly 
in 
committed to furthering these goals and to proceed 
with  the  implementation  of  ongoing  reforms  in 
their Growth Strategy. 

these  areas,  but 

Challenges 

The  analysis  above  shows  that  several  reforms 
have been implemented in Greece over the last five 
years.  However,  the  current  incentives  present  in 
the system are not necessarily conducive to the use 
of  cost-effective  interventions,  while  individuals 
pay a significant share of expenditure directly out 
of their own pockets. On  the  basis of the analysis 
the  main  challenges  for  the  Greek  health  care 
system are as follows:  

quality 

spending, 

promoting 

•  To continue increasing the efficiency of health 
care 
and 
integrated  care  as  well  as  a  focusing  on  costs, 
to  tackle  the  impact  on  spending  due  to 
and  non-demographic 
population 
factors.  To  this  end,  rationalise  health  care 
expenditure  by  discouraging  the  overuse  of 
products and services. In addition to encourage 

ageing 

120 

to 

the  use  of  generics, 
improve  hospital 
management, to strengthen public procurement 
and to further the efforts in the development of 
protocols for treatment.  

•  To improve the basis for more sustainable and 
efficient  financing of  health care in the  future, 
aiming  at  a  better  balance  between  resources 
and  spending.  This  can  reduce  the  size  of 
private  payments  through  enhanced  coverage 
and  reduce  inequalities  in  the  access  and 
quality  of  care  and  its  distribution  between 
population groups and regional areas. To tackle 
the issue of arrears in payments by EOPYY. 

•  Despite 

the 

progress 

in 
observed 
pharmaceuticals  expenditure,  more  efforts  are 
needed to ensure that spending stays within the 
envelope  and  that  spending  targets  are  not 
achieved  just  due  to  the  implementation  of 
cost-containment  mechanisms 
established 
(clawbacks), for instance, further increasing the 
penetration  of  generics, 
the 
application  of 
therapeutic  protocols  and 
consolidate  and  expand  the  use  of  HTA  to 
evaluate pharmaceuticals. 

expanding 

•  To  reduce  the  excessive  use  of  secondary 
specialist and hospital care. To promote greater 
efficiency  in  the  hospital  setting,  including  by 
rationalising  the  use  of  resources  to  ensure  all 
capacity  within  public  hospitals  is  utilised.  To 
this  end,  consider  whether  there  is  scope  to 
regulate  the  flows  of  patients  towards  private 
providers  by  linking  this  possibility  to  a 
threshold 
time/local 
capacity.  In  addition,  consider  adjusting  the 
existing  reimbursement  schemes  to  increase 
efficiency  and  productivity  in  the  delivery  of 
hospital services and implement a proper DRG 
system. 

terms  of  waiting 

in 

•  To  implement  a  comprehensive  strategy  for 
primary  health  care  over  the  territory,  for  it  to 
act as a gatekeeper. To adjust staff training and 
the staff skill mix towards having more primary 
care  doctors  and  nurses,  correcting  the  current 
inefficient  allocation  of  resources  that  sees  an 
oversupply  of  doctors  and  an  undersupply  of 
the  existing 
nurses.  It  should  consolidate 
financial and non-financial incentives including 
the  extent  of  cost-sharing  to  encourage  the 

 
proper  use  of  primary  care.  Relatedly, 
authorities should improve follow-up care so as 
to  reduce  the  unnecessary  use  of  acute  care 
settings  for  long-term  care  patients.  To  this 
end, to make use of the existing e-health tools. 

•  To improve governance (general coherence and 
management)  of  the  health  care  sector  for 
instance  by  clearer  definition  of  strategic, 
evidence-based objectives and by strengthening 
technical  expertise.  To  tackle  the  issue  of 
corruption and to eliminate waste. 

so 

that 

•  To  enhance  and  continue  data  collection  and 
monitoring  of  inputs,  processes,  outputs  and 
outcomes 
performance 
assessment  can  be  conducted  and  used  to 
continuously 
improve  access,  quality  and 
sustainability  of  care.  This  includes  efforts  to 
assess and publish evaluations of the quality of 
care provided for example. 

regular 

•  To  make  more  use  of  cost-effectiveness 
information in determining the basket of goods 
and  the  extent  of  cost-sharing  to  induce  cost-
effective behaviour.  

•  To  enhance  health  promotion  and  disease 
prevention activities i.e. promoting healthy life 
styles  and  disease  screening  given  the  recent 
pattern  of  risk  factors  (diet,  smoking,  lack  of 
exercise, obesity).  

care  of 

•  To  ensure  access  to  primary  and  secondary 
health 
the  vulnerable  groups, 
particularly the uninsured. In that respect, close 
monitoring  of  the  respective  costs  will  be 
necessary,  particularly  those  related  to  the 
health  needs  of  the  refugee/migration  flows  in 
order  to  disentangle  the  relevant  budgetary 
effects  and  seek  for 
the  appropriate  EU 
funding. 

Health care systems 

2.12. Greece 

121 

 
1
2
2

Table 2.12.1:  Statistical Annex – Greece 

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

199

25.1

0.3

:

2006

218

26.3

5.3

:

2007

233

26.0

3.0

:

2008

242

25.2

-0.6

:

2005

2006

2007

2008

:

8.2

:

:

5.9

5.6

1,139

0.36

:

14.1

100.0

34.8

:

8.2

:

:

5.7

5.7

1,204

0.03

:

14.2

100.0

32.9

:

7.9

:

:

5.7

5.6

1,267

0.07

:

14.2

100.0

34.6

:

9.0

:

:

5.6

5.5

1,287

0.08

:

13.1

100.0

37.9

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

2009

238

23.2

-4.6

:

2009

10.2

9.5

0.7

2010

226

21.5

-5.6

-12.2

2011

207

19.6

-9.0

-6.0

2012

191

19.0

-6.8

-11.8

2013

181

19.5

-2.5

-2.6

2014

179

20.5

1.4

-11.5

2015

176

21.2

0.4

4.6

2010

2011

2012

2013

2014

2015

9.5

9.6

-0.1

9.8

9.1

0.7

9.3

8.8

0.5

9.3

8.3

0.9

8.1

7.9

0.1

8.4

8.4

0.0

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,312

2,042

1,931

1,694

1,611

1,400

1,449

2,745

2,895

6.6

6.5

6.6

6.6

6.0

6.0

5.8

5.8

1,487

1,430

1,191

1,066

0.06

64.3

12.0

:

29.3

0.04

70.0

11.3

:

28.1

0.04

61.7

9.9

:

30.9

0.03

62.9

8.8

:

30.5

5.2

5.2

902

0.03

56.0

7.4

:

34.0

4.6

4.6

804

0.03

57.4

9.2

:

36.8

5.0

5.0

858

0.04

59.3

8.1

86.0

35.5

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

8.0

7.7

7.8

7.6

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

11.0

82.5

76.8

67.4

65.9

110

3.8

11.0

82.7

77.1

68.1

66.5

104

3.7

11.0

82.5

76.9

67.6

66.0

97

3.5

11.1

83.0

77.5

66.2

65.6

92

2.7

11.1

83.3

77.5

66.8

66.1

86

3.1

11.1

83.3

78.0

67.7

66.1

79

3.8

11.1

83.6

78.0

66.9

66.2

129

3.4

11.1

83.4

78.0

64.9

64.8

133

2.9

11.0

84.0

78.7

65.1

64.7

125

3.7

10.9

84.1

78.8

64.8

64.1

125

3.7

10.9

83.7

78.5

64.1

63.9

127

4.0

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

:

:

:

:

:

:

:

:

:

2.0

2.1

2.3

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

1.5

1.6

1.8

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

3.7

0.1

2.2

2.6

0.2

0.1

0.2

3.1

0.1

0.7

2.0

0.2

0.1

0.2

3.8

0.1

2.1

2.7

0.2

0.1

0.2

3.0

0.1

0.7

2.1

0.2

0.1

0.1

3.3

0.1

2.0

2.8

0.2

0.1

0.2

2.4

0.1

0.7

2.1

0.2

0.1

0.2

3.7

0.0

1.6

2.6

0.2

0.1

0.2

2.7

0.0

0.6

1.8

0.1

0.1

0.2

3.3

0.0

1.7

2.3

0.1

0.1

0.2

2.3

0.0

0.8

1.4

0.1

0.1

0.2

3.1

0.0

1.6

2.1

0.2

0.1

0.3

2.0

0.0

0.7

1.1

0.1

0.1

0.2

3.4

0.0

1.8

2.2

0.2

0.1

0.2

2.2

0.0

1.0

1.1

0.2

0.1

0.2

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

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Table 2.12.2:  Statistical Annex - continued – Greece 

Composition of total as % of total current health expenditure

2005

2006

2007

2008

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants *

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Note: *EL data is for physicians licenced to practice.

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP **

AWG reference scenario

AWG risk scenario

Note: **Excluding expenditure on medical long-term care component.

:

:

:

:

:

:

:

:

:

24.4%

25.8%

29.5%

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

26.4%

28.1%

33.0%

:

:

:

2006

1.63

0.9

2.6

0.0

16.4

40.0

9.4

:

:

:

2007

1.79

0.9

2.9

0.0

:

:

9.7

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2008

1.96

0.9

3.1

0.0

17.6

31.8

9.5

2009

39.0%

0.6%

22.9%

27.1%

2.4%

1.3%

1.9%

47.0%

0.9%

10.5%

31.0%

2.5%

1.8%

2.3%

2009

2.17

1.0

3.4

0.0

17.3

31.9

9.1

2010

39.3%

0.6%

21.5%

28.7%

2.2%

1.3%

1.8%

45.9%

0.9%

11.1%

32.1%

2.3%

1.8%

2.0%

2010

2.26

1.0

3.4

0.0

:

:

9.0

2011

35.7%

0.8%

22.0%

30.8%

2.3%

1.2%

2.2%

40.3%

1.2%

11.8%

35.2%

2.5%

1.8%

2.7%

2012

41.6%

0.3%

18.5%

29.0%

2.2%

1.0%

2.5%

46.7%

0.5%

10.7%

31.0%

2.2%

1.6%

3.1%

2011

2012

:

:

:

:

:

:

:

:

:

:

:

:

8.0

8.2

2013

39.1%

0.4%

20.3%

27.7%

1.7%

1.1%

2.8%

44.1%

0.6%

15.5%

26.6%

1.7%

1.7%

3.5%

2013

2.43

1.1

3.5

0.1

:

:

7.5

EU- latest national data

2014

39.3%

0.5%

19.8%

26.7%

2.4%

1.5%

3.3%

44.3%

0.9%

15.4%

23.9%

3.0%

2.6%

4.8%

2015

40.1%

0.5%

21.4%

25.9%

2.4%

1.3%

2.6%

44.0%

0.8%

19.6%

22.6%

3.2%

2.0%

3.4%

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

2014

2015

2009

2011

2013

2015

EU- latest national data

:

:

:

:

16.9

27.3

7.5

:

:

:

:

:

:

:

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

541

321

14

617

2006

4.0

:

:

75.0

5.8

:

2020

5.1

5.3

563

319

15

608

612

322

17

559

621

331

17

553

623

340

18

546

625

341

20

535

627

333

21

528

628

329

23

523

632

323

30

524

632

321

32

518

2007

2008

2009

2010

2011

2012

2013

2014

2015

:

19

:

72.5

6.9

:

2025

5.3

5.5

:

20

:

73.4

6.6

:

2030

5.5

5.8

:

20

:

72.5

6.7

:

2035

5.7

6.1

:

20

:

70.6

6.6

:

2040

5.9

6.4

:

20

:

72.3

6.8

:

2045

6.1

6.6

:

20

:

73.6

7.0

:

2050

6.2

6.8

:

20

:

:

:

:

2055

6.3

7.0

:

:

:

:

:

:

:

:

:

:

:

:

2060

6.3

7.0

2065

6.2

7.0

324

837

77

416

2009

6.2

17

6362

77.1

8.0

28.0

2070

6.2

6.9

:

:

:

2005

1.32

0.9

2.5

0.0

:

:

10.0

2005

506

330

14

690

2005

3.9

:

:

73.0

5.6

:

2016

5.0

5.0

330

835

78

408

2011

6.2

16

6584

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7635

76.8

7.6

32.3

Change 2016-2070, in pps.

Greece

1.2

2.0

EU

0.9

1.6

Change 2016-2070, in %

Greece

EU

H
e
a

Population projections

2016

2020

2025

2030

2035

2040

2045

2050

2055

2060

2065

2070

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

1
2
3

2
.
1
2
.

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2.13. HUNGARY 

 General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

Hungary  has a population estimated at around 9.8 
million inhabitants in 2016. With a GDP of around 
€111 bn, or 17,200 PPS per capita, it is below the 
EU average GDP PPS per capita of 29,600.  

Total and public expenditure on health as % of 
GDP 

Total expenditure (183) on health as a percentage of 
GDP  (7.8%  in  2015)  has  decreased  slightly  over 
the last decade (from 8.3% in 2005, although it has 
been  relatively  flat  since  2010),  below  the  EU 
average (184) of 10.2%. Public expenditure is lower 
than  in  2005,  5.7%  of  GDP,  though  it  has  been 
relatively  flat  since  2007.  It  is  also  below  the  EU 
average  of  7.8%  in  2015.  Looking  at  health  care 
without  long-term  care  (185)  reveals  a  similar 
picture  with  public  spending  being  below  but 
slightly  closer  to  the  EU  average  (5%  vs  6.8%  in 
2015). 

When expressed in per capita terms, total spending 
on health at 1457 PPS is far below the EU average 
of  3305  in  2015.  So  is  public  spending  on  health 
care:  1006  PPS  vs.  an  average  of  2609  PPS  in 
2015.  

Expenditure projections 

As a consequence of demographic changes, health 
care expenditure is projected to increase by 0.8 pps 
of  GDP,  below  the  average  growth  expected  for 
the  EU  (0.9  pps  of  GDP)  (186),  according  to  the 

(183) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(184) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(185) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

(186) I.e. considering the "reference scenario" of the projections 
Report: 
2018 

(see 
https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf ). 

Ageing 

The 

"AWG  reference  scenario".  When  taking  into 
account the impact of non-demographic drivers on 
future  spending  growth  (AWG  risk  scenario), 
health care expenditure  is expected to increase by 
1.8 pps of GDP from now until 2070 (EU average: 
1.6). 

Hungary faces low fiscal sustainability risks in the 
short  run.  In  the  medium  and  long  term  the  fiscal 
sustainability risks are high, but the contribution of 
health  care  and  long-term  care  is  relatively  low 
(187).  

Health status 

Life expectancy at birth (79.0 years for women and 
72.3  years  for  men  in  2015)  is  far  below  the 
respective EU averages (83.3 and 77.9 years of life 
expectancy  in  2015).  However,  healthy  life  years, 
at  birth  60.1  years  for  women  and  58.2  years  for 
men,  are  closer  to  the  EU  averages  of  63.3  and 
62.6  in  2015.  The  infant  mortality  rate  of  4.2 
deaths  per  1000  live  births  (4.2‰)  is  higher  than 
the EU average of 3.6‰ in 2015, having gradually 
fallen over the last decade (from 6.2‰ in 2005). 

As  for  the  lifestyle  of  the  population,  the  rate  of 
daily  smokers  was  25.8%  in  2014,  according  to 
Eurostat,  above  the  EU  average  of  20.9.  The 
obesity  rate  of  the  population  was  at  20.6%,  in 
2014,  the  second  highest  proportion  in  the  EU 
(after  Malta)  and  far  above  the  EU  average  of 
15.5% in 2014. 

Alcohol consumption  was 10.9 litres per capita in 
2014,  above  the  EU  average  of  10.2,  and  it  has 
decreased from 13.2 in 2006.   

System characteristics  

Coverage 

The health care system operates within the scheme 
of  a  social  security  system  based  on  societal 
solidarity.  A  Bismarckian  model  of  insurance  has 
been  established:  the  main  feature  is  the  right  to 
benefits  in  exchange  for  contributions.  Health 
insurance  contributions  and  direct  government 
transfers provide the funding for cash benefits and 
benefits  in  kind.  Health  insurance  contributions  is 

(187) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

124 

 
                                                           
                                                           
proportional  to  income:  In  case  of  employees  it 
amounts  to  7%  of  the  gross  salary  (3  %  cash 
benefits,  4  %  benefits  in  kind).  The  health  care 
system covers virtually entire population (less than 
1% is not covered). Membership is compulsory for 
all residents. 

Gainfully  employed  and  assimilated  persons  are 
insured against all risks: employees (including the 
public  sector), 
(including 
members  of  co-operatives),  several  assimilated 
groups,  and  beneficiaries  of  income  subsidy,  job-
seeker  benefit  and  job-seeker  aid  paid  prior  to 
retirement. 

the  self-employed 

Various  groups  of  the  not  gainfully  employed 
population  are  entitled  to  health  care  benefits: 
Minors  permanently  resident  in  Hungary,  persons 
who  have  fulfilled  the  minimum  retirement  age 
and  whose  monthly  income  does  not  exceed  30% 
of the minimum wage, homeless people, prisoners, 
full-time  students,  pensioners,  beneficiaries  of 
various  benefits,  allowances,  or  income  supports, 
persons placed in residential institutions providing 
personal  care,  restrained  persons,  persons  whose 
need has been recognised by the local government 
(including  income  supports  of  the  unemployed), 
social  supports,  persons  whose  ability  to  work  is 
reduced at least by 50%. For those who fall under 
this  category, 
transfers  a 
monthly  amount  of  5,790  HUF/person  as  health 
service  contribution  into  the  Health  Insurance 
Fund (HIF).  

the  central  budget 

Self-employed persons who perform activities in a 
complementary  way  or  their  joint  ventures,  and 
otherwise  not  insured  or  entitled  persons  are 
obliged  to  pay  a  health  care  contribution  (in  case 
of  continuous  residence  in  Hungary  for  a  year  - 
HUF  7,320  per  month).  Financing  for  groups 
covered  without  contributing  is  provided  by  the 
central  budget  in  terms  of  a  fixed  per  capita  fee. 
Dependant  close  family  members  or  their  spouses 
are  also  obliged  to  pay  health  care  contribution 
unless  they  are  socially  entitled,  which  must  be 
justified  by  the  local  government  (and  their 
obligation can also be undertaken). 

Persons  not  insured  or  not  entitled  to  health  care 
can  enter  into  contractual  arrangements  with  the 
National  Institute  of  Health  Insurance  Fund 
Management 
Nemzeti 
Egészségbiztosítási  Alapkezelő)  for  entitlement  to 

NEAK 

– 

( 

Health care systems 

2.13. Hungary 

health  care  services.  In  case  of  adults, 
the 
contribution  amounts  to  half  of  the  minimum 
wage,  in  case  of  minors  and  students  30%  of  the 
minimum  wage  (only  for  benefits  in  kind  –not 
necessary Hungarian Certificate of domicile). 

The  government  elected  in  2010  opted  for  a 
systematic  move  on  the  way  to  a  national  health 
service  by  further  centralising  the  allocation  of 
capacities;  establishing  a  new  hierarchical  system 
of  actively  managed  patient  routes;  organising 
more  effective  competition  of  generics  in  public 
purchases  of  pharmaceutics;  and  making  steps 
towards replacing contributions by taxes. 

Administrative  organisation  and 
collection mechanism  

revenue 

The  health  care  budget  is  made  up  of  three 
components:  (1)  the  budget  of  the  HIF  derived 
from health insurance contributions and earmarked 
health  care 
in  2016);  (2)  direct 
government transfers from the central budget (21% 
in  2016)  and  other  incomes  (7%  -social  tax, 
incomes from pharmaceutical companies, accident 
tax, public health product tax). 

tax  (72% 

In  addition,  local  government  budgets  are  derived 
from  local  taxes  and  from  the  central  government 
grants 
budget-setting 
investment.  The 
processes  at  different 
levels  are  practically 
independent,  apart 
from  central  government 
subsidies for regional and local levels. 

for 

A  key  principle  is  the  institutional  separation  of 
capital  and  recurrent  costs,  which  applies  to  all 
sub-sectors. While investment is decided upon and 
financed by either local or central government, the 
HIF covers recurrent costs only.   

Since  2012,  the  hospitals  owned  by  the  capital, 
cities and counties are state-owned. Dual financing 
still prevails, so recurrent costs are financed by the 
Health  Insurance  Fund,  while  capital  costs  by  the 
maintainer.  However,  as  the  National  Healthcare 
Service  Center  (earlier:  National  Institute  for 
Quality-  and  Organisational  Development 
in 
Healthcare and Medicines) fulfils maintenance and 
supervisory  duties  over  state  owned  health 
institutions. 

Restructuring  was  launched  in  2011,  and  the 
operation of the new structure started as of 1 July 

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2012. The basic principle of the new structure is to 
centralise  specialised  care  with  high  costs  and 
relatively low patient numbers. Forms of care with 
higher  case  numbers,  being  less  specialised  and 
less  costly  should  be  provided  close  to  the 
population.  A  change  of  function  or  profile 
refining  was  introduced  for  58  service  providers. 
4.3%  of  inpatient  care  capacities  was  closed.  In 
line  with  changes  in  structure,  function  and 
integration,  a  number  of  economic  interventions 
aiming at improving effectiveness were introduced 
-  essentially  contributing  to  sustained  institutional 
functioning.  Consequently,  a  part  of  resources 
made  available  could  be  reallocated  to  financing 
outpatient care.  

decision-making  power  rests  with  the  Ministry  of 
Human  Capacities,  is  not  high.  Public  and  total 
expenditure on health administration and insurance 
as  a  percentage  of  GDP  (0.15%  and  0.14% 
respectively)  are  well  below  the  EU  average 
(0.38% and 0.26% respectively in 2015). 

Role  of  private  insurance  and  out  of  pocket 
co-payments  

In 2015, private expenditure accounted for 31% of 
total  health  spending,  considerably  more  than  in 
the  EU  on  average  (21.6%).  Also  very  large  in 
comparison to the EU average is the share of out-
of-pocket payments (29% vs. 15.9% in the EU).   

In  2011,  the  "Semmelweis  Plan"  reorganised  the 
health  care  system.  The  new  structure  basically 
centralised the administrative functions and system 
management  under  the  responsibility  of  the  State 
Secretariat  for  Health  Care  of  the  Ministry  of 
Human Capacities  and related institutions such as 
the  National 
and 
Organisational  Development  in  Healthcare  and 
Medicines (at present: National Healthcare Service 
Center), the National Centre for Patient Rights and 
Documentation 
the  Office  of  Health 
Authorisation  and  Administrative  Procedures. 
Epidemiological  and  other  public  health  issues 
belong to the National Public Health and Medical 
Officer Service and its affiliates. 

for  Quality- 

Institute 

and 

The  management  of  the  provision  of  service  and 
patient  pathways  is  split  between  the  level  of 
NUTS3 administrative units and the higher level of 
health-regions  and  nationally.  Service  providers, 
including  outpatient  and  care  centres  manage 
patient pathways at lower levels.  

All agents within this system are linked to the HIF, 
which is in charge of managing the finances of the 
health  care  system.  The  emergence  of  new 
institutions in the management of patient pathways 
means that the importance of the HIF as a central 
institution in the health sector has been reduced. Its 
role  has  been  further  eroded  by  the  partial 
devolution of responsibilities to a new network of 
government  offices  at  NUTS3-level  (known  as 
“government windows”). 

The  level  of  expenditure  on  the  administration  of 
such a system, where entitlements are not linked to 
contribution  payments  and  virtually  the  entire 

126 

Types of providers, referral systems and patient 
choice 

services 

Health  care  provision  is  the  state's  responsibility. 
The  delivery  system  is  organised  on  the  basis  of 
"territorial  supply  obligation",  which  assigns  the 
responsibility  to  different  levels  of  government 
according  to  the  principle  of  subsidiarity  (the 
service  should  be  provided  at  the  lowest  effective 
level of organisation). This way, municipalities are 
responsible  for  providing  primary  care,  while 
responsibility  for  secondary  and  tertiary  health 
the  central  government’s 
care 
responsibility. Nevertheless, even if obliged by law 
to  provide  a  given  level  of  care,  the  local 
authorities are not obliged to deliver it. Each level 
is allowed to outsource service delivery to private 
providers.  Moreover,  the  owner  of  health  care 
facilities  (whether  private  or  public)  is  obliged  to 
keep it in working order, i.e. to cover capital costs, 
which  is  particularly  relevant  in  case  of  state-
owned  equipment  and  facilities  being  used  by 
private providers to deliver subcontracted services.  

is 

Control,  coordination,  supervision  and  delivery  of 
public health  services are the responsibility of the 
central  government  which  provides  the  services 
through  the  National  Public  Health  and  Medical 
Officer Service, in some cases in cooperation with 
the other institutions. 

Provision  of  primary  care  is  within  the  area  of 
responsibility  of  the  municipalities.  They  may 
provide  it  through  salaried  doctors  or  contract  the 
delivery  to  independent  physicians,  who  need  to 
have  relevant  qualifications  and  a  "practice  right" 
to  be  eligible.  The  "practice  right"  is  the  right  to 

 
perform  the  professional  activities,  which  can  be 
sold and bought by another qualified physician. By 
establishing  the  territorial  reach  of  the  primary 
care  districts  and  the  number  of  practices  in  each 
of them, local governments can control the amount 
and  type  of  care  provided  to  the  population. 
Patients  can  freely  choose  a  family  doctor  and 
change him/her once a year.  Doctors cannot refuse 
the patients who live in their primary care district, 
but  are  allowed  to  refuse  patients  from  other 
districts. 

A  number  of  reforms  have  been  enacted  over  the 
last  decade  to  provide  incentives  to  take  up  the 
posts of physicians and nurses. In order to increase 
the income of healthcare workers, the government 
implemented  a  total  of  27%  rise  in  the  salary  of 
specialist  workers  in  2012-2013,  and  a  further 
growth  of  65,5%  will  be  achieved  in  2016-2019 
through  a  multi-step  wage  increase..  Although 
slightly  higher  than  a  decade  ago,  the  number  of 
practicing physicians (310 per 100 000 inhabitants 
in  2015),  practising  nurses  (647  in  2015)  and  in 
particular general practitioners (34 in 2010) is still 
below the EU respective averages in the respective 
years (344, 833 and 78 per 100 000 inhabitants).  

referrals 

Although  there  is  an  official  referral  system  and 
family  doctors  formally  act  as  gatekeepers,  the 
payment  system  includes  no  incentives  to  provide 
definitive  care  and  avoid  unnecessary  referrals.  
Consequently, 
to 
the  number  of 
specialists  and  hospitals  is  high.  Only  the  2007 
reform (reducing impatient capacity of hospitals by 
setting  up  a  few  regional  universal  hospitals  and 
the  referral 
medical  clinics,  strengthening  of 
system  and 
transparent 
introducing  a  formal 
system of waiting lists) has allowed the authorities 
to 
the 
limit  hospital  overutilisation.  Indeed, 
number  of  acute  hospital  beds  per  100000 
inhabitants  is,  at  428,  above  the  EU  average  of 
402.  It  has  fallen  since  2005  (596).  Inpatient 
discharges  per  100  inhabitants  fell  from  24.9  in 
2005 to 19.6 in 2015 (EU average: 16.2). 

Responsibility  for  secondary  and  tertiary  care  is 
shared among different levels of local and regional 
government.  Formally,  the  state  (through  the 
National  Healthcare  Service  Center)  owns  large 
providing 
multi-speciality 
secondary and tertiary inpatient and outpatient care 
to  the  acutely  and  chronically  ill.  However, 
municipalities  and  central  government  also  play  a 

hospitals 

county 

Health care systems 

2.13. Hungary 

role,  the  former  being  responsible  for  polyclinics 
(outpatient specialist care), dispensaries (outpatient 
care  for  the  chronically  ill)  and  state-owned 
hospitals (secondary inpatient and outpatient care), 
while the latter own – through specific ministries – 
a  number  of  acute  and  chronic  hospitals.  Dialysis 
and  home  care  have  in  comparison  a  significant 
share of private ownership. 

Treatment options, covered health services 

Local  authorities  are  required  by  law  to  provide 
services at a given level of care.  

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Family doctors can be employed according to four 
different schemes: (1) municipality employee paid 
on the basis of a monthly salary; (2) family doctor 
under a contract using public equipment and paid a 
capitation  fee  from  the  HIF;  (3)  family  doctor 
being  an  independent  provider  with  no  municipal 
contract and no territorial supply obligation (large 
majority  of  the  GPs);  he/she  is  entitled  to  a 
capitation  fee  from  the  HIF  only  if  he/she  has 
minimum  threshold  of  registered  patients;  (4) 
"freelance  medical  doctor",  not  being  subject  to 
public  employee  regulations,  but  not  having  a 
status of self-employed private entrepreneur either; 
he/she  receives  an  out-of-pocket  payment  directly 
from the patient.  

Capitation fees paid under schemes (2) and (3) are 
adjusted  to  the  age  structure  of  the  patients 
covered: children and elderly weigh most, working 
age  population  least.  Moreover,  in  order  to  avoid 
negative  impact  of  the  excessive  practice  size  on 
the  quality  of  care,  a  threshold  of  the  number  of 
patients is set above which the capitation payment 
is only partial.  

specialist 

The payment system in secondary and tertiary care 
depends  on  the  type  of  institution  and  services 
provided.  Outpatient 
services  are 
financed  by  fee-for-service  points,  whereby  each 
procedure 
is  assigned  a  number  of  points 
according  to  its  complexity  and  requirement  of 
services and providers report total monthly number 
of  points  to  the  HIF  for  reimbursement.    The 
monetary  value  of  a  point  is  defined  in  advance, 
and  part  of  the  sub-budget  is  put  aside  at  the 
beginning of each year to compensate for possible 

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In 

of 

limit. 

services. 

provision 

'excessive' 
  The 
sustainability of outpatient budget is achieved by a 
so-called  performance  volume 
the 
beginning  of  each  year,  based  on  previous  years’ 
data,  the  performance  volume  limit  is  defined  for 
every  single  outpatient  health  service  provider. 
Performance volume limit for the year of 2014 was 
defined, in agreement with professional bodies. In 
2018,  1  financing  point  equals  to  1.98  HUF. 
Consequently,  even  if  control  mechanisms  have 
been  set  in  place,  the  fee-for-service  payment 
scheme in  hospitals could discourage treatment as 
an outpatient and encourage hospitals to treat as an 
inpatient for financial gain, rather than for the ideal 
treatment of the patient. 

Inpatient  services  are  reimbursed  according  to  the 
DRG-based  prospective  payment  system,  except 
for  a  few  high-cost  interventions  reimbursed  on  a 
case  basis.  State  owned  hospitals  are  paid  by  
DRGs.  In  addition,  there  are  income  flows  to 
hospitals 
for  outpatient  care,  chronic  care, 
laboratory  care  and  wages.  Hospitals  report  the 
total  amount  of  completed  procedures  to  the  HIF 
which  calculates  their  total  value  by  multiplying 
the DRG points by the national base fee (value of 
one  point)  -  set  in  advance  for  each  year.    The 
fiscal  sustainability  of  financing  inpatient  care  is 
also  ensured  by  the  performance  volume  limit. 
Currently  one  single  weight-point  equals  198  000 
HUF.  Chronic  care  is  financed  by  a  daily  fee. 
Wages  transfers  are  calculated  by  a  monthly 
request  of  providers  and  it’s  financed  by  the 
National  Institute  of  Health  Insurance  Fund 
Management. 

The market for pharmaceutical products 

(public 

in  2015.  Reimbursement 

Pharmaceutical  spending  accounts  for  29.1%  of 
total 
current  health 
and  private) 
expenditure  and  22.2%  of  current  public  health 
is 
care  expenditure 
regulated  while  prices  are  (to  some  extent)  freely 
determined  by  the  market  (even  if  decisions  on 
reimbursement  have  impact  on  market  operators' 
price  policies).  Prices  of  original  drugs  are 
established  on 
the  basis  of  external  price 
referencing  (comparison  with  the  prices  in  the 
other  EEA  countries),  while 
the  maximum 
generics'  prices  are  additionally  linked  to  the 
original drug price. Reimbursement applies to two 
positive  lists:  one  includes  drugs  which  can  be 
prescribed by any physician and are reimbursed at 

128 

either  0%,  25%,  55%  or  80%;  the  other  includes 
drugs with special indications, to be prescribed by 
specialists  and  reimbursed  at  either  50%,  70%, 
90% or 100%. Moreover, physicians are obliged to 
prescribe reference medicines. 

The  2010-2012  reform  of  the  pharmaceutical 
market  launched  in  the  context  of  the  state  debt 
reduction  aimed  at  rationalising  medication  use 
and  strengthening  competition  for  generic  drugs. 
The  decision  was  made  to  improve  the  efficiency 
of  the  pharmaceutical  reimbursement  system  in 
order to meet the needs of patients. In practice, this 
also  meant  cuts  in  the  pharmaceutical  budget.  A 
number  of  austerity  measures  were  introduced  in 
order 
the  budgetary  constraints.  In 
particular these measures are: 

to  meet 

•  modified  legal  provisions  regulating  payment 
obligations for the pharmaceutical companies, 

•  enhanced generic competition, 

• 

• 

• 

• 

requirements for enforcing patient compliance, 

revision of pharmaceutical treatment protocols, 

re-contracting of volume agreements, and the 

introduction of prescribing by active substance. 

As  a  result  of  these  measures,  a  substantial 
decrease in prices of pharmaceuticals in outpatient 
care  could  be  realised  during  recent  years,  and 
public  expenses  could  be  decreased  without 
increasing  the  (even  sometimes  with  decreasing) 
financial  burden  on  patients.  At  the  same  time,  a 
number of new innovative drugs could be included 
in the reimbursement scheme. 

E-Health, Electronic Health Record 

the 

the  paper-based  or 

In  2017  the  Hungarian  national  eHealth  platform 
the  aim  of 
(EESZT)  was 
introduced  with 
transforming 
locally 
working healthcare system into a modern, service-
focused  nation-wide  eHealth  system  which  meets 
all  the  latest  demands  and  requirements  related  to 
data 
technologies  and 
healthcare.  

information 

security, 

 
EESZT electronically stores information about the 
patients,  connects  all  the  Hungarian  healthcare 
providers  (such  as  hospitals,  pharmacies,  general 
practitioners)  making  it  easier  for  physicians 
working  in  different  institutions  to  access  all 
important  health  information  about  the  patient. 
Medical documents, related to all the treatments a 
patient  has  received,  shall  be  sent  to  the  system, 
building up a complete patient case history.  

is 

EESZT 
integrated  with  existing  systems, 
therefore  clinicians,  GPs  and  pharmacists  can  use 
their  own  health  information  systems  (HIS).  By 
using EESZT the physicians can rely on a detailed 
and comprehensive  medical history of the patient, 
which  allows  for  more  precise  medical  decisions, 
greatly  enhancing  patient  safety.  On  the  other 
hand, the availability of previous diagnostic results 
greatly  reduces  the  number  of  repeated diagnostic 
procedures.  

a 

specific 

through 

The  general  public  can  also  benefit  from  the 
developments 
portal: 
eeszt.gov.hu.  Citizens  are  able  to  access  all  their 
medical records through the so-called “government 
gateway”  or  “Client  Gate”,  which  is  the  official 
central electronic administration web service of the 
country.  The  portal  allows  citizens  to  view  their 
medical  record,  electronic  prescriptions,  health 
care  encounters  etc.  In  order  to  protect  sensitive 
medical  data,  the  portal  allows  citizens  to  grant 
and  restrict  access  to  health  professionals  and  to 
review the access log to their data. 

improve 

in  order 

New  services  and  processes  are  continuously 
introduced 
the  system.. 
to 
Standardisation  of  EHRs  and  improvement  of 
interoperability  will  have  a  crucial  impact  on  the 
cooperation  between  Hungarian  health  care 
providers.  A  centralised  e-consultation  and 
telemedicine framework and a centralised imaging 
database  necessary  for  e-consultation  are  also 
among the  goals to be achieved by  the end of the 
EFOP project in 2020. 

the  Hungarian 
The  central  component  of 
Electronic  Health  System  is  the  e-prescription 
system. Its purpose is, on the one hand, to provide 
transparency  and  traceability  and  on  the  other 
hand, to avoid medicine abuse. 

Health care systems 

2.13. Hungary 

Health  and  health-system 
information  and 
reporting  mechanisms/  Use  of  Health 
Technology  Assessments  and  cost-benefit 
analysis 

Further  measures  to  improve  quality  will  include 
implementing a  monitoring and evaluation system 
based on defined indicators. Major IT development 
plans  include  establishing  a  database  for  the 
personal 
insurance 
identification 
remote 
diagnostics and telemedicine.  

a 
improving 

developing 

system, 

system, 

Healthy  lifestyle  and  disease  prevention  activities 
have  received  a  lot  of  attention  mainly  through 
programmes aiming at improving the health status 
and  quality  of  life  of  the  population.  Total 
expenditure  on  prevention  and  public  health 
services as 0.19% of GDP is below the EU average 
(0.25%  in  2015)  while  public.  Similarly,  public 
expenditure  on  prevention  and  public  health 
services  as  %  total  public  current  expenditure  on 
health  is  in  line  with  the  EU  average  (2.3%  vs. 
3.2% in 2015).  

Recently 
reform  

legislated  and/or  planned  policy 

reduce 

shortages  of  medical 

To 
staff,  a 
comprehensive  residency  support  programme  was 
introduced  in  2011  and  was  announced  again  for 
2018.  Beyond  emigration,  attrition  puts  further 
pressure  on  skills  shortages.  To  address  this 
challenge,  wages  of  health  professionals  were 
increased  substantially  since  2012.  Government 
implemented  a  total  of  27%  rise  in  the  salary  of 
specialist  workers  in  2012-2013,  and  a  further 
growth  of  65,5%  will  be  achieved  in  2016-2019 
through  a  multi-step  wage  increase.    However, 
they remain low in a European perspective. 

For  the  further  development  of  primary  health 
care,  the  general  practitioner's  application  for 
praxis  purchase  or  resettlement  was  announced 
since  2015  yearly.  In  2017 
the  amount  of 
resettlement  support  was  doubled  and  that  the 
dentists  could  also  apply.  Candidates  had  to 
undertake  to  provide  the  care  for  at  least  6  years 
after winning the tender.  

Significant policy goals were achieved by reducing 
waiting 
the  diagnostic 
background  of  oncology  care.  For  public-funded 

ensuring 

lists 

and 

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it 

providers, 

diagnostic 

CT/MRI 
became 
mandatory  by  regulation  to  perform  a  diagnostic 
test  for  patients  with  a  clinical  suspicion  of 
malignant  neoplasm  within  14  working  days.  To 
this  end,  a  supplementary  code  outside  the  scope 
of Performance Volume Limit was introduced. 

As a result of the Waiting List Reduction Program 
introduced in 2014, the number of patients waiting 
for  surgery  decreased  by  15,910  between  2014  -
2017.  According  to  the  mandatory  waiting  list 
records  of  the  institutions,  28,082  patients  were 
waiting  for  surgical  treatment  on  December  31, 
2017 (compared with the 43 992 patients in 2014). 

This 

considerations. 

Efforts continue to improve the quality of financial 
management  in  the  system.  A  support  system  has 
been  developed  taking  into  account  quality  and 
management 
requires 
managers  to  adopt  "active  planning"  to  improve 
their  liquidity  situation,  providing  them  with 
incentives  to  improve  their  performance  rather 
than  simply  asking  for  an  increase  in  central 
resources.  As  a  result  of  these  measures,  hospital 
debt  has  been  moderated.  As  of  December  31, 
2017,  total  liabilities  of  health  care  providers 
totaled  HUF  51.9  billion,  of  which  HUF  15.0 
billion was overdue debt.  

For  the  further  improvement  of  the  financing  of 
healthcare providers and to create  a balance within 
the  professional  and  economic  field  as  well,  over 
the  years  of  2016-2017  the  coverage  available  to 
health  workers  for  wage  increases  was  built  into 
the  performance  financing  instead  of  the  direct 
transfer of wage elements. 

the  EBP  (Egészséges  Budapest 
As  part  of 
Program)  program  to  renovate  and  reorganise  the 
hospital  sector  there  are  plans  to  build  three  large 
central  hospitals  in  Budapest,  which  represent  the 
highest level of care,  giving  emergency care at 0-
24  hours  of  the  year  365  days.  Beside  them,  the 
smaller  co-hospitals  are  also  undergoing  major 
developments: most medical and IT developments, 
energy  renovations  start,  and  in  many  places  new 
buildings  or  wings  are  built.  Two  of  the  new 
central  hospitals  are  expected  to  complement 
already existing hospitals.  

130 

Challenges 

to 

The analysis above shows  that a range of reforms 
have  been  implemented  in  recent  years  like  for 
improve  hospital  efficiency  and 
example 
inpatient care supply or to promote the healthy life 
of the population in particular. Therefore, Hungary 
should continue to pursue them together with new 
challenging  reforms.  The  main  challenges  for  the 
Hungarian health care system are as follows:  

•  To  improve  the  long-term  sustainability  of 
health  insurance  system,  to  avoid  negative 
consequences  for  access  and  equity.  This  may 
mean improving the basis for more sustainable 
and 
larger  financing  of  health  care  (e.g. 
considering  additional  sources  of  general 
budget  funds),  with  a  better  balance  between 
resources and demand, between the number of 
contributors  and  the  number  of  beneficiaries 
and  which  can  improve  access  and  quality  of 
care  and  its  distribution  between  population 
groups  and  regional  areas.  If  more  resources 
are brought into the  sector, it is important that 
they  are  pooled  together  through  the  strong 
pooling mechanisms in place today. 

•  To  foster  effective  coordination  mechanism 
between  public 
for 
entities 
investment  decisions  and  providers  actually 
using health care facilities.   

responsible 

•  To  continue  efforts 

to 

strengthen  care 
coordination, by promoting the role of GPs and 
avoiding  unnecessary  use  of  secondary  and 
tertiary  care.  On  one  hand,  supply  of  human 
resources  to  the  primary  care  sector  should  be 
fostered  by  providing  an  adequate  set  of 
financial 
component 
(performance-related 
added 
capitation-based 
current 
remuneration)  incentives.  On  the  other  hand, 
measures 
control 
strengthening  the  referral  system  should  limit 
the use of specialist and hospital care.  

organisational 

and 

the 

to 

•  To  develop  the  mechanism  of  updating  the 
hospital payment system (relationship between 
the  actual  costs  of  treatments  and  tariffs 
become  outdated).  A  sector-wide  survey  has 
been conducted recently in order to tackle this 
problem. 

 
•  To  strengthen  monitoring  and  control  by 
modernising 
information 
and  developing 
technologies  as  well  as  by  supporting  human 
resources  involvement  in  the  decision  making 
process. To introduce effective mechanisms for 
assuring  quality  of  care:  clear  definition  of 
tasks  and  competences  of  the  health  care 
providers  (especially  in  the  area  of  emergency 
care),  more  stringent  conditions  for  licensing 
and  accreditation,  consistent  development  and 
application of medical guidelines.  

•  To  strengthen  efforts 

to  promote  healthy 
lifestyles, in particular by preventing smoking, 
excessive  alcohol  consumption,  unhealthy  diet 
and  physical  activity.  Public  health  has  been 
underlined  as  a  priority  in  the  development  of 
recent health strategy for the  health system. In 
this  framework,  the  public  health  programme 
should  continue,  the  importance  of  medical 
screening should be stressed.  

Health care systems 

2.13. Hungary 

131 

 
 
 
1
3
2

Table 2.13.1:  Statistical Annex - Hungary 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

91

17.7

4.6

:

2006

92

17.8

4.0

6.0

2007

102

17.5

0.6

-4.8

2008

108

17.4

1.0

3.6

2009

94

16.1

-6.5

-9.0

2010

99

16.5

0.9

-2.0

2011

101

16.8

2.0

3.0

2012

100

16.5

-1.1

-1.9

2013

102

16.5

2.4

-0.4

2014

106

16.7

4.5

2.9

2015

111

17.2

3.6

8.7

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

8.3

7.1

1.2

8.4

8.1

0.3

8.0

7.8

0.2

8.2

8.0

0.2

8.0

7.8

0.1

7.7

7.6

0.2

7.8

7.6

0.2

7.7

7.5

0.2

7.5

7.3

0.2

7.4

7.1

0.3

7.8

7.2

0.5

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

1,243

1,281

1,350

1,468

1,247

1,272

1,320

1,293

1,291

1,321

1,457

2,745

2,895

2,975

3,305

5.9

5.7

887

0.21

71.4

11.6

100.0

25.8

5.8

5.5

884

0.29

69.0

10.7

100.0

25.0

5.1

5.0

871

0.19

64.5

10.3

100.0

26.3

5.0

4.9

898

0.15

61.1

9.2

97.0

26.4

5.1

5.0

795

0.12

63.7

10.4

97.0

25.9

5.2

5.1

863

0.17

67.8

10.5

97.0

27.4

5.3

5.0

891

0.22

67.5

10.1

96.0

28.2

5.2

4.9

861

0.24

66.5

10.5

96.0

29.4

5.0

4.9

863

0.17

66.8

10.1

96.0

28.4

5.1

4.8

902

0.27

68.3

9.8

95.0

28.3

0.54

69.0

10.5

95.0

29.0

5.4

4.8

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

1,006

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

10.1

77.2

68.7

54.3

52.2

130

6.2

10.1

77.8

69.2

57.2

54.4

121

5.7

10.1

77.8

69.4

57.8

55.1

119

5.9

10.0

78.3

70.0

58.2

54.8

114

5.6

10.0

78.4

70.3

58.2

55.9

113

5.1

10.0

78.6

70.7

58.6

56.3

111

5.3

10.0

78.7

71.2

59.1

57.6

288

4.9

9.9

78.7

71.6

60.5

59.2

281

4.9

9.9

79.1

72.2

60.1

59.1

270

5.0

9.9

79.4

72.3

60.8

58.9

266

4.5

9.9

79.0

72.3

60.1

58.2

268

4.2

Composition of total current expenditure as % of GDP

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: €OSTAT, OECD and WHO. 

2.2

0.1

1.8

2.6

0.3

0.4

0.1

1.9

0.1

1.0

1.6

0.2

0.2

0.1

2.1

0.1

1.8

2.6

0.4

0.3

0.1

1.8

0.1

0.9

1.6

0.2

0.2

0.1

2.0

0.1

1.6

2.4

0.3

0.3

0.1

1.7

0.1

0.9

1.2

0.2

0.2

0.1

1.9

0.1

1.6

2.3

0.3

0.3

0.1

1.7

0.1

0.9

1.1

0.2

0.2

0.1

1.9

0.1

1.6

2.5

0.3

0.3

0.1

1.6

0.1

0.9

1.2

0.2

0.2

0.1

1.9

0.1

1.7

2.5

0.2

0.3

0.1

1.6

0.1

0.9

1.4

0.1

0.2

0.1

1.8

0.1

1.7

2.7

0.2

0.3

0.1

1.6

0.1

0.9

1.5

0.1

0.2

0.1

1.9

0.1

1.7

2.4

0.2

0.2

0.1

1.7

0.1

0.9

1.2

0.1

0.1

0.1

1.9

0.2

1.7

2.2

0.2

0.2

0.1

1.7

0.1

0.9

1.1

0.1

0.1

0.1

1.9

0.1

1.7

2.2

0.2

0.2

0.1

1.7

0.1

0.9

1.1

0.1

0.1

0.1

1.9

0.1

1.8

2.1

0.2

0.2

2.7

0.2

2.5

1.2

0.3

0.3

2.6

0.2

2.5

1.2

0.3

0.2

2.7

0.3

2.4

1.5

0.4

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.15

0.42

0.41

0.39

0.38

1.8

0.1

0.9

1.1

0.1

0.1

2.6

0.1

1.8

0.9

0.1

0.2

2.5

0.2

1.8

0.9

0.1

0.2

2.5

0.3

1.7

1.0

0.2

0.2

2.5

0.3

1.8

1.0

0.2

0.3

0.14

0.32

0.30

0.28

0.26

r

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
Table 2.13.2:  Statistical Annex - continued – Hungary 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

30.3%

1.2%

25.7%

35.9%

4.8%

5.2%

1.3%

32.6%

1.2%

17.0%

27.7%

3.5%

4.2%

1.4%

2005

0.26

0.3

0.7

0.1

:

:

12.9

2005

278

595

:

690

2005

12.9

25

526

76.0

6.5

2.2

2016

4.9

4.9

2016

9.8

2006

25.5%

0.9%

22.2%

31.4%

4.3%

4.2%

1.1%

32.3%

1.2%

16.6%

28.9%

3.6%

4.0%

1.4%

2006

0.26

0.3

0.7

0.1

:

:

13.2

2006

304

620

:

617

2006

12.8

24

594

70.0

6.3

2.5

2020

5.1

5.2

2020

9.8

2007

25.0%

1.1%

20.9%

30.2%

3.7%

4.0%

1.2%

34.3%

1.5%

17.3%

24.6%

3.0%

4.0%

1.6%

2007

0.28

0.3

0.7

0.1

:

:

12.6

2007

280

595

:

608

2007

10.8

21

825

69.2

9.0

4.0

2025

5.2

5.5

2025

9.7

2008

23.5%

1.1%

19.3%

28.9%

3.6%

3.7%

1.1%

34.3%

1.6%

17.9%

23.5%

3.3%

3.9%

1.4%

2008

0.28

0.3

0.7

0.1

20.0

26.1

11.6

2009

24.0%

1.1%

20.4%

32.0%

3.8%

4.3%

1.1%

32.7%

1.6%

18.0%

24.6%

3.6%

3.8%

1.4%

2009

0.28

0.4

0.7

0.0

20.0

26.5

11.5

2008

2009

309

615

:

559

2008

11.3

21

1,122

75.3

9.2

5.4

2030

5.4

5.8

2030

9.7

302

621

35

553

2009

11.9

21

1,238

74.3

9.2

5.6

2035

5.5

6.1

2035

9.6

2010

24.7%

1.2%

22.8%

33.2%

2.6%

3.8%

1.7%

32.3%

1.6%

17.8%

27.6%

2.0%

3.7%

2.4%

2010

0.30

0.4

0.7

0.0

:

:

10.8

2010

287

621

34

546

2010

11.6

20

1,261

71.6

9.5

5.9

2040

5.6

6.3

2040

9.5

2011

24.3%

1.2%

22.6%

35.0%

2.8%

3.4%

1.6%

32.1%

1.4%

17.9%

28.8%

2.4%

3.2%

2.2%

2011

0.30

0.4

0.7

0.0

:

:

11.5

2011

296

621

:

535

2011

11.8

20

1,507

71.1

9.5

6.9

2045

5.7

6.5

2045

9.4

2012

25.7%

1.9%

22.9%

32.5%

2.8%

2.8%

1.7%

35.0%

2.4%

17.9%

24.6%

2.2%

2.6%

2.2%

2012

0.28

0.4

0.8

0.0

:

:

11.3

2012

309

632

:

528

2012

11.8

20

1,724

69.2

9.6

8.0

2050

5.8

6.6

2050

9.3

2013

26.5%

2.1%

23.7%

30.3%

2.7%

2.7%

1.8%

35.4%

2.9%

18.9%

22.2%

2.3%

2.5%

2.3%

2013

0.30

0.4

0.8

0.0

:

:

10.9

2013

321

643

:

523

2013

11.7

20

1,854

70.4

9.3

8.5

2055

5.8

6.7

2055

9.2

2014

26.9%

2.0%

23.2%

30.1%

2.8%

2.7%

2.0%

36.1%

2.7%

18.4%

22.1%

2.3%

2.5%

2.5%

2014

0.31

0.4

0.8

0.1

20.6

25.8

10.9

2015

26.8%

1.9%

24.6%

29.1%

2.9%

2.6%

2.1%

36.4%

2.7%

18.2%

22.2%

2.3%

2.3%

2.9%

2015

0.36

0.6

0.8

0.1

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2014

2015

2009

2011

2013

2015

332

641

:

524

2014

11.8

20

2,009

70.8

9.4

9.1

2060

5.8

6.8

2060

9.1

310

647

:

518

2015

11.8

20

2,209

69.3

9.5

9.9

2065

5.8

6.8

2065

9.0

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

5.7

6.7

2070

8.9

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Hungary

0.8

1.8

EU

0.9

1.6

Change 2016-2070, in %

Hungary

-9.6

EU

2.0

Source: €OSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

H
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a

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3
3

2
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1
3
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2.14. IRELAND 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

GDP per capita in PPS thousand is at €47.8 and far 
above EU average of €29.6  in 2015. Ireland has a 
population  of  4.7  million  inhabitants  (188).  It 
should  be  noted  that  in  2015  the  GDP  of  Ireland 
grew  by  25.1%  from  its  2014  level,  which  has  a 
strong effect on some of the variables presented as 
a ratio of GDP in this country profile.  

During  the  coming  decades  the  population  will 
steadily  increase  to  6  million  inhabitants  in  2070. 
Thus,  Ireland  is  facing  a  considerable  increase  of 
its  population  by  29%,  while  the  EU  average 
population is estimated to increase by 2%.  

Total and public expenditure on health as % of 
GDP 

Total expenditure (189) on health as a percentage of 
GDP (8.2% in 2015) has fallen sharply from 2014, 
although this is due to the increase in GDP in that 
year  rather  than  to  an  actual  fall  in  health 
expenditure.  It  is  below  the  EU  average  (190)  of 
10.2%  in  2015.  Public  expenditure  also  fell  from 
7.1%  of  GDP  in  2014  to  5.6%  of  GDP  in  2015 
versus  the  EU  average  of  8%.  Looking  at  health 
care  without  long-term  care  (191)  reveals  a  similar 
picture  with  public  spending  being  below  but 
slightly  further  from  the  EU  average  (4.2%  vs 
6.8% in 2015). 

in  per  capita 

To  provide  more  context  one  can  look  at  these 
terms.  Total  current 
variables 
spending on health at 4115 PPS in Ireland is above 
the EU average of 3305 in 2015. Similarly, public 
current  spending  on  health  care  is,  at  2849  PPS, 
higher than the EU average of 2609 PPS in 2015.  

(188) This is according to Eurostat projections. 
(189) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(190) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(191) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

134 

Expenditure projections and fiscal sustainability  

As a consequence of demographic changes, health 
care expenditure is projected to increase by 1.0 pps 
of  GDP,  above  the  average  growth  expected  for 
the  EU  (0.9)  (192),  according  to  the  Reference 
Scenario.  When  taking  into  account  the  impact  of 
non-demographic  drivers  on 
future  spending 
scenario),  health  care 
growth 
expenditure  is  expected  to  increase  by  1.7  pps  of 
GDP from now until 2070 (EU 1.6). 

(AWG 

risk 

Ireland  faces  low  fiscal  sustainability  risks  in  the 
short run and  medium term, but risks are  medium 
in  the  long  term,  risks,  due  to  the  significant 
projected increase in ageing costs including health 
care and long-term care (193).  

Health status 

Life expectancy at birth (83.4 years for women and 
79.6  years  for  men  in  2015)  is  close  to  the 
respective EU averages (83.3 and 77.9 years of life 
expectancy  in  2015)  (194).  However,  healthy  life 
years, at 67.9 years for women and 66.6 years for 
men,  were far above the EU averages of 63.3 and 
62.6  in  2015.  The  infant  mortality  rate  of  3.4 
deaths  per  1,000  live  births  is  also  slightly  lower 
than  the  EU  average  of  3.6  deaths  per  1,000  live 
births  in  2015,  having  gradually  fallen  over  most 
of the last decade (from 3.8%% in 2005), although 
it has been relatively flat since 2006. 

As  for  the  lifestyle  of  the  Irish  population,  data 
from  the  2017  Healthy  Ireland  survey  has  shown 
that 22% of the Irish population aged 15 and over 
are regular smokers. In contrast, Eurostat reports a 
proportion  of  19%  for  2015.  The  2017  Healthy 
Ireland  survey  also  shows  that  23%  of  the  Irish 
population  aged  15  and  over  are  obese  (Eurostat 
report  18.9%)  while  the  survey  also  shows  a 
reduction  in  alcohol  consumption  from  12.7  litres 
per  capita  in  2003  to  11  litres  in  2015,  but  still 
above the EU average of 10.0 in 2012. 

(192) The 

2018 

Ageing 

Report 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf . 

(193) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(194) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

 
                                                           
                                                           
Health care systems 

2.14. Ireland 

System characteristics  

Coverage 

All  persons  ordinarily  resident  in  the  country  are 
eligible,  subject  to  certain  charges,  for  all  in-
patient  public  hospital  services  in  public  wards 
including  consultant  services  and  out-patient 
services.  Some  groups  are 
public  hospital 
exempted from the charges (e.g. pregnant women, 
those  suffering  from  certain  medical  conditions, 
medical card holders) and there is an annual cap of 
€800 for these charges.A medical card ensures free 
services, 
to  all  general  practitioner 
access 
(195),  emergency, 
inpatient, 
prescribed  drugs 
outpatient,  certain  dental  aural  ophthalmic  and 
maternity  care.  Currently,  33%  of  the  population 
are eligible for a medical card. In addition, persons 
with  an  income  up  to  50%  above  the  income 
threshold for a medical card are eligible to receive 
free  general  practitioner  services  under  the  GP 
visit  card  scheme,  which  equates  to  an  additional 
10.4%  of  the  population.  Since  Summer  2015,  all 
children under 6 years of age (1 July 2015) and all 
persons  70  years  and  older  (4  August  2015)  are 
eligible for free general practitioner services. From 
1  September  2018,  all  recipients  of  a  Carer’s 
Allowance  (full  and  half-rate)  or  Carer’s  Benefit 
will  be  eligible  for  free  General  Practitioner 
Services.  The  remainder  of  the  population  is  not 
entitled to free GP services (196). Non-medical card 
holders  are  not  covered  for  aural,  ophthalmic  and 
dental  care  and  must  also  pay  the  first  €134  each 
pharmaceuticals; 
prescribed 
month 
thereafter the public health system covers 100% of 
the cost.   

towards 

Administrative  organisation  and 
collection mechanism  

revenue 

In 2015, 69.3% of total health expenditure funding 
came  from  government  sources  (taxes  at  central 
level)  and  from  the  Health  Contribution  Levy 
(substituted  by  a  new  Universal  Social  Charge  in 
2011).  

(195) A prescription charge of €2.50 per item in respect of items 
dispensed to medical card holders subject to a monthly cap 
of €25.00 per person or family.  

(196) As  a  result,  Ireland  scores  a  bit  above  5  on  the  scope  of 
basic  coverage  (the  third  lowest  OECD  value)  and  a  bit 
below 5 out of 6 on the depth of coverage according to the 
OECD scoreboard.  

There has been an effort in recent  years to reduce 
administrative  costs  and  improve  the  general 
management  of  the  sector.  The  Health  Service 
Executive (HSE) was established under the Health 
Act  2004  as  the  single  body  with  statutory 
responsibility  for the  management and delivery of 
health and personal social services in the Republic 
of Ireland. As outlined in the Health Act 2004 the 
objective  of  the  Executive  is  to  use  the  resources 
available to it in the most beneficial, effective and 
efficient  manner  to  improve,  promote  and  protect 
the health and welfare of the public.   

(Oireachtas).  Each  year 
to  fund 

As  regards  the  funding  of  the  HSE  and  the 
Department of Health, the budget is determined by 
the  Parliament 
the 
the 
Parliament  votes  public  monies 
Department of Health and services provided by or 
on  behalf  of  the  HSE.  Since  the  start  of  2015  the 
HSE  no  longer  has  a  separate  Vote  and  its 
spending and funding are accounted for as part of 
the  Health  Vote.  The  HSE  submits  its  National 
Service Plan for the Minister of Health's approval, 
setting  out  the  type  and  volume  of  health  and 
social care services to be provided by the HSE that 
year.  The  HSE  is  required  to  operate  within  the 
limits  of  its  allocation,  delivering  the  levels  of 
service which are provided for in the Plan. During 
the course of the year, detailed information related 
to performance of the  health  service in relation  to 
Access  to  and  Integration  of  services,  the  Quality 
and Safety of those services,  Finance, Governance 
and  Compliance,  and  Workforce  are  provided  to 
the  Department  of  Health  by  way  of  monthly 
Performance Monitoring Reports against the Plan..  

Role  of  private  insurance  and  out  of  pocket 
co-payments  

In recent years, private expenditure as a percentage 
of  total  health  expenditure  has  increased  (from  a 
trough of 23.3% in 2003 to 30.7% in 2015) and is 
above the EU average (21.6% in 2015).  

Note  also  that  more  than  40%  of  the  private 
expenditure  is  voluntary  community-rated  health 
insurance  (197)  (which  45.8%  of  the  population 
takes  up) 
to  help  cover  for  a)  cost-sharing 
(complementary insurance) when not eligible for a 

(197) See  for  instance  McDaid  D,  Wiley  M,  Maresso  A  and 
Mossialos  E.  Ireland:  Health  system  review,  Health 
Systems in Transition, 2009; 11(4): 1 – 268. 

135 

 
                                                           
                                                           
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medical  card,  b)  the  services  and  goods  excluded 
from the benefit basket (supplementary) and c) the 
same  goods  and  services  as  the  primary  coverage 
(duplicative)  (198).  It  would  be  important  that  this 
type of insurance does not discourage the recourse 
to  the  most  cost-effective  services  (e.g.  more 
primary  care  than  specialist  care  or  hospital  care 
when the latter are unnecessary).  

Out-of-pocket  payments  are  about  15.2%  of  all 
health-expenditure  and  have  decreased  since  their 
highest value of 18.2 in 2010. 

Types of providers, referral systems and patient 
choice 

The  public  health  service  is  a  mix  of  public  and 
private  provision.  Primary  care  is  delivered  in 
public  health  centres  and  private  premises  of 
general  practitioners  (GPs).  In  recent  years, 
Primary Care Centres have been developed within 
which  both  GPs  and  a  range  of  primary  care 
professionals  employed  by  the  HSE  are  housed. 
Outpatient  specialist  care  is  delivered  in  hospital 
outpatient  departments.  Approximately  85%  of 
acute  care  beds  are  within  the  public  hospital 
system. Persons may also decide to access services 
in  the  private  hospital  sector  and  in  most  such 
cases patients use private health insurance to meet 
the costs involved. 

The  number  of  licensed  physicians  per  100  000 
inhabitants  in  Ireland  is,  at  288,  below  the  EU 
average  of  344  in  2015,  below  the  2010  peak  of 
308 (before which it had been steadily increasing). 
The number of general practitioners (GPs) per 100 
000  inhabitants  was  75  in  2015,  below  the  EU 
average of 78.3. The number of nurses per 100 000 
inhabitants  (1240  in  2013)  is  far  above  the  EU 
average of 825. 

Medical card and GP Visit card holders are free to 
select any GP participating in the General Medical 
Services (GMS) Scheme but  must continue to use 
this GP subject to applying to and getting approval 
from  the  Health  Service  Executive  (HSE)  for  a 
change  of  GP  under  the  GMS  Scheme.  The 
remainder  of  the  population  make  their  own 

(198) In  addition,  in  2002  the  Government  established  the 
National Treatment Purchase Fund to pay for the treatment 
in  the  private  hospital  sector  of  patients  deemed  to  have 
been waiting for too long for surgery in the public hospital 
system. 

arrangements to access primary care physicians but 
must  pay  the  full  private  fee  for  this  service. 
Access  to  specialist  medical  services  in  acute 
hospitals is available only on foot of a referral by a 
primary  care  physician.  The  delivery  of  specialist 
medical  care  and  care  utilisation  is  strongly 
centred  on  hospitals  where  most  specialists  work 
(199).  Authorities  have  planned  the  greater  use  of 
ICT  and  a  standard  approach  to  the  use  of 
electronic  health  information,  which  can  help  in 
implementing  more  effective  referral  systems  and 
care  coordination  and  as  a  consequence  improve 
effectiveness and efficiency of care (see below for 
more details).  

In 2014 the number of acute care beds per 100 000 
inhabitants  was  243,  compared  to  an  EU  average 
of 402. The number has decreased since 2003, but 
has been relatively flat since 2011.  

Inpatient hospital discharges per 100 inhabitants in 
2014 were, at 13.7, below the EU average of 16.2.  
There  were  20,8  day  case  discharges  per  100 
inhabitants  in  2014,  far  above  the  EU  average  of 
16.4.  As  a  result,  the  ratio  of  day  cases  to  longer 
stays is amongst the highest in Europe. 

Acute  care  bed  occupancy  rates  in  2015  were  
94.7%,  far  above  the  EU  average  of  76.8%.  The 
rates have been increasing since a value of 85% in 
2003. 

Average  length  of  stay  has  fallen  slightly  from  a 
peak of 7,7 in 2008 to 6.4  days in 2015, below the 
EU average of 7.6.  

It should be noted that hospital bed data for Ireland 
excludes  private  hospitals,  and  is  therefore  under-
reported  compared  with  other  countries.  This  also 
applies 
to  hospital  discharge  data  and  may 
contribute  to  explain  the  extremely  high  bed 
occupancy  rates  as  well  as  the  low  levels  of 
discharges. 

There  is  a  Common  Basket  of  services  of  the 
public health system that has to be delivered to the 
whole population covered.  

(199) Indeed,  according  to  the  OECD,  the  level  of  choice  has  a 
score  of  a  bit  more  than  4  out  of  6,  while  gatekeeping 
scores 2 out of 6. 

136 

 
                                                           
                                                           
Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

  However, 

GPs  are  paid  on  a  capitation  (per  number  of 
registered  patients)  basis  plus  a  fee-per-item  basis 
for  specified  services  (e.g.  immunisations)  for 
medical  card  and  GP  visit  card  patients  (i.e.  44% 
of  the  population  as  of  April  2017)  (200)(201). 
Heretofore,  there  has  been  limited  room  to  use 
performance-related payments to encourage health 
promotion,  chronic  disease  prevention  or  disease 
management  actions. 
in  2015,  a 
package  of  measures  was  introduced,  including 
terms for the delivery of GP care without fees for 
all children under 6 years and the provision of GP 
care without fees to all persons aged 70 years and 
over. These represent the first phase in the delivery 
of  a  universal  GP  service.    The  new  enhanced 
under-6  service  involves  age-based  preventive 
checks  focused  on  health  and  wellbeing  and  the 
prevention  of  disease  and  also  covers  an  agreed 
cycle  of  care  for  children  under  6  diagnosed  with 
asthma. 

A  Diabetes  Cycle  of  Care  for  adult  Medical  Card 
and  GP  Visit  Card  patients  who  have  Type  2 
Diabetes was also introduced in 2015. 

in  private  fee-for-service  practice 

Historically,  specialists  have  been  permitted  to 
in 
engage 
conjunction  with  the  receipt  of  salary  as  public 
hospital  employees.  This  dual  practice 
in 
conjunction  with 
the  presence  of  duplicative 
private insurance (private insurance that covers the 
same goods and services as the primary coverage) 
risked  inducing  specialists  to  devote  an  excessive 
proportion  of  their  time  to  private  practice,  with 
consequent  negative  effects  of  the  service  for 
public  patients.  In  an  attempt  to  mitigate  the 
problem,  in  2008  authorities  negotiated  a  new 
employment contract for specialists, granting that a 
proportion  of  consultants  will  not  have  any  fees 
from  private  practice  while  those  who  engage  in 
private practice are obliged to have a minimum of 
80% public patients workload (202).  

(200) The  remaining  56%  of  the  population  must  pay  GPs  on  a 

private fee per visit basis.   

(201) The  OECD  score  for  remuneration  incentives  to  raise  the 
volume  of  care  is 3  out  of 6  for  Ireland  as  a  result  of  this 
mix of fee-for-service, salary and capitation systems. 
(202) Monitoring  arrangements  based  upon  measurement  of 

activity and case-mix have been introduced.   

Health care systems 

2.14. Ireland 

Public  remuneration  of  doctors  is  determined  by 
the  central  government  and  following  the  severe 
economic  crisis  national  authorities  have  focused 
on controlling wages in the health sector.  

Hospitals  are  paid  or  funded  using  a  combination 
of  prospective  global  budgets  and  activity-
related/DRG payment. Efforts continue to improve 
cost transparency and efficiency in the sector.  

The  introduction  of  an  activity-based  funding 
mechanism  is  a  key  health  reform  initiative.  In 
May 2015, the authorities published an action plan 
for 2015-2017 to implement activity-based funding 
in  public  hospitals.  The  actual  transition  from 
block-funding  of  hospital  activities  is  a  gradual 
process that commenced in January 2016 and will 
extend  over  several  years,  starting  with  inpatient 
and  day-cases  before  widening  to  outpatient  care. 
In  the  longer  term,  the  programme  will  consider 
implementation  of  activity-based  funding  in  other 
areas  such  as  emergency,  community  and  home 
care.  Activity-based  funding  is  meant  to  improve 
quality,  transparency,  data  collection  and  the 
allocation  of  resources  across  hospitals.  It  is 
important  to  note  that  while  the  new  funding 
model will encourage hospitals to use resources at 
their  disposal  more  efficiently  within  their  overall 
budgetary ceilings, activity-based funding does not 
seek  to  reduce  current  expenditure  on  acute 
hospital 
the 
forthcoming stages could prove challenging in the 
absence of a complete system of patient identifiers 
and fully reformed financial management systems.  
A  new  Healthcare  Pricing  Office  (HPO)  was 
established  on  an  administrative  basis  in  January 
2014 to set the national DRG (203) prices on which 
the  activity-based  funding  system  is  based  and  to 
manage the HIPE (204) dataset.  

Implementation 

services. 

of 

The market for pharmaceutical products 

on 

clinical 

The  initial  price  of  all  reimbursable  medicines  is 
based 
economic 
evaluation,  the  cost  of  existing  medicines  and 
international prices (currently based on the average 
manufacturing  price  in  AT,  BE,  DK,  ES,  FI,  FR, 

performance, 

(203) Diagnosis-Related  Groups  (or  DRGs)  are  a  classification 
which groups hospital case types that are clinically similar 
and are expected to have a similar hospital resource usage. 
(204) HIPE  (Hospital  Inpatient  Enquiry)  is  the  principal  source 
of  national  data  on  discharges  from  acute  hospitals  in 
Ireland. 

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GR, DE, IT, LU, NL, PT, SE and  UK, in line with 
current  agreement  with  industry).  Discounts  and 
rebates plus price freezes and cuts are measures to 
control  expenditure  directly.  The  authorities, 
through 
the  Health  Service  Executive  have 
established a Medicines Management Programme.  
A key focus of the programme is on cost-effective 
prescribing  and  the  reduction  in  drug  expenditure 
through more rational prescribing.  

Public pharmaceutical spending as a proportion of 
public current health spending was.13.8% in 2015, 
above the EU average of 12.7%. It should be noted 
that, given the large increase of GDP in 2015 this 
probably 
in 
pharmaceutical expenditure. 

the  difference 

underestimates 

report 

The  ESRI 
"Pharmaceutical  Prices, 
Prescribing  Practices  and  Usage  of  Generics  in  a 
Comparative  Context"  was  published  in  2013  and 
in-patent 
showed 
medicines  and  generic  medicines  were  higher  in 
Ireland compared to other EU Member States. 

for  originator 

that  prices 

Several policies have been implemented to reduce 
the  price  of  pharmaceuticals  and  details  of  the 
main policy initiatives are as follows: 

•  Agreement with Industry. The authorities have 
entered 
into  a  series  of  price  reduction 
agreements  with  both  the  Irish  Pharmaceutical 
Healthcare  Association 
the 
Association  of  Pharmaceutical  Manufacturers 
in  Ireland  (APMI).  Taking  these  Agreements 
together, it is estimated that cumulative savings 
in  excess  of  €1.5  billion  have  been  generated 
between 2006 and 2014. Successor agreements 
are expected  to be introduced in 2016. 

(IPHA)  and 

•  Generic  Substitution  and  Reference  Pricing. 
The impact of this legislation has been positive 
in  terms  of  increasing  the  level  of  generic 
penetration  in  the  Irish  market.  A  target  for 
generic penetration of the off-patent market by 
volume  of  70%  by  end  2016  has  been 
the  end  of  2017,  generics 
exceeded.  At 
accounted  for  74%  of  the  total  off-patent 
market by volume and 42% by value. 

•  Reference  pricing.  This  involves  setting  a 
common reimbursement amount for designated 
interchangeable  groups  of  medicines,  has 

138 

delivered  savings  in  the  region  of  €50  million 
in 2014 and a further €25 million in 2015. 

information  and 
Health  and  health-system 
reporting  mechanisms/  Use  of  Health 
Technology  Assessments  and  cost-benefit 
analysis 

technology  assessment. 

The  Health  Information  and  Quality  Authority 
(Incorporating the Office of the Chief Inspector of 
Social  Services)  was  established  in  mid-2007.  It 
has  a  broad  range  of  functions  which  include  the 
setting  and  monitoring  of  service  standards  and 
health 
  The  Chief 
Inspector  of  Social  Services  currently  registers 
regulates  residential  services  for  older  people, 
regulates residential and residential respite services 
for  children  and  adults  with  disabilities  and 
inspects children’s residential centres, special care 
units and foster care settings.  

Future  plans  to  develop  HIQA's  role  include 
extending the Authority's remit for standard setting 
to private hospitals, overseeing a licensing system 
for  public  and  private  healthcare  providers  and  to 
Technology 
continue 
Assessments 
support 
to 
investment and disinvestment decisions. 

undertaking  Health 
areas 

in  priority 

The  National  Clinical  Effectiveness  Committee 
(NCEC)  is  a  Ministerial  committee  established  in 
2010.  It  provides  oversight  for  the  National 
Framework for Clinical Effectiveness. Its terms of 
reference are to prioritise and quality assure to the 
level  of  international  methodological  standards  a 
suite of National Clinical Guidelines and National 
Clinical  Audit,  prioritised,  as  significant  for  the 
Irish  healthcare  system.  Each  guideline  has  a  full 
budget  impact  assessment  and  Health  Technology 
Assessment if required. 

A  policy  mandate  for  guideline  implementation  is 
provided through Ministerial endorsement.  

Relevant Key Performance Indicators and audit are 
identified  for  each  guideline  to  track  and  monitor 
implementation  through  the  HSE  Performance 
Assurance  Reports,  compliance  with  HIQAs 
National Standards for Safer Better Healthcare. It 
is  intended  that  increased  alignment  with  the 
clinical  indemnity  scheme  and  plans  for  licensing 
of hospitals will further strengthen the mandate for 
guideline implementation.  

 
E-Health, Electronic Health Record 

An eHealth – Strategy for Ireland was published in 
December  2013.    eHealth  Ireland  and  the  role  of 
the  Chief  Information  Officer  were  established  in 
2014  and  are  responsible  for  implementing  the 
eHealth  strategy  and  driving  eHealth  initiatives.  
The  development  of  a  national  Electronic  Health 
Record  (E.H.R.),  along  with  the  development  of 
the Individual Health Identifier (I.H.I) are essential 
elements to ensure that patient data can be securely 
connected  and  shared  within  the  health  service, 
to  patients.  The 
providing  safer,  better  care 
technical 
IHI  has 
commenced  with  a  roll-out  for  the  integration  of 
the  identifier  into  various  ICT  systems  nationally 
on a phased basis across acute and primary health 
services.  The  national  EHR  Strategic  Business 
Case  published  in  2016  sets  out  the  rationale  and 
investment  required  for  the  development  of  and 
implementation  of  a  national  E.H.R  and  work  is 
ongoing  in  progressing  the  three  core  elements  of 
the  programme:  (i)  acute  EHR,  (ii)  Community 
Operational  Systems  and  (iii)  a  Shared  Care 
Record  supported  by  an  integration  capability  to 
share data across the various health domains. 

implementation  of 

the 

In  addition  to  the  I.H.I.  and E.H.R.  other  national 
ICT systems are being introduced or standardised.  
The  Maternal  and  New-born  system  (MN-CMS) 
continues  to  be  deployed  nationally  on  a  phased 
basis  while  other  systems  such  as  the  national 
laboratory system (MedLIS), the national oncology 
management  system  (MOCIS),  eReferrals  and 
ePrescribing continue to be progressed. 

Recently 
reforms  

legislated  and/or  planned  policy 

Legislation  was introduced in 2013 to provide for 
the  charging  of  all  private  in-patients  in  public 
hospitals. 

The  Nursing  Homes  Support  Scheme  (NHSS), 
often referred to as the “Fair Deal” is a scheme of 
financial support for people who require long-term 
nursing  home  care.  The  statutory  based  scheme 
commenced  on  the  27th  October  2009  with  the 
enactment of the Nursing Homes Support Scheme 
Act  2009  and  replaced  the  former  Nursing  Home 
Subvention  scheme  which  had  been  in  existence 
since  1993.    The  NHSS  is  operated  by  the  HSE. 
This  Scheme  was  reviewed  and  a  report  of  the 

Health care systems 

2.14. Ireland 

Review was published in 2015. Work is underway 
in  implementing  the  recommendations  contained 
in the Review. 

In  June  2016,  the  All-Party  Committee  on  the 
Future of Healthcare was established with the goal 
of  developing  a  consensus  on  the  future  direction 
of  healthcare  policy  in  Ireland.  The  Committee 
consulted  with  a  broad  range  of  stakeholders  and 
published the Sláintecare Report in May 2017. The 
report  presents  a  ten-year  vision  for  a  health 
service  where  the  majority  of  care  is  delivered  in 
the  community,  care  is  integrated  across  different 
services  and  access  is  based  on  need  and  not 
ability  to  pay.  The  report  details  key  reforms 
needed to move towards that vision.  

The Government gave approval for the Department 
of Health to advance key actions in the Sláintecare 
Report and to develop a full response to the report. 
Among these actions, was the establishment of an 
independent  group  to  examine  the  effects  of 
removing  private  practice  from  public  hospitals. 
This  group  is  expected  to  report  by  the  end  of 
2018.  

A  new  implementation  and  governance  structure 
has been put in place to drive reform. A dedicated 
been 
Programme  Office 
Sláintecare 
established  and  a  new  Executive  Director 
recruited.  The  Chair  of 
the  new  Sláintecare 
Advisory Council was appointed in July 2018. The 
council  will  provide  both  Irish  and  international 
health  expertise  to  support  the  work  of  the 
Sláintecare Programme Office.  

has 

In  August  2018,  the  Sláintecare  Implementation 
Strategy  was  published  following  approval  by 
government.  This  is  the  Government’s  ten-year 
strategy to reform Ireland’s  health and social care 
services.  The  strategy  provides  a  framework  for 
reform  with  four  over-arching  goals,  and  10 
strategic actions. 

An 
Independent  Review  Group  has  been 
established to examine and enquire into the effects 
of  the  removal  of  private  activity  from  public 
hospitals  and  examine  potential  benefits  and 
potential  adverse  consequences,  including  any 
unintended  consequences  that  may  arise  in  the 
removal. 

139 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

is  committed 

The  Department  of  Health 
to 
evolving the current health structures, in line with 
other reforms, in order to devolve decision-making 
line  with  demonstrated 
and 
functionality,  as  outlined 
the  Sláintecare 
Implementation Strategy. 

autonomy 

in 

in 

Irish  National  Dementia  Strategy  was 
The 
launched in December 2014. The Strategy aims to 
improve  dementia  care  to  allow  people  with 
dementia  to  live  well  for  as  long  as  possible  and 
have  services  and  supports  delivered  as  well  as 
possible.  A  National  Dementia  Office  was 
established  in  the  HSE  in  2015  to  drive  the 
Strategy’s  implementation.  A  mid-term  review  of 
the Strategy (May 2018) noted that good progress 
has  been  made  on  implementing  many  of  the 
Strategy’s  35  priority  and  additional  actions  but 
that additional financial and staffing resources will 
be  required  in  the  areas  of  diagnosis,  post-
diagnostic  supports,  primary  care,  acute  care, 
home care and housing if the Strategy is to be fully 
implemented. 

The  introduction  of  activity-based  funding  and  a 
Healthcare  Pricing  Office  described  under  “Price 
of healthcare services, purchasing, contracting and 
remuneration  mechanisms”  above  will  help  to 
deliver  greater  efficiency  and  transparency  in  the 
delivery of services and therefore will enhance the 
fiscal sustainability of the health system. 

The Department of Health conducts an annual data 
collection of the private hospital sector. This is an 
important  step  in  closing  current  data  gaps,  and 
allows statistics for Ireland to be viewed in a more 
comparable way with other Member States. 

The  Department  of  Health  launched  a  public 
consultation  on  a  new  Health  Information  Policy 
Framework  in  late  2017  with  a  view  to  finalising 
the policy in early 2019. 

The  National  Development  Plan  provides  €10.9 
billion,  over  the  ten  year  period,  for  a  number  of 
major capital investment projects and programmes 
along  with  significant  reform  initiatives  for  the 
health  sector  including  new  healthcare  facilities 
that  allow  for  implementation  of  new  models  of 
care,  for  the  delivery  of  services  in  high  quality 
modern  facilities  and  expanded  bed  numbers  and 
health  services  to  build  a  better  health  service  for 

140 

the  future  consistent  with  the  National  Planning 
Framework. 

The  Health  Service  Capacity  Review  was 
published  in  January  2018.  The  Review  forecasts 
future  capacity  requirements  in  acute  hospitals, 
primary  care  and  in  services  for  older  persons 
(residential  and  homecare  services)  for  the  period 
2016 to 2031. The analysis took account of current 
levels  of  demand  and  capacity,  demographic  and 
non-demographic  factors  that  will  drive  future 
demand,  and  the  potential  impact  that  key  system 
reforms can have on capacity needs. 

in 

commitments 

The analysis of the Capacity Review informed the 
investment 
the  National 
Development  Plan.  Arising  from  the  findings  of 
the  Capacity  Review,  the  Government  committed 
to  funding  an  extra  2,600  acute  hospital  beds, 
4,500 residential care beds and three new elective-
only  hospitals  in  major  population  centres.  This 
commitment  is  part  of  a  broader  programme  of 
reform in the health sector. Investment and reform 
will  go  hand  in  hand,  in  order  to  drive  change  in 
the  delivery  of  health  and  social  care  services  in 
Ireland (205). 

Challenges 

schemes) 

•  To consider changes in payment procedures to 
physicians  (e.g.  through  the  use  of  mixed 
payment 
encourage  health 
to 
promotion,  disease  prevention  and  disease 
management  activities  in  primary  care  and 
make  primary  care  more  attractive;  To 
implement  measures 
to  prevent  chronic 
diseases and their complications. 

increasing 

•  To continue to enhance primary care provision 
by 
spatial 
distribution  of  primary  care  professionals  and 
ensuring  an  effective  referral  system  from 
primary to specialist care and from specialist to 

the  numbers  and 

for 

the 

(205) Project Ireland 2040 is the overarching policy and planning 
framework 
social,  economic  and  cultural 
development  of  Ireland.  It  includes  both  the  20-year 
National  Planning  Framework  and  the  detailed  capital 
investment plan  for  the period 2018 to  2027, the  National 
Development  Plan.  The  Framework  outlines  the  broad 
policy principles and priorities to plan for future population 
and economic growth in Ireland over the next 20 years. The 
principles of the Planning Framework will be underpinned 
by the National Development Plan, a ten-year, €116 billion 
capital investment programme. 

 
                                                           
Health care systems 

2.14. Ireland 

•  To  further  enhance  health  promotion  and 
disease  prevention  activities  i.e.  promoting 
healthy  life  styles  and  disease  screening  given 
the recent pattern of risk factors (diet, smoking, 
alcohol, obesity). 

related 

costs.  A 

primary  care.  This  could  improve  access  to 
care by different population groups and reduce 
unnecessary  use  of  hospital  care  and  therefore 
in 
overall 
streamlining  patient  care  is  the  introduction  of 
individual  patient  identifiers  which  is  being 
addressed.  These 
improvements  could  be 
complemented  with  incentives  for  patients, 
both  financial  and  non-financial,  to  encourage 
the use of primary care versus specialist care.  

challenge 

is  provided 

•  To  reduce  unnecessary  use  of  specialist  and 
hospital care and within hospitals, ensuring that 
the  most  clinically 
in 
care 
appropriate 
for 
cost-effective  way, 
example  by    maximising  the  proportion  of 
elective care provided on a day case basis, day-
of-surgery 
reducing 
inappropriate lengths of stay.  

admission 

and 

and 

•  To  explore  the  means  to  improve  the  way 
private  and  public  provision  are  better 
integrated  in  an  overall  provision  framework 
and  reconsider  the  current  system  of  payment 
incentives  which  may  be  detrimental  to  public 
patients and the public sector. 

•  To  consider  additional  measures  regarding 
direct  pharmaceutical  expenditure  control, 
product  reimbursement  on  the  basis  of  cost-
effectiveness  information  and  greater  use  of 
generics vs. branded medicines.  

•  To 

to 

continue 

enhance  managerial 
accountability  and  decrease  administrative 
costs  while  aligning  incentives  (payments, 
cost-sharing)  with  national  public  health  goals 
and effectiveness and efficiency. The efforts in 
setting  up  activity-based  costing  should  help 
improve  quality,  transparency,  data  collection 
and a reallocation of resources across hospitals, 
and in time the wider health care system. 

•  To  improve  data  collection  in  some  crucial 
areas  such  as  resources  and  care  utilisation. 
Better  monitoring  of  activity  in  the  sector, 
combined with greater use of health technology 
assessment  could  be  used 
for  planning 
purposes  and  for  defining  the  extent  of  cost-
sharing. The work to develop IHIs should be a 
key plank of future developments.  

141 

 
1
4
2

Table 2.14.1:  Statistical Annex - Ireland 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2005

170

32.7

3.6

:

2006

185

33.8

2.8

-0.2

2007

197

35.1

2.1

7.9

2008

188

32.1

-6.0

8.7

2005

2006

2007

2008

8.0

6.7

1.4

7.8

7.0

0.8

8.2

7.2

1.0

9.5

7.6

1.9

2009

170

30.6

-5.5

8.1

2009

10.9

7.5

3.4

2010

168

33.1

1.3

1.1

2010

10.9

7.8

3.1

2011

172

34.2

2.6

-2.4

2011

10.4

9.1

1.3

2012

176

34.5

-0.2

4.1

2012

10.8

10.5

0.3

2013

180

34.5

1.4

2.6

2013

10.9

10.4

0.5

2014

195

37.1

8.0

2.6

2014

10.4

9.9

0.5

2015

262

47.8

24.8

-1.9

2015

8.2

7.8

0.4

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

2,997

3,089

3,374

3,618

3,696

3,613

3,509

3,721

3,849

3,920

4,115

2,745

2,895

2,975

3,305

6.3

6.0

6.1

5.8

6.5

6.2

7.5

7.2

8.3

8.1

8.3

8.0

7.8

7.5

7.9

7.6

7.5

7.3

7.1

6.9

5.6

5.4

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

2,358

2,399

2,643

2,845

2,827

2,748

2,638

2,728

2,639

2,693

2,849

2,153

2,263

2,324

2,609

0.29

78.7

21.4

100.0

16.0

0.21

77.7

21.8

100.0

16.1

0.28

78.3

20.5

100.0

14.8

0.28

78.6

18.2

100.0

15.3

0.24

76.5

16.9

100.0

16.1

0.25

76.0

13.0

100.0

18.2

0.24

75.2

18.3

100.0

17.7

0.29

73.3

19.3

100.0

11.4

0.21

68.6

20.1

100.0

15.0

0.26

68.7

19.6

100.0

15.4

0.22

69.3

18.9

100.0

15.2

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

4.1

81.3

76.7

64.0

62.9

59

3.8

4.2

81.7

76.9

64.9

63.2

57

3.9

4.3

82.1

77.3

65.6

62.9

53

3.2

4.5

82.4

77.9

65.1

63.5

55

3.4

4.5

82.7

77.8

65.2

63.9

50

3.3

4.5

83.1

78.5

66.9

65.9

48

3.6

4.6

83.0

78.6

68.3

66.1

126

3.5

4.6

83.1

78.7

68.5

65.9

122

3.5

4.6

83.1

79.0

68.0

65.8

117

3.5

4.6

83.5

79.3

67.5

66.3

112

3.3

4.7

83.4

79.6

67.9

66.6

111

3.4

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

1.2

1.2

1.3

1.5

1.6

1.6

1.4

1.4

:

:

:

:

:

:

0.8

:

0.2

:

:

:

:

:

:

:

0.9

:

0.2

:

:

:

:

:

:

:

0.9

:

0.2

:

:

:

:

:

:

:

1.1

:

0.2

:

:

:

:

:

:

:

1.2

:

0.2

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

1.2

1.1

1.1

:

:

:

:

:

:

:

:

:

2.5

0.7

2.1

1.5

0.0

0.3

0.3

1.7

0.4

1.4

1.1

0.0

0.2

0.1

2.4

0.7

1.9

1.4

0.0

0.3

0.4

1.6

0.4

1.3

1.0

0.0

0.2

0.1

1.9

0.5

1.5

1.0

0.1

0.2

0.2

1.3

0.3

1.0

0.8

0.0

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2.14.2:  Statistical Annex - continued – Ireland 

Composition of total as % of total current health expenditure

2005

2006

2007

2008

2009

2010

2011

2012

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

17.7%

17.6%

17.7%

19.0%

21.2%

20.0%

15.7%

13.5%

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

13.8%

15.3%

15.1%

15.1%

15.0%

15.1%

14.8%

14.5%

:

:

:

:

:

3.3%

3.4%

3.2%

2.8%

2.5%

:

:

:

:

:

2005

:

:

1.1

:

:

:

13.3

2005

:

1236

51

690

2005

:

14

2006

0.80

:

1.3

:

:

:

13.4

2006

272

1274

51

617

2006

:

14

2007

0.85

:

1.4

0.1

15.0

29.0

13.6

2007

280

1296

53

608

2007

3.3

14

2008

0.90

:

1.5

0.2

:

27.0

12.7

2008

290

1288

53

559

2008

:

14

2009

1.19

:

1.5

0.2

:

:

11.4

2009

301

1274

55

553

2009

:

13

:

:

:

2010

1.24

:

1.6

0.2

:

:

11.9

2010

308

1294

56

546

2010

3.8

13

:

:

:

2011

1.31

:

1.6

0.2

:

:

11.7

2011

267

1261

72

535

2011

:

13

:

:

:

2012

1.24

:

1.7

0.2

:

:

11.5

2012

271

1260

72

528

2012

:

14

2013

23.5%

6.7%

20.0%

14.5%

0.4%

2.8%

3.1%

22.8%

5.9%

19.6%

14.7%

0.4%

2.5%

1.2%

2013

1.33

:

1.8

0.2

:

:

10.5

2013

269

1240

73

523

2013

:

14

2014

23.8%

6.8%

19.3%

14.0%

0.4%

2.7%

3.5%

23.6%

6.1%

18.8%

14.1%

0.3%

2.3%

1.2%

2014

1.34

:

1.7

0.2

18.2

12.7

10.8

2014

281

:

78

524

2014

:

14

10,667

15,542

16,500

17,425

18,404

18,998

19,311

20,016

20,270

20,809

86.0

6.5

44.0

87.0

6.3

53.2

87.1

7.4

54.6

88.8

7.7

56.3

89.2

6.7

58.1

91.4

6.6

59.3

91.9

6.4

60.0

92.6

6.2

59.4

93.8

6.0

60.0

93.3

6.0

60.3

2015

24.2%

6.7%

19.6%

13.0%

1.2%

2.7%

2.8%

23.6%

6.1%

19.2%

13.8%

0.4%

2.4%

1.1%

2015

1.41

:

1.8

0.2

18.0

19.0

:

2015

288

:

75

518

2015

5.7

:

:

94.7

6.4

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

330

835

78

408

2009

2011

6.2

17

6.2

16

338

825

78

407

2013

6.2

16

344

833

78

402

2015

6.3

16

6,362

6,584

7,143

7,635

77.1

8.0

28.0

76.4

7.8

29.1

76.5

7.7

30.9

76.8

7.6

32.3

Projected public expenditure on healthcare as % of GDP*

2016

2020

2025

2030

2035

2040

2045

2050

2055

2060

2065

2070

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

4.1

4.1

4.3

4.4

4.4

4.6

4.6

4.9

4.8

5.2

4.9

5.4

5.0

5.5

5.1

5.6

5.1

5.7

5.2

5.8

5.2

5.8

5.1

5.8

Population projections

Population projections until 2070 (millions)

2016

4.7

2020

4.9

2025

5.0

2030

5.1

2035

5.3

2040

5.4

2045

5.5

2050

5.7

2055

5.8

2060

5.9

2065

6.0

2070

6.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

1
4
3

Change 2016-2070, in pps.

Ireland

1.0

1.7

EU

0.9

1.6

Change 2016-2070, in %

Ireland

29.4

EU

2.0

H
e
a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

2
.
1
4
.

I
r

l

e
a
n
d

 
 
 
 
 
 
 
 
 
 
2.15. ITALY 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

0.9% in nominal terms over the period 2007-2016, 
against the 7.1% of the period 2000-2006 (208).  

General  country  statistics:  GDP,  GDP  per 
capita; population 

GDP  per  capita,  26,077  PPS  in  2015,  is  slightly 
under  the  EU  average  for  the  same  year  (29,610 
PPS) slightly up from 25,300 in 2014. Population, 
recorded  at  60.8  million  in  2015,  is  projected  to 
decrease  to  54.9  million  in  2070,  which  at  -9.6% 
represents  a  growth  rate  that  is  more  than  11  pps 
lower than the average for the EU (2.0 % over the 
same period). 

Total and public expenditure on health as % of 
GDP,  per  capita  PPP,  public  expenditure  as  % 
of 
total  government  expenditure.  Recent 
trends and vs. EU average 

Total (public plus private) expenditure on health as 
a percentage of GDP (9.3% in 2015) is below the 
EU  average  (206)  (10.2%  in  the  same  year).  It  has 
increased  from  8.7%  in  2005.  Public  expenditure 
on  health  as  a  percentage  of  GDP  is  also  slightly 
below  the  EU  average  (7.0%  vs.  8.0  %  in  2015), 
up  from  6.8%  in  2005.  Total  (2,495  PPS)  and 
public (1,887 PPS in 2015) per capita expenditure 
were below the EU average (3,305 PPS and 2,609 
PPS in 2015), having increased since 2005 (2,219 
PPS and 1,732 PPS), but with moderate changes in 
the  second  part  of  the  decade.  Looking  at  health 
care  without  long-term  care ( 207)  reveals  a  similar 
picture,  with  spending  below  the  EU  average  but 
with a smaller gap (6.3% vs 6.8% in 2015). 

The  significant  slowdown  of  the  increase  in  the 
public  health  care  expenditure  has  been  achieved 
due  to  the  governance  regulations  and  procedures 
implemented  in  the  last  years,  namely  the  Health 
Pact between State and Regions, the monitoring of 
the  fulfilment  of  the  budget  objectives  and  the 
activation of the Deficit Reduction Plan procedure 
for  those  regions  not  complying  with  the  agreed 
budget  rules.  As  a  result,  public  health  care 
expenditure  has  grown  by  an  annual  average  of 

(206) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions  of  units  or  units  of  staff  where  relevant.  The  EU 
average  for  each  year  is  based  on  all  the  available 
information in each year. 

(207) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

144 

Expenditure projections and fiscal sustainability 

As  a  result  of  ageing,  health  care  expenditure  is 
projected to increase by 0.7 pps of GDP until 2070 
(below  the  average  change  in  the  EU  of  0.9  pps) 
(209). When taking into account the impact of non-
demographic  drivers  on  future  spending  growth 
(AWG  risk  scenario),  health  care  expenditure  is 
expected to increase by 1.1 pps of GDP from now 
until 2070 (EU: 1.6). 

Medium  and  long  term  sustainability  risks,  which 
are classified as high for Italy, mainly derive from 
the  high  debt-to-GDP  ratio  and  are  only  partly 
linked to health care expenditure and the projected 
cost of ageing (210). 

Health  status  and  disability  (life  expectancy, 
healthy life years, mortality, infant mortality) 

Life expectancy at birth (84.9 years for women and 
80.3  years  for  men  in  2015)  is  above  the  EU 
average (83.3 and 77.9 years in 2015). Healthy life 
years  at  birth  for  women  and  for  men  (62.7  and 
62.6 respectively in 2015) are very close to the EU 
average  for  the  same  year  (63.3  for  females  and 
62.6 for males).  

System characteristics  

System  financing:  taxed-based  or  insurance-
based 

A  regionally  based  National  Health  Service 
(NHS), with a division of responsibilities between 
the 
regional 
the 
the  2001  Constitutional 
governments  (set  by 

central  government 

and 

(208) Ministero  dell’economia  e  delle  finanze  –  RGS  (2017), 
no.4. 

Il_monitoraggio_del_sistema_sanitario, 
http://www.rgs.mef.gov.it/_Documenti/VERSIONE-
I/Attivit--i/Spesa-soci/Attivit-monitoraggio-
RGS/2017/IMDSS-RS2017.pdf.  

Report 

(209) I.e. considering the "reference scenario" of the projections 
Report: 

(see 
https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en.  

Ageing 

2018 

the 

(210) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

 
                                                           
                                                           
Health care systems 

2.15. Italy 

Amendment),  and  funded  mainly  by  taxation, 
provides full coverage of resident population ( 211). 

1. 

the  regional 
(IRAP); 

tax  on  production  activities 

Starting from 2013, a new mechanism has been set 
for  the  distribution  of  financial  resources  among 
regions,  according  to  the  procedure  envisaged  in 
legislative  decree  68/2011,  which  may  be 
summarised as follows: 

1.  each  year,  the  total  amount  of  resources 
addressed  to  the  financing  of  health  system 
(according to the evolution of macroeconomic 
variables and budget constraint) is defined (so 
called ”fabbisogno nazionale standard”); 

2. 

3. 

4. 

five  benchmark  regions  are  identified,  among 
regions which: a) have guaranteed the delivery 
of health services efficiently and appropriately 
ensuring,  at  the  same  time,  a  budget  balance 
position;  b)  have  fulfilled  the  achievements 
(“Adempimenti”)  foreseen  by  law,  according 
to  the  assessment  of  the  relevant  Committee  
(so-called  “Tavolo  degli  Adempimenti”);  c) 
have  reached  a  high  score  in  health  quality 
ranking,  according  to  the  set  of  indicators 
envisaged in the Health Pact; 

three regions out of the 5 benchmark ones are 
selected  by  the  Conference  of  regions,  being 
fixed the top ranked region; 

the  average 
regional  standard  costs  are 
computed  on  the  basis  of  the  actual  costs  of 
the three reference regions; 

5.  standard  costs  are  applied  to  the  regional 
regional  age 

population,  weighted  with 
structure; 

6. 

the  resulting  distribution  is  applied  to  the 
fabbisogno  nazionale  standard,  obtaining  the 
region 
fabbisogno 
(“fabbisogno regionale standard”). 

sanitario 

each 

of 

The  financial  coverage  of  the  regional  fabbisogno 
sanitario is  guaranteed through a  mix of  financial 
resources: 

(211) Including  foreign  citizens,  and  their  dependent  relatives, 
who are in one of the following positions: a) employed; b) 
enrolled  in  the  employment  lists;  c)  had  applied  for  a 
renewal  of  the  permit  of  stay.  As  for  dispositions 
concerning non- EU citizens, see law 40/1998, articles 32-
34. 

2. 

the surcharge on personal income tax; 

3. 

revenues  of 
the  ASL/AO  (Local  Health 
Bodies/Hospital  Bodies  -  Aziende  Sanitarie 
Locali/Aziende  Ospedaliere)  from  either  sale 
of  services  or  fees  paid  by  citizens  (so-called 
“tickets”); 

4.  as  for  Regions  with  ordinary  institutional 
status (regioni a statuto ordinario), a share of 
VAT 
the 
is  granted 
difference  between  their  fabbisogno  sanitario 
and 
the 
financial channels under points a)-c); 

resources  obtained 

to  cover 

revenue 

through 

the 

5.  as for Regions with special institutional status 
(regioni a statuto speciale), the quota of  their 
the 
fabbisogno  sanitario  not  covered  by 
financial  channels  under  points  a)-c)  is  to  be 
financed 
resources 
through 
(additional contribution) ( 212). 

their 

own 

they  fail 

to  comply  with 

Regions  are  required  to  ensure  a  budget  balance 
position.  If 
this 
requirement,  a  set  of  automatic  measures  is 
foreseen  in  order  to  restore  the  budget  balance 
position (mainly the increase of regional taxes). In 
case  of  a  deficit  exceeding  the  5%  threshold 
(computed as a ratio between the value of regional 
deficit in nominal terms and the financial resources 
assigned to regions to finance health expenditure), 
regions are obliged to present a 'Deficit Reduction 
Plan'  (Piano  di  Rientro).  The  latter  has  a  time 
horizon  of  three  years  and  lays  down  all  the 
necessary  measures  to  be  taken  by  the  region 
concerned to achieve the budgetary balance. 

Revenue  collection  mechanism  (tax/social 
security contributions/premium) 

In 2015, 75.6% of total health expenditure funding 
came  from  earmarked  public  sources,  including 
regional  tax  on  production  activities  (corporation 
tax  on  the  value  added  of  companies  and  on  the 
salaries of public sector workers - IRAP), regional 

(212) For region Sicily only, this additional contribution accounts 
for  at  maximum  49.11%  of  its  fabbisogno  sanitario.  The 
remaining  part  is  financed  by  the  National  Health  Fund 
(Fondo Sanitario Nazionale). 

145 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

surcharge  on  income  tax  and  a  share  of  VAT 
revenue (see §. 1).  

organisation: 

of 
Administrative 
government, levels and types of social security 
settings 
involved,  other 
institutions 

involved,  Ministries 

levels 

the  national 

According  to  the  organisational  setting  of  the 
Italian Health Care System, the Ministry of Health, 
in  agreement  with  the  Ministry  of  Economy  and 
Finance,  defines  general  objectives  and  national 
policy  priorities,  as  well  as  the  basic  levels  of 
health care treatments which are provided for free 
over 
territory  (so  called  Livelli 
Essenziali  di  Assistenza-LEA);  regions  are  in 
charge  with  planning,  coordinating  and  providing 
health  services 
(including  primary,  specialist 
outpatient  and  hospital  care,  health  promotion, 
disease  prevention  and  rehabilitation,  long-term 
nursing  and  psychiatric  care)  for  their  residents. 
They  have  large  autonomy  in  the  way  they 
organise  care  delivery,  within 
the  general 
framework designed at national level. The funds to 
be  allocated  to  each  type  of  care  are  somewhat 
determined  by  both  the  central  government  and 
regions. 

A  Committee  (so-called  Comitato  LEA)  is  in 
charge  of  monitoring  the  provision  of  LEAs  in 
each  region;  the  Committee  is  composed  of 
representatives of the ministries concerned (Health 
and  Economy  and  Finance),  the  Department  of 
Regional  Affairs  (within  the  Presidency  of  the 
Council of Ministers) and Regions (213).  

Regions  may  choose 
to  provide  extra  LEA 
benefits, and some do, but the relative costs should 
be covered through their own financial resources. 

As  foreseen  by  Law  208/2015,  a  new  Decree 
regulating the LEA was issued, in January 2017, in 
replacement  of  the  previous  one  adopted  in  2001. 
The  principal  novelties  introduced  by  the  decree 
are as follows: 

•  health provisions that were already included in 

the LEA have been better detailed; 

(213) Such a Committee was first established in 2005, according 

to article 9 of the Health Pact of 23rd March 2005. 

146 

•  out  of  date  health  provisions  have  been 
eliminated  and  replaced  with  others  more 
technologically advanced; 

• 

the lists of  chronical and invalidating diseases 
which  give  right  to  the  exemption  from  co-
payments have been updated; 

•  new compulsory vaccines have been foreseen. 

Coverage (population) 

Health services are provided for free to all citizens; 
however, a fee (co-payment) may be requested for 
the  provision  of  some  health  services  (e.g. 
specialist  health  services)  depending  on  income 
and age requirements. 

Treatment options, covered health services 

Primary care and hospital inpatient care are free at 
the point of use. Outpatient specialist consultations 
that  follow  a  referral  from  a  general  practitioner 
(GP  -  family  doctor),  diagnostic  procedures 
involve  a  small  fee  as  do  pharmaceuticals 
prescribed  by  a  physician  in  those  regions  who 
have  chosen  to  use  a  fee.  Unwarranted  visits  to 
emergency departments also involve a  fee. Dental 
care  is  guaranteed  for  specific  groups  of  the 
populations  (children,  vulnerable  groups  such  as 
disabled,  people  with  HIV  and  those  with  rare 
diseases)  and  in  emergency  cases,  while  others 
purchase dental care are out-of-pocket. Eyeglasses 
and  contact  lenses  and  dental  prostheses  are  not 
funded  or  provided  by  regions.  Patients  visiting  a 
physician  without  a  referral  or  buying  over-the- 
counter  medicines  have  to  pay  for  the  full  cost  of 
care  out  of  their  pockets.  Children  below  six,  and 
elderly  (65+)  individuals  with  an  income  below  a 
certain threshold, pregnant women and people with 
certain medical conditions are exempted from cost-
sharing. According to the OECD (2010) 15.6% of 
the  population  buys  duplicative  private  insurance 
(to  cover  for  the  same  services  covered  by  public 
provision/ funding).  

Waiting  times  and  lists  for  specialist  consultation 
and  hospital  surgery  are  considered  long  by  the 
population  and 
important  regional 
variations in the waiting time, which are seen as a 
problem in Italy. To reduce waiting times, the 28th 
of  October  2010  the  Agreement  between  the 

there  are 

 
                                                           
Government, 
the  Regions  and  Autonomous 
Provinces  on  the  Government  National  Plan  of 
waiting  lists  (PNGLA)  for  2010-2012  was  signed 
(214).  In  addition,  patients  are  allowed  to  obtain 
hospital care in other regions and there is a system 
of  interregional  compensation  whereby  regions 
paid  for  the  patients  they  send  away  and  receive 
the payments of those who come into the region to 
receive  treatment.  The  interregional  mobility  is 
directly  related  to  the  right  of  citizens  to  choose 
health  care  treatments,  for  example  by  accessing 
high  specialised  health  structures  located  out  of 
their own region.  

Role  of  private  insurance  and  out  of  pocket 
payments 

came 

expenditure 

In 2015, 24.4% of total (public and private) health 
care 
from  out-of-pocket 
payments  and  private  insurance  altogether.  The 
remaining  75.6%  was  publicly  funded.  The  share 
of  out-of-pocket  payments  in  Italy  is  currently 
above EU average (15.9% in 2015). 

Types of providers, referral systems and patient 
choice 

As  the  responsibility  for  care  delivery  has  been 
delegated to the regions, there  may be differences 
in the way the various types of care are organised/ 
delivered. 

In  general,  health  care  services  are  provided  for 
free 
through  public  providers  (ASLs,  public 
hospitals,  university  public  hospitals)  as  well  as 
private  accredited  providers.  Health  services  can 
be  delivered  also  by  private  non-accredited 
providers but the relative costs are fully charged on 
the users.  

Primary  care  is  provided  by  independent  general 
practitioners (GPs) and paediatricians acting on the 
basis of a contract with the NHS, and running their 
activities  in  single  practices  or  in  joint  practices 
(for which a financial incentive is provided).  

Outpatient specialist care is provided by specialist 
doctors  in  outpatient  departments  in  hospitals  as 
well  as  in  private  ambulatories  (both  accredited 

(214) For 

further 

see: 
http://www.salute.gov.it/portale/temi/p2_5.jsp?area=qualita
&menu=liste. 

information, 

Health care systems 

2.15. Italy 

conditions 

to  Decree 

and not accredited). A decree of Ministry of health 
(issued  according 
law  78/2015, 
converted  into  Law  125/2015)  has  laid  down 
appropriateness 
supplying 
indications,  which  doctors  must  report  in  their 
prescriptions.  In  case  doctors  do  not  comply  with 
this  obligation, 
their 
compensation  is  reduced  and  any  specialist  care 
provided  in  contrast  with  the  decree  is  charged  to 
patients. 

the  additional  part  of 

and 

Day  case  and  inpatient  care  also  take  part  in 
hospitals.  Provision  has  traditionally  been  public 
but  currently  health  services  are  provided  also  by 
private providers. According to the OECD (2012), 
about 68% of all acute hospital beds are public, 4% 
are  private  not-for  profit  and  28%  is  private  for 
profit. 
(Aziende 
Ospedaliere)  have  also  been  given  financial  and 
technical  autonomy  (contracting  with  the  ASLs), 
while  others  remain  under  the  direct  management 
of the ASLs.  

hospitals 

public 

Some 

The  ASLs  oversee  also  health  promotion,  disease 
prevention and occupational diseases activities. 

The  number  of  practising  physicians  per  100  000 
inhabitants (384 in 2015) is above the EU average 
(344  in  2015).  The  number  of  GPs  per  100  000 
inhabitants (74 in 2015) is broadly in line with the 
EU average for the same year (78). The number of 
nurses  per  100  000  inhabitants  (544  in  2015)  is 
well below the EU average of 833. 

The  authorities'  efforts  to  encourage  the  use  of 
primary  care  vis-à-vis  specialist  and  hospital  care 
include  compulsory  registration  with  a  GP  and  a 
to 
compulsory  referral  system  from  primary 
secondary  care  (i.e.  GPs  act  like  gatekeepers  to 
specialist and hospital care), while allowing patient 
choice  of  GP,  specialist  and  hospital  (215).  The 
coverage of primary care services in health centres 
is  guaranteed  over  24  hours,  through  the  primary 
care out of hours (so called guardia medica). Over 
time there has been a strong emphasis on primary 
care  as  the  first  point  of  access  to  care,  emphasis 
that is to continue to ensure quality and efficiency 
of care. Patient satisfaction with primary care GPs 
and  paediatricians 
the 
authorities have been introducing a number of ICT 

is  high.  Moreover, 

(215) Indeed,  according  to  the  OECD,  the  level  of  choice  of 
provider and gatekeeping in Italy both score of 6 out of 6. 

147 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

methods are defined at central level with the DRG 
weights  and  other  service  rates  negotiated  at 
regional level. 

looking  at  hospital  activity, 

When 
inpatient 
discharges  per  100  inhabitants  are  below  the  EU 
average  (11  vs.  16  in  2015).  Day  case  discharges 
have almost halved through the decade (contrary to 
the  EU  trend  which  has  seen  a  steady  increase 
(219)),  and  they  are  well  below  the  EU  average 
(7635  in  2015).  On  the  contrary,  overall  inpatient 
hospital length of stay (7.8 days in 2015) (220) is in 
line  with  the  EU  average,  though  slightly  above 
(7.6 days). 

The market for pharmaceutical products 

as 

expenditure 

pharmaceutical 

Total  (1.6%)  and  public  (1.0%)  expenditure  on 
pharmaceuticals  as  a  percentage  of  GDP  was 
broadly  in  line  with  the  EU  average  (respectively 
1.4%  and  1%)  in  2015.  Total  (17.9%)  and  public 
(15.0%) 
a 
percentage  of  total  current  health  expenditure  is 
respectively  above  and  slightly  below  the  EU 
average  (14.6%  and  12.7%  in  2015).  The  policy 
priority  is  to  keep  under  control  the  dynamics  of 
public  pharmaceutical  expenditure  by 
fixing 
appropriate  ceilings  as  a  share  of  the  financing 
level  of  the  National  Health  Service  (Servizio 
Sanitario  Nazionale  -  SSN)  contributed  by  the 
State ( 221). 

The  authorities  have  implemented  a  number  of 
policies to control expenditure on pharmaceuticals, 
based on (i) limits to expenditure dynamics and (ii) 
control  of  pharmaceuticals  prices.  Expenditure 
rules on pharmaceutical products exist since 2001; 
however,  since  2008,  a  new  rule  was  introduced, 
foreseeing  thresholds  for  pharmaceutical  products 
supplied  by  pharmacies  or,  directly,  by  the  ASLs. 
The  rule  established  two  expenditure  ceilings  for 
pharmaceutical  products  (including  patient  co- 
payments)  expressed  as  a  percentage  of 
the 
financing  level  for  the  National  Health  Service 

(219) This refers to the aggregate EU-28. 
(220) Eurostat,  Last  update  10.07.15,    In-patient  average  length 

of stay (in days), Services of curative care. 

(221) For the details, see section 6. 

and  e-health  solutions  to  allow  for  nationwide 
electronic  exchange  of  medical  data  (including 
patient  electronic  medical  records  and  patient  e-
card) to support care coordination, reduce medical 
errors  and  increase  cost-efficiency  as  well  as 
monitoring activity and consumption. 

The  number  of  acute  care  beds  per  100  000 
inhabitants (264 in 2015) is below the EU average 
(402  in  2015).  In  line  with  the  EU  trend,  the 
number of acute beds in Italy has been decreasing 
over  the  last  decade  (344  in  2005),  as  a  result  of 
the  policies  run  over  the  last  years  aimed  at 
reducing  the  rate  of  acute  beds  towards  the 
standard  levels  set  by  the  current  legislation  ( 216). 
In  some  areas  there  may  be  a  shortage  of  follow-
up/long-term  care  beds/  facilities  which  might 
create  bed-blockages  in  acute  care.  It  is  regional 
government  to  plan  for  the  number  of  hospitals, 
the provision of specific specialised services. 

Pricing,  purchasing  and  contracting  of 
healthcare 
remuneration 
mechanisms 

services 

and 

Primary  care  physicians  are  paid  on  a  capitation 
basis,  while  outpatient  and  inpatient  specialists 
acting in public structures are paid by a salary. The 
pay  scale  is  determined  at  national  level.  Primary 
care  physicians  appear  to  be  eligible  to  receive 
bonuses  regarding  preventive  care  or  disease 
management activities (217). Private sector doctors 
are paid a fee-for-service. 

Hospitals  remuneration  is  on  a  payment  per  case 
basis  using  DRGs  (218).  Hospital  remuneration 

(216) According  to  law  decree  95/2012,  the  standard  rate  for 

acute care beds is set at 300 per 100 000 inhabitants. 

(217) It  is  foreseen  by  article  8  of  the  National  General 
Agreement  (Accordo  nazionale  collettivo)  concerning  the 
discipline of GP. 

(218) The  OECD  score  for  remuneration  incentives  to  raise  the 
volume  of  care  in  Italy  is  a  bit  more  than  3  out  of  6  as  a 
result  of  the  use  of  activity  related  payment  in  hospital 
remuneration though not in other areas. The OECD overall 
efficiency  score  for  Italy  is  slightly  higher  than  its  group 
average (about 1.8 years potential gain to be made through 
greater  efficiency  in  the  sector  compared  to  the  group 
average  of  2.6  years)  and  above  the  OECD  average  (2.3 
years).  There  are  nevertheless  areas  for  improvement 
including:  continue  to  improve  efficiency  in  the  hospital 
sector  notably  through  the  publication  of  comparable 
information  on  activity  and  quality  and/or  through  an 
element  of  activity  related  payment  of  physicians; 
increasing consistency in the allocation of resources across 
levels of government. 

148 

 
                                                           
                                                           
contributed  by  the  State.  Starting  from  2017,  the 
thresholds are set as follows (222): 

•  7.96% for pharmaceutical products supplied by 

pharmacies; 

•  6.89%  for  pharmaceutical  products  directly 

supplied by the ASLs and hospitals; 

The expenditure ceilings must be respected both at 
regional and national levels. 

As  for  the  latter  expenditure  item,  since  2008  an 
automatic  procedure  (so-called  pay-back)  is  in 
place to compensate for possible overruns.  

the 

companies 

the  disease, 

the  effect  of 

pharmaceutical 

Concerning  price  control  policies,  the  initial  price 
of  a  new  pharmaceutical  product  is  based  on 
clinical  performance,  economic  evaluation,  on  the 
cost  of  existing  treatments.  There  are  controlled 
price  updates.  Price  setting  involves  important 
negotiations  between  the  Italian  Pharmaceutical 
Agency  (Agenzia  Italiana  del  Farmaco  -  AIFA) 
and 
and 
negotiations  take  into  consideration  the  social 
relevance  of 
the 
medicines,  the  expected  utilisation  and  financial 
impact, prices in other countries, prices of  similar 
products  in  Italy.  Discounts,  payback  and  price 
freezes and cuts are some of the mechanisms used 
to directly control expenditure. There is a positive 
list  of  reimbursed  products  which  is  based  on 
information/ 
health 
economic  evaluation.  Reference  pricing 
for 
reimbursement  purposes 
is  also  applied.  For 
medicines  for  which  generics  are  available  the 
reimbursement  level  is  set  at  the  lowest  price  of 
the  drugs  in  a  group  (defined  as  drugs  with  same 
active 
and 
therapeutic  indications),  and  the  cheapest  price 
must  be  at  least  20%  lower  than  the  originator 
the 
product.  For 
reimbursement  level  of  a  new  drug  is  based  on  a 
sort  of  average  cost  of  a  defined  group  of 
medicines  that  are  related  but  slightly  different 
chemically. 

those  without  generics, 

bioequivalent 

technology 

assessment 

ingredient, 

form 

Authorities  promote 
physicians 

through 

rational  prescribing  of 
treatment  and  prescription 

(222) Before 2017, the threshold were, respectively, 11.35%, and 
3.5%,  being  the  pharmaceutical  products  supplied  by  the 
ASLs included in the former instead of in the latter. 

Health care systems 

2.15. Italy 

guidelines  complemented  with  education  and 
information campaigns on the prescription and use 
of  medicines  and  the  monitoring  of  prescribing 
behaviour  (by  regions  and  ASLs).  GPs  receive 
some  kind  of  feedback  on  their  prescription 
patterns.  Authorities  also  pursue  information  and 
education campaigns directed at patients and some 
regions have introduced a small fee for either pack 
or  receipt  to  make  patients  more  sensitive  to  the 
cost  of  medicines  and  encourage  a  rational  use  of 
medicines on the patients' side. There is an explicit 
generics  policy.  Generic  sales'  targets  are  set  by 
Italian  Pharmaceutical  Agency.  Generic 
the 
substitution takes place i.e. pharmacies are obliged 
to  offer  the  generic  medicine  when  available.  If 
patients refuse a generic, they will have to pay the 
difference between the reimbursement price of the 
branded drug and the pharmacy retail price of the 
cheapest available generic. Generics are exempted 
from the mandatory discount of pharmacies to the 
NHS  so  as  to  encourage  pharmacies  to  hold  and 
sell generics. 

In  order  to  monitor  and  keep  under  control  the 
dynamics  of  pharmaceutical  expenditure  and  GPs' 
prescriptions, a comprehensive information system 
called  “Sistema  Tessera  sanitaria”  has  been 
implemented. 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

there 

levels  although 

Health  Technology  Assessment  is  undertaken  at 
various 
is  no  national 
structure  responsible  for  conducting,  promoting, 
coordinating or financing  HTA. There are clinical 
guidelines for medical interventions and medicines 
established  through  the  National  Programme  on 
Clinical Guidelines. 

E-health (e-prescription, e-medical records) 

Starting  from  2003, 
the  “Tessera  Sanitaria” 
information  system  (herehence  “TS”)  has  been 
gradually  implemented  under  the  supervision  and 
management  of  the  Ministry  of  Economy  and 
Finance  -  Department  of  General  Accounts.  In 
2009, such a system  was fully implemented in all 
regions and since then it has been regularly utilised 
for  the  monitoring  of  the  full  procedure  for 
pharmaceutical and specialist care provisions, from 
the prescription to the delivery. Besides, through a 
the  Tessera 
set  of  performance 

indicators, 

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Sanitaria  system  allows  to  make  cross-regional 
comparative  analysis  on 
the  efficiency  and 
appropriateness of prescriptions. 

Since  2013,  the  TS  has  also  been  utilised  for  the 
gradual  implementation  of  the  electronic  medical 
prescription  (ricetta  elettronica)  over  the  entire 
national  territory,  in  line  with  the  programme  of 
the  Italian  Digital  Agenda  (Agenda  Digitale 
Italiana)  which  foresees  the  full  dematerialisation 
of  medical  prescriptions.  In  this  regards,  the  TS 
has implemented a technological infrastructure for 
doctors, 
electronic 
pharmacies, hospitals and other public health body, 
or  private  health  body  accredited  by  the  National 
Health System (223). 

interconnection 

with 

own 

their 

private 

expenses 

Since  2015,  the  TS  also  allows  patients  to  check 
on-line 
on 
pharmaceutical  and  specialist  care before  they  are 
submitted  to  the  Fiscal  Agency  (Agenzia  delle 
entrate)  for  the  pre-filled  income  tax  statement 
(730-precompilato).  More  recently,  based  on  the 
Budget  law  for  2016,  such  electronic  procedures 
have  further  strengthen  in  order  to  allow  all 
patients  to  access  and  check  on-line  their  health 
expenses  all  over 
the 
transmission to the Fiscal Agency. 

regardless 

the  year 

the 

creating 

Finally, 
the  patient’s 
implementation  of 
electronic  health  record  (Fascicolo  Sanitario 
Elettronico),  that  was  foreseen  by  law  decree 
179/2012, article 12, has been sped up through the 
involvement of the TS. In fact, the Budget Law for 
2017  (Law  232/2016)  assigned  to  the  TS  the  task 
system 
of 
(interconnection 
the 
(interconnection  amongst 
subsidiarity 
health  bodies  within  a  region),  for  those  regions 
still lacking of it. The directorial decree regulating 
both electronic systems was issued in August 2017 
and,  to  date,  the  activities  involved  are  nearing 
completion.  

the 
amongst 

interoperability 

regions) 

system 

and 

(223) All  this  further  strengthens  the  accuracy  and timeliness  in 
checking prescription appropriateness and requirements for 
co-payment  exemptions.  In  2015,  about  350  million  of 
dematerialised prescriptions  were  issued.  Thanks  to the  e-
prescription  system,    since  1st March 2016 the  validity  of 
prescriptions has  been  extended also  to  regions  other  than 
that of residence.  

150 

Health  and  health-system 
reporting mechanisms 

information  and 

Following  a  pilot  period,  a  comprehensive 
information  and  monitoring  system  (National 
Healthcare  Information  System)  -  using  130 
indicators  and  covering  population  health  status, 
budgetary  and  economic  efficiency,  organisation 
climate  and  staff  satisfaction,  patient  satisfaction, 
performance  indicators  (appropriateness,  quality) 
and  effectiveness  in  reaching  regional  targets  -  is 
now  fully  operational.  A  comprehensive  set  of 
indicators  has  been  introduced  by  the  Health  Pact 
2010-2012,  for  evaluating  the  performance  of 
regional health services. 

Several  regions  have  adopted  the  system  which 
uses standard codes. As a result, Italy will be able 
to  gather  extensive  information  at  regional  and 
sub-regional levels, which is publicly available on 
a website allowing for public comparisons. Such a 
system,  allows  regions  to  identify  good  practices 
as  well  as  areas  for  improvement.  Physicians  are 
being  monitored  in  terms  of  their  activity  and 
compliance  with  guidelines  as  well  as 
their 
prescription  behaviour.  They  receive  feedback  on 
their prescription patterns. 

Health  promotion  and  disease  prevention 
policies 

The  central  Government  through  the  Ministry  of 
Health sets and monitors public health priorities in 
terms  of  process,  outcomes  and  the  reduction  of 
health inequalities. There are some risk factors that 
can  translate  into  an  important  burden  of  disease 
and financial costs. The latest National Health plan 
lists  a  number  of  priority  areas  for  health 
promotion  and  disease  prevention  which 
is 
proposed  as  good  practice  across  the  regions. 
Health promotion and disease prevention activities 
have  not  historically  received  the  same  emphasis 
as  in  other  countries  in  the  EU,  as  seen  by  its 
pattern  of  expenditure  and  some 
indicators. 
However, in 2015, public and total expenditure on 
prevention  and  public  health  services  as  a  %  of 
GDP  are  in  line  with  the  EU  average  (0.3%  and 
0.4%  vs.  0.3%  and  0.3%  for  the  EU  average  in 
2015),  after  a  decade  of  consistently  being 
markedly  lower  than  average.  Public  and  total 
expenditure  on  prevention  and  public  health 
services  as  a  %  of  current  health  expenditure 
(public  and  total,  respectively)  are  currently  both 

 
                                                           
Health care systems 

2.15. Italy 

above  the  EU  average  (4.7%  vs.  3.2%  and  4.0% 
vs. 3.2% in 2015). 

evaluating 
services.  

the  quality  of  regional  health 

Transparency and corruption 

In  order  to  guarantee  the  full  accountability  and 
monitoring of health sector, Italy has implemented 
an integrated governance framework. 

Furthermore, the budget law for 2016, introduced a 
Deficit  Reduction  Plan 
(Piano  di  Rientro) 
procedure also for hospital bodies as an additional 
tool  to  restore  budget  balance  positions  and 
improve an efficient use of public resources. 

Health  expenditure  trends  are  analysed  on  a 
quarterly  and  yearly  basis,  relating  on  a  set  of 
standardised  economic  accounts,  mainly  based  on 
a  profit  and  losses  account  and  a  balance  sheet 
account.  These  accounts  are  filled  at  the  regional 
level and single public provider of health services, 
on the basis of harmonised recording criteria. 

A  dedicated  committee  (named  “Tavolo  degli 
Adempimenti”)  is  in  charge  with  the  analysis  of 
expenditure  trend,  the  verification  of  the  budget 
balance  position  and  the  fulfilment  of  the  other 
requirements envisaged in the legislation. 

is  granted 

A bonus (equal to the 3% of the regional share of 
to  regions 
national  health  fund) 
conditionally  to  a  positive  evaluation  by  the 
Tavolo  degli  Adempimenti  about  the  fulfilment  of 
all  the  requirements  (and,  firstly,  the  budget 
balance position) envisaged in the legislation. 

Since 2015, a few interventions have been adopted 
in order to set and revise the level of resources for 
the financing of the public health care system: 

−  Law  208/2015  (art.  1,  paragraph  508)  has  
redefined the level of the financing resources in 
111.002  euro  for  2016  and  set  it  to  113.063 
euro for 2017, 114.998 for  2018 and  117.988 
euro for  2019; 

−  Law  232/2016  (art.  1,  paragraph  392)  has  
downsized the level of the financing resources 
to  113.000  euro  for  2017,  114.000  euro  for 
2018 and 115.000 euro for  2019; 

−  Decree  foreseen  by  Law  232/2016,  art.  1, 
paragraph 394 has further reduced the level of 
the  financing  resources  to  112.577  euro  for  
2017, 113.396 euro for  2018 and 114.396 euro 
for  2019. 

Recently 
reform  

legislated  and/or  planned  policy 

In  July  2014,  a  new  Health  Pact  was  signed 
between central government and regions. The main 
issues regulated by the Pact were as follows: 

− 

the  financial  framework,  i.e.  the  national  level 
of  public  resources  for  the  financing  of  the 
LEA  (fabbisogno nazionale standard) for each 
of the years 2014-2016; 

−  a procedure for the revision of the current basic 
healthcare 
(LEA),  which  was 
subsequently  adopted  by  a  pertinent  decree 
issued in January 2017 (see above);  

levels 

−  a strengthening of monitoring activity, through 
an  increased  role  of  the  National  Agency  for 
regional  Health  Services  (Agenzia  Nazionale 
per  i  Servizi  Sanitari  Regionali,  AGENAS)  in 

More  recently,  in  January  2017,  a  decree  was 
adopted  that  updated  the  basic  health  care  levels 
(LEA), to be guaranteed to all citizens. 

In  the  same  year,  a  legislative  intervention  laid 
down  the  obligation  for  children  younger  than 
sixteen to undergo ten  vaccines, charging the cost 
on the NHS. 

Challenges 

implemented 

The analysis above shows  that a range of reforms 
have  been 
in  recent  years,  for 
example, to strengthen primary care provision and 
its  use,  to  improve  efficiency,  to  improve  data 
collection,  information  and  monitoring  systems 
and  the  use  of  ICT  solutions,  to  control  overall 
expenditure and pharmaceutical expenditure while 
delivering quality healthcare. They  were to a very 
large extent successful and, therefore, Italy should 
continue  to  pursue  them.  The  main  challenges  for 
the Italian health care system are as follows: 

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areas  for  improvement.  To  encourage  debate, 
information  exchange,  and  peer 
reviews 
between  regions  once  the  system  is  fully 
implemented. In this context, the patient e-card 
(Tessera Sanitaria) should be fully exploited. 

•  To  continue  to  monitor  regional  expenditure 
policies  making  regions  showing  deficit  in  the 
health  sector  budget  restore  the  balance  and 
ensure  efficiency  and  appropriateness  in  the 
provision  of  LEAs.  To  continue  to  improve 
accountability  and  governance  of  the  system 
and identify possible cost-savings in the health 
sector  administration,  as  it  currently  involves 
national and regional institutions. 

•  To  further  the  efforts  to  support  public  health 
priorities  and  enhance  health  promotion  and 
disease  prevention  activities,  i.e.  promoting 
healthy life styles and disease screening. 

spending, 

promoting 

•  To continue increasing the efficiency of health 
care 
and 
integrated  care  as  well  as  a  focusing  on  costs, 
to  tackle  the  impact  on  spending  due  to 
population 
and  non-demographic 
factors. 

quality 

ageing 

•  To  extend  the  possibilities  of  hospitals  to 
provide ambulatory and day  care as  well as to 
transfer  more  health  care  services  into  the 
ambulatory  sector  in  order  to  reduce  the 
number of inpatient care treatments, as well as 
to  strategically  direct  more  resources  towards 
providers  of  lower  levels  of  care,  to  increase 
efficiency. 

•  To  tackle  unwarranted  regional  variation  in 
waiting  times  and  resource  distribution.  In 
particular, monitor and correct potential uneven 
distribution  of  hospital  beds  (follow-up  and 
long-term  care),  to  free-up  capacity  in  acute 
settings as a driver of  lower  waiting times. To 
the same end, further develop ICT solutions to 
increase service efficiency of operations. 

•  To  re-think  the  current  mix  between  doctors 
and nurses, to favour solutions that relying less 
heavily  on  doctors,  in  the  cases  where  nurses 
can  represent  a  substitute,  consistently  with  a 
more primary-care oriented system. 

•  To 

in 

the 

further 

the  efforts 

field  of 
pharmaceuticals  by  considering  additional 
measures,  both  on  the  side  of  patients  and  of 
health  care  professionals, 
the 
rational  prescribing  and  usage  of  medicines. 
The policies could help reducing the high level 
of  out-of-pocket  payments  and 
improving 
access  to  cost-effective  new  medicines  by 
generating savings to the public payer.  

improve 

to 

•  To ensure a greater and nationally coordinated 
use  of  health 
to 
determine  new  high-cost  equipment  capacity, 
the  benefit  basket  and  the  cost-sharing  design 
across medical interventions. 

technology  assessment 

•  To implement the National Health Information 
System  across  all  regions  and  sub-regional 
levels  which  has  a  strong  potential  to  monitor 
and  relate  expenditure  with  activity  and  with 
outcomes and in identifying good practices and 

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Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.15.1:  Statistical Annex – Italy 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

1
5
3

EU- latest national data

2005

1,490

27.8

0.3

:

2006

1,548

28.6

1.6

2.9

2007

1,610

29.2

0.9

-2.6

2008

1,632

28.4

-1.8

2.6

2009

1,573

26.1

-6.0

-0.5

2010

1,605

26.5

1.3

1.4

2011

1,637

26.7

0.2

-1.4

2012

1,613

26.3

-3.3

-3.2

2013

1,605

25.3

-2.2

-2.4

2014

1,622

25.3

-0.1

0.3

2015

1,652

26.1

1.0

0.8

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

8.7

7.9

0.8

8.8

7.9

1.0

8.5

8.2

0.3

8.9

8.4

0.5

9.4

8.5

0.9

9.4

8.2

1.3

9.3

8.6

0.7

9.3

9.0

0.3

9.3

9.0

0.3

9.3

9.0

0.3

9.3

9.0

0.3

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,219

2,328

2,329

2,448

2,483

2,527

2,531

2,495

2,463

2,455

2,495

2,745

2,895

6.8

6.5

6.9

6.6

6.6

6.3

7.0

6.7

7.4

7.0

7.4

7.0

7.1

6.8

7.1

6.8

7.1

6.8

7.1

6.8

7.0

6.7

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

1,732

1,817

1,819

1,925

1,960

1,981

1,935

1,916

1,894

1,877

1,887

2,153

2,263

2,324

2,609

0.32

78.1

15.1

100.0

20.7

0.31

78.1

14.5

100.0

20.4

0.32

78.1

15.1

100.0

20.7

0.34

78.6

14.9

100.0

20.6

0.40

79.0

14.6

100.0

19.7

0.36

78.4

14.5

100.0

19.5

0.28

76.5

14.2

100.0

21.0

0.31

76.8

13.9

100.0

21.7

0.31

76.9

14.1

100.0

21.8

0.29

76.4

13.9

100.0

22.1

0.28

75.6

13.9

100.0

22.8

2005

2006

2007

2008

2009

57.9

83.6

78.1

67.8

66.6

:

3.3

58.1

84.1

78.6

64.7

65.2

62

3.2

58.2

84.2

78.8

62.6

63.4

61

3.1

58.7

84.2

78.9

61.8

62.9

61

3.1

59.0

84.3

79.1

62.6

63.4

59

3.2

2010

59.2

84.7

79.5

:

:

55

3.0

2011

2012

2013

2014

2015

59.4

84.8

79.7

62.7

63.5

100

2.9

59.4

84.8

79.8

61.5

62.1

99

2.9

59.7

85.2

80.3

60.9

61.8

94

2.9

60.8

85.6

80.7

62.3

62.5

90

2.8

60.8

84.9

80.3

62.7

62.6

93

2.9

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

:

:

3.0

1.7

:

0.2

0.1

:

:

2.0

0.9

:

0.0

0.1

:

:

3.0

1.7

:

0.2

0.1

:

:

2.1

0.9

:

0.0

0.1

:

:

2.9

1.6

:

0.2

0.1

:

:

2.2

0.9

:

0.0

0.1

:

:

3.1

1.6

:

0.2

0.1

:

:

2.1

0.9

:

0.0

0.1

:

:

3.3

1.7

:

0.3

0.1

:

:

2.2

0.9

:

0.0

0.1

:

:

3.3

1.7

:

0.3

0.1

:

:

2.4

0.9

:

0.0

0.1

:

:

3.3

1.6

:

0.2

0.1

:

:

2.5

0.8

:

0.0

0.1

2.7

0.4

1.9

1.5

0.3

0.4

0.2

2.6

0.4

1.2

0.9

0.1

0.3

0.1

2.6

0.4

1.9

1.5

0.3

0.4

0.2

2.5

0.4

1.2

0.9

0.1

0.3

0.1

2.6

0.4

2.0

1.5

0.3

0.4

0.2

2.5

0.4

1.2

0.9

0.1

0.3

0.1

2.5

0.4

2.0

1.6

0.3

0.4

0.2

2.4

0.4

1.2

1.0

0.1

0.3

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
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1
5
4

Table 2.15.2:  Statistical Annex - continued – Italy 

Composition of total as % of total current health expenditure

2005

2006

2007

2008

2009

2010

2011

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

:

:

37.9%

21.6%

:

2.8%

0.9%

:

:

30.6%

14.0%

:

0.5%

1.1%

2005

1.48

:

2.8

:

9.9

22.3

8.7

:

:

38.3%

21.7%

:

2.9%

1.0%

:

:

32.6%

13.9%

:

0.5%

1.2%

2006

1.67

:

2.9

:

10.2

23.0

8.4

:

:

35.8%

19.9%

:

2.8%

0.9%

:

:

34.1%

13.6%

:

0.6%

1.2%

2007

1.85

1.0

3.0

0.2

9.9

22.4

8.4

:

:

37.0%

19.7%

:

2.9%

1.0%

:

:

31.5%

12.8%

:

0.6%

1.2%

2008

1.97

1.1

3.0

0.2

9.9

22.4

8.0

2005

2006

2007

2008

:

:

79

617

:

:

79

608

:

:

78

559

:

:

80

690

2005

6.1

15

:

:

39.1%

20.1%

:

3.0%

1.0%

:

:

31.5%

12.9%

:

0.6%

1.2%

2009

2.12

1.2

3.1

0.2

10.3

23.3

7.3

2009

368

:

77

553

:

:

40.9%

20.6%

:

3.1%

1.2%

:

:

34.4%

12.8%

:

0.6%

1.4%

2010

2.20

1.2

3.2

0.2

10.3

23.1

7.0

:

:

38.9%

19.1%

:

2.8%

1.1%

:

:

36.2%

12.3%

:

0.6%

1.4%

2011

2.36

1.3

3.2

0.2

10.0

22.5

7.0

2010

2011

:

:

76

546

:

:

76

535

2012

30.0%

4.6%

21.1%

16.5%

2.8%

4.0%

1.9%

38.1%

5.6%

17.4%

13.0%

0.7%

4.7%

1.8%

2012

2.46

1.3

3.3

0.3

10.4

22.1

7.5

2012

387

:

76

528

2013

29.4%

4.2%

21.5%

17.0%

2.8%

4.0%

1.9%

37.2%

5.1%

17.9%

13.5%

0.7%

4.8%

1.6%

2013

2.52

1.3

3.3

0.3

10.3

21.1

7.3

2014

28.6%

4.3%

22.2%

17.0%

2.9%

4.1%

1.8%

36.4%

5.3%

18.2%

13.8%

0.7%

4.8%

1.6%

2014

2.62

1.4

3.3

0.3

10.5

19.7

7.6

2015

27.9%

4.2%

22.7%

17.9%

2.8%

4.0%

1.9%

35.9%

5.2%

18.1%

15.0%

0.7%

4.7%

1.6%

2015

2.82

1.4

3.3

0.3

9.8

19.8

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2013

2014

2015

2009

2011

2013

2015

390

508

75

523

2013

6.8

12

388

528

74

524

384

544

74

518

2014

2015

:

11

:

11

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

2006

2007

2008

2009

2010

2011

2012

:

14

:

14

:

14

:

13

:

13

:

12

:

12

6,803

6,649

6,156

5,958

5,414

5,097

4,757

4,350

4,070

3,771

3,467

6,362

6,584

77.0

6.7

31.8

2016

6.3

6.3

2016

60.8

78.0

6.7

31.5

2020

6.2

6.2

2020

60.7

78.3

7.5

30.7

2025

6.3

6.5

2025

60.5

78.8

7.6

:

2030

6.5

6.7

2030

60.4

79.4

7.6

29.0

2035

6.7

6.9

2035

60.2

78.7

7.6

28.5

2040

6.9

7.1

2040

60.0

78.5

7.7

28.0

2045

7.1

7.3

2045

59.6

77.5

7.7

26.4

2050

7.2

7.5

2050

59.0

77.3

7.7

25.6

2055

7.2

7.6

2055

58.0

77.6

7.8

24.8

2060

7.1

7.5

2060

56.9

78.9

7.8

23.2

2065

7.0

7.5

2065

55.8

77.1

8.0

28.0

2070

7.0

7.5

2070

54.9

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Italy

0.7

1.1

EU

0.9

1.6

Change 2016-2070, in %

Italy

-9.6

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.16. LATVIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

spending growth (AWG risk scenario), health care 
expenditure  is  expected  to  increase  by  1.8  pps  of 
GDP from now until 2070 (EU: 1.6) (227). 

General  statistics:  GDP,  GDP  per  capita; 
population 

With a GDP of around €24 bn or 16,200 PPS per 
capita  in  2015,  Latvia  is  below  the  EU  average 
GDP per capita of €29,600.  

Latvia  faces  only  low  fiscal  sustainability  risks  in 
the  short,  medium  and  long-term.  Nonetheless, 
addressing  the  underfinancing  of  the  healthcare 
services  might  lead  to  higher  public  spending  in 
the medium to long term ( 228). 

During  the  coming  decennia  the  population  of 
Latvia  will  gradually  decline,  from  2.0  million 
inhabitants  in  2016  to  1.3  million  inhabitants  in 
2070. This 32% fall contrasts sharply with the EU 
average increase of 2%.  

Total and public expenditure on health as % of 
GDP 

Total expenditure (224) on health as a percentage of 
GDP (5.7% in 2015) is below the EU average ( 225) 
of 10.2%. Public expenditure is at 3.3% (2015) of 
GDP,  far  below  the  average  of  7.8%  in  2015.  
Looking  at  health  care  expenditure  without  long-
term care (226) reveals a similar picture with public 
spending being below but slightly closer to the EU 
average (2.8% vs 6.8% in 2015). 

When expressed in per capita terms, total spending 
on  health  at  1185  PPS  in  Latvia  is  below  the  EU 
average of 3305 in 2015. So is public spending on 
health care: 709 PPS vs. an average of 2609 PPS in 
2015.  

Expenditure projections and fiscal sustainability  

As a consequence of population ageing, health care 
expenditure  is  projected  to  increase  by  0.6  pps  of 
GDP,  below  the  average  growth  expected  for  the 
EU  of  0.9  pps  of  GDP  according  to  the  AWG 
reference  scenario.  When  taking  into  account  the 
impact  of  non-demographic  drivers  on  future 

(224) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(225) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(226) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

Health status 

Life  expectancy  at  birth  continues  to  increase 
gradually  in  Latvia  (79.6  years  for  women  and 
69.8 years for men in 2016) but it is far below the 
respective EU averages (83.6 and 78.2 years of life 
expectancy)(229).  Healthy  life  years,  at  54.9  years 
for  women  and  52.3  for  men  are  below  the  EU 
averages  of  64.2  and    63.5  in  2016.  The  infant 
mortality  rate  of  3.7‰  is  around  EU  average  of 
3.6‰ in 2016.  

As for the lifestyle of the Latvian population, there 
is a proportion of regular smokers of 24.1 % above 
the  EU  average  of  20.9%  in  2014(230).  Alcohol 
consumption  is,  at  10.4  litres  per  capita,  slightly 
higher than the EU average of 10.2 (231).  

System characteristics (232)  

Coverage 

The  Latvian  health  system  is  a  tax-funded  social 
insurance  system.  The  services  included  in  the 
statutory provision are determined by law. 

(227) The 

2018 

Ageing 

Report 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(228) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(229) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

(230) European 

health 

interview 

survey 

https://ec.europa.eu/eurostat/statistics-
explained/index.php/Tobacco_consumption_statistics. 
A  third  wave  of  the  European  health  interview  survey  (the 

source of these data) is being conducted in 2019. 

(231) OECD  Health  at  a  glance  (2018)  and  World  Health 
Organisation, 
(2014) 
alcohol 
https://gateway.euro.who.int/en/indicators/hfa_426-3050-
pure-alcohol-consumption-litres-per-capita-age-
15plus/visualizations/#id=19443&tab=table. 

consumption, 

Pure 

(232) This section draws on ASISP (2014) 

155 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Public  health  care  benefits  provided  in  kind 
include a wide range of services provided by GPs, 
specialists,  hospitals  and  emergency  care  units,  as 
well  as  pharmaceutical  care.  Cash  health  care 
benefits  (including  maternity  and  sickness)  are 
provided 
financed 
through  mandatory  insurance  contributions  from 
employers and employees (233). 

through  social 

insurance, 

Despite  full  population  coverage,  the  services 
available  100%  free  of  charge  are  limited.  The 
system  suffers  from  low  accessibility  due  to 
financial reasons. In 2016, 5.3% of the population 
reported unmet needs for health care (according to 
EUROSTAT)  because  they  could  not  afford  it 
financially  (in  contrast  with  the  EU  average  of 
1.6%), while in the lowest income quintile the rate 
reported  is  close  to  13.1%.  This  is  one  of  the 
highest levels of unmet need for health care in the 
EU  and  has  been  so  for  a  decade,  being 
significantly  different  from  its  Baltic  neighbours 
(Lithuania and Estonia). Self-reported unmet need 
for  dental  examination  due 
to  affordability 
concerns are also the highest in the EU (26.8% for 
the 1st income quintile, i.e. the poorest, and 13.2% 
for  the  total  population  in  2016,  in  comparison 
with the EU average of 3.6%). 

most 

psychotherapy, 

Patients pay directly for those services that are not 
financed by the state, for example, dental care for 
adults, 
available 
rehabilitation and physiotherapy services as well as 
a significant proportion of medicines. Patients also 
pay the full cost if they do not follow the standard 
procedure for accessing publicly financed care (for 
example, directly visiting a specialist without first 
obtaining  a  primary  care  referral  when  required). 
This  is  most  often  the  case  when  patients  wish  to 
avoid  waiting  lists  for  publicly  funded  care. 
Additionally, patients also pay in full the cost of all 
services  provided  by  health  care  providers  who 
have not contractual agreements with the National 
Health  Service 
there  are 
numerous  direct  access  specialists  to  whom  no 
referral  is  required  (detailed  information  in  next 
section).  The  patient  contribution  (for  adult 
patients)  if  of  €1.42  for  a  visit  to  the  general 
practitioner  and  €4.27  for  a  visit  to  the  specialist 
with  referral  and  out-patient  visit  to  direct  access 
specialist:.2015 data shows that Latvia has the fifth 
highest incidence of "under-the-table payments" to 

(NHS).  However, 

doctors on the part of patients (Health Powerhouse 
( 2015)).  

During  the  economic  crisis  until  2012  some  new 
measures  were  introduced  as  an  additional  social 
safety net. An exemption from patient charges was 
introduced  for  those  households  with  a  monthly 
income  below  €171  per  family  member.  Those 
with  an  income  below  €213  euro  were  exempted 
from 50% of fees. From 2012 this was scaled back, 
with only those with an income below €128 being 
exempted. This threshold appears to be too low to 
ensure  good  health  care  access  for  those  from 
vulnerable groups. As obtaining this status requires 
several  administrative  procedures  such  as  means-
testing, and the latter may act as barriers to access 
for the elderly and infirm.  

Nevertheless 
from  2015  payment  of  daily 
treatment  in  hospital  was  reduced  from  €13.52  to 
10 euro, as well as the patient's co-payment (for a 
surgical  procedure  in  hospital)  was  reduced  from 
€42.69  to €31. Since 2015 in order to improve the 
availability  of  pharmaceuticals  and  medical 
devices  for  children  under  the  age  of  18,  the 
reimbursable pharmaceuticals and medical devices 
in  accordance  with  positive  list  are  reimbursed  at 
100 %.  

Since January 2016, amount of State compensated 
medicines  for  treatment  hepatitis  C  increase  from 
75%  to  100%.  Also,  since  2018  the  amount  of 
State  compensated  medicines  for  treating  Crohn’s 
disease,  Psoriasis  and  ulcerative  colitis  has 
increased from 75% to 100%. 

The share of private expenditure on health in total 
health  expenditure  (  40.2%  in  2015)  is  far  higher 
than  the  EU  average  of  21.6%.  Out-of-pocket 
expenditure  constitutes  about    42.07%  of  total 
health  expenditure,  far  above  the  EU  average 
(21.8% in 2015).  

Beyond  affordability,  low  accessibility  is  also 
influenced by long waiting lists for diagnostics and 
treatments. As of 2014, cancer patients with cancer 
had  to  wait  on  average  25  working  days  after 
diagnosis  for  treatment.  the  waiting  time  for  an 
appointment  with  a 
rheumatologist  was  86 
working days ( 234). 

(233) ASISP (2014). 

(234) ASISP (2014). 

156 

 
                                                           
                                                           
and 

examinations 

Since  October,  2016  patients  where  there  is 
suspicion  of  malignancy  are  able  to  receive  the 
necessary 
investigations 
(primary diagnostics) within 10 working days from 
the  date  of  signing  up  for  the  examination.  This 
referral  can  be  made  by  general  practitioners, 
gynaecologists  or  prison  doctors  and,  after 
diagnosis  can  lead  to  specialist  referral  at  a 
specialised  hospital.  The  hospital  then  has  to 
provide  a  consultation  for  the  patient  within  10 
working  days  from  the  date  of  signing.  The 
specialist  decides  about  the  necessary  additional 
in 
examinations 
specialised  hospitals  and  gives  a  referral  to  the 
patient. Secondary diagnostic examinations should 
be  provided  in  tiem  to  ensure  that  the  decision 
about the treatment is taken within a month of the 
first  specialist  consultation.  It  encourages  priority 
of  health  care  service  receipt,  shifting  these 
patients from the total patient flow and allowing to 
plan the necessary resources for early diagnosis of 
oncological patients.  

diagnostics) 

(secondary 

However,  according 
law  passed  on 
to 
December 2017, from 2019 the basket of publicly 
available  services  will  however  be  divided  into  a 
minimum and a maximum basket.  

the 

The  minimum  basket  of  services  includes:  1)  full 
access to the GP (incl. diagnostic examinations for 
the  treatment  according  to  the  competence  of  the 
GP);  as  well  as  medicines  and  medical  devices 
prescribed  by  the  GP  for  outpatient  treatment  of 
diseases which have a significant impact on public 
health or endanger public health. 2) maternity care; 
3) emergency services; 4) health services related to 
the  treatment  of  diseases  that  have  a  significant 
effect on public health indicators or which threaten 
public 
illness, 
tuberculosis),  as  well  as  medicines  and  medical 
devices for ambulatory treatment of these diseases. 
However,  it  does  not  include  access  to  public 
specialised  care  beyond  the  cases  considered 
above. 

(including  mental 

health 

Minimum  basket  is  granted  for  all  citizens  and 
non-citizens of Latvia, third-country nationals who 
have  a  permanent  residence  permit  in  Latvia  and 
stateless persons to  whom  the status of a  stateless 
person  has  been  granted  in  Latvia  as  well  as 
refugees,  asylum  seekers  or  persons  who  have 
been granted an alternative status. 

Health care systems 

2.16. Latvia 

The list of the health care services in the minimum 
basket  will  be  stipulated  in  the  Regulation  of 
Cabinet of Ministers by 1 September 2018. 

The Healthcare Financing  Law  states also the  full 
basket  of  services  which  includes:  1)  all  services 
provided in the minimum basket; 2) secondary and 
tertiary  health  care  services,  as  well  as  medicines 
and  medical  devices 
intended  for  outpatient 
treatment  in  accordance  with  the  regulatory  acts 
regarding  the  procedure  for  the  reimbursement  of 
expenses  for  the  purchase  of  medicines  and 
medical devices for ambulatory treatment. 

Full basket of the health care services provided by 
the state is granted for socially insured persons or 
those  persons  who  have  made  health  insurance 
contributions.  In  addition,  there  is  a  list  of  other 
groups qualifying for the full basket guaranteed by 
state,  meaning  they  do  not  have  to  pay  any 
contribution  (except  patient  contributions  if  they 
are  not  exempted  from  those  as  well).  In  the  list 
inter  alia  is  included  children  up  to  18  years, 
persons  with  I  and  II  disability  group  (from 
01.01.2021.  also,  persons  with  III  disability 
group),  persons  receiving  services  of  long-term 
social  care  institutions,  persons  studying  in  the 
educational 
institutions,  unemployed  persons, 
persons  who  have  reached  the  age  of  old-age 
pension etc.  

Those  groups,  which  are  not  paying  social 
contributions  (for  example  those  working  under 
micro-enterprise  tax  regime)  to  state  budget,  to 
receive  the  full  basket  are  expected  to  pay  a 
contribution  set  at  1%  of  minimum  remuneration 
in 2018 (€51.6 annually), rising to 3% of minimum 
remuneration amount in 2019 and 5% of minimum 
remuneration amount from 2020 onwards. 

While  this  new  reform  aims  at  improving  the 
to  make  health  care 
incentives  for  citizens 
contributions so as to receive the maximum basket, 
it  effectively  limits  the  universality  of  access  to 
health  care  by  curtailing  the  access  to  specialised 
care  for  those  who  receive  only  the  minimum 
basket.  As  such 
the 
is 
it 
accessibility of health care in Latvia(235).  

to  worsen 

likely 

(235) See 

LV 

Country 
https://ec.europa.eu/info/sites/info/files/2018-european-
semester-country-report-latvia-en_1.pdf. 

Report 

2018 

157 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Administrative  organisation  and 
collection mechanism  

revenue 

(state  or  municipal  budgets), 

Public  funding,  including  transfers  from  general 
together 
taxes 
constitute  59.8%  of 
total  health  expenditure 
funding (2015), compared with the EU average of 
78.4%.  

Financial  resources  for  the  public  health  system 
come  from  central  government  general  taxation. 
As  explained  above,  out-of-pocket  payments  are 
also  a  very  important  financial  source  for  the 
system.  

The Saeima in 27.07.2017 adopted amendments to 
the  Law  "On  State  Social  Insurance",  which 
determines  that  the  part  of  mandatory  social 
contributions  corresponding  to  1  percentage  point 
of  mandatory  contribution  rates  (0.5%  paid  by 
employers and 0.5% by employees) is foreseen to 
finance  health  care  services.    In  the  state  budget 
planning  process  the  annual  fund  collection  is 
estimated  and  allocated  to  the  Ministry  of  Health. 
In  2018,  these  funds  are  allocated  to  increase  the 
In 
remuneration 
December 2017, the Saeima adopted a Health Care 
Financing  Law  which  introduces  state  health 
insurance system  with two service baskets linking 
the  right  to  receive  a  basket  of  full  health  care 
services  with  the  payment  of  social  contributions. 
State  health  insurance  system  with  two  service 
baskets  (a  full  and  a  minimum)  will  be  in  force 
starting with January 1, 2019 (see further). 

for  health  care  specialists. 

Types of providers, referral systems and patient 
choice 

The total number of practising physicians per 100 
000  inhabitants  (321  in  2016)  is  below  the  EU 
average (344) and has increased since 2005 (288). 
Data  on  the  physician  skill-mix  indicates  that  the 
number  of  GPs  per  100  000  inhabitants  (72  in 
2016)  is  below  the  EU  average  (78.3)  although  it 
registered a steady increase since 2003 (45) as part 
of  the  authorities'  effort  to  improve  primary  care 
provision.  The  number  of  nurses  (463.6  in  2016) 
per  100  000  inhabitants  is  far  below  the  EU 
average (833 in 2015).  

Latvia  has  340  hospital  beds  (2016)  per  100  000 
inhabitants (down from 543 in 2003), below to the 
EU (EU average of 402 in 2015). 

158 

The General Practitioner (GP) acts as a main point 
of  entry  into  the  health  care  system  and  as  a 
gatekeeper  to  secondary  ambulatory  and  hospital 
care.  In  order  to  receive  the  state  financed 
secondary  ambulatory  or  hospital  care  the  referral 
from GP or other doctor is required. The referral to 
receive  state  financed  health  care  services  can  be 
issued  by  doctors  who  are  contracted  with  NHS. 
there  are  numerous  direct  access 
However, 
specialists 
is  required 
to  whom  no  referral 
(gynaecologists,  ophthalmologists,  paediatricians, 
child surgeons, dentists). Also patients with certain 
disease may go directly to the relevant specialists. 
No referral is needed to attend the endocrinologist 
in  case  of  diabetes,  psychiatrist 
in  case  of 
psychiatric  disease,  oncologist  and  oncologist-
chemotherapist  in  case  of  oncological  disease, 
pneunomologist 
tuberculosis, 
dermatologist  in  case  of  sexually  transmitted 
disease, infectologist in case of HIV, narcologist in 
case  of  an  alcohol,  narcotic  or  psychotropic 
substance addiction. No referral is required also in 
case of emergency medical assistance.  

case 

of 

in 

The patient has the right to choose a physician and 
health  care  institution.  The  patient  has  a  right  to 
freely  register  with  a  chosen  GP  and  may  freely 
change and register with a new GP. 

Treatment options, covered health services 

Services  included  in  the  statutory  provision  are 
defined  by  law.  The  statutory  health  care  system 
covers  only  services  provided  by  physicians  and 
institutions  that  have  contractual  agreements  with 
the NHS. 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

The NHS acts as the main purchaser of health care 
for  the  population,  directly  commissioning  both 
public  and  private  providers  (including  GPs, 
dentists  and  hospitals).  In  2016,  it  held  contracts 
with 1322 GPs and 41 hospitals.  

Large tertiary and specialised hospitals are owned 
by the state, whereas smaller and regional hospitals 
tend to be owned by municipalities. GPs and those 
medical  specialists  not  working  for  hospitals  or 
health  centres  tend  to  work  as  self-employed 
private providers. 

 
since  2017 

service  providers, 

To  increase  the  efficiency  of  the  use  of  funding 
allocated  to  health  care,  improve  the  quality  of 
services  and  increase  competition  between  health 
service 
care 
providers in certain service areas are selected using 
a strategic procurement procedure according to set 
criteria. This selection process is implemented  for 
the  following  groups  of  services:  planned  in-
patient  cancer 
radiation, 
mammography; 
chemotherapy); 
medical 
rehabilitation.  To 
strengthen  the  competencies  of  the  personnel  of 
the  Ministry  of  Health  and  NHS  in  the  field  of 
strategic procurement a training seminar supported 
by EC Structural Reform  Support Service (SRSS) 
was held in 2017. 

fertilisation;  and 

out-patient 

treatment 

(surgery, 

The market for pharmaceutical products 

Total  pharmaceutical  expenditure,  at  1.6%  of 
GDP,  above  the  EU  average  of  1.  4%.  However, 
public pharmaceutical expenditure at 0.5% of GDP 
is  far  below  the  1%  EU  average.  This  difference 
reflects  partly  the  level  of  co-payments  in  the 
pharmaceutical sector.  

in 

the 

and  policies 

the  responsibility  of 

field  of 
Legislation 
pharmaceuticals  are 
the 
Department of Pharmacy of the Ministry of Health. 
In  addition, 
institutions 
concerned  with  regulation  of  pharmaceuticals:  the 
SAM  (State  agency  of  Medicines)  and  the  NHS, 
is  responsible  for  reimbursement  and 
which 
pricing decisions. 

two  main 

there  are 

for 

Treatment” 

the  Reimbursement 

There  is  a  positive  list  in  accordance  with  the 
Regulations  of  the  Cabinet  of  Ministers  Nr.899 
of 
“Procedures 
Expenditures  for  the  Acquisition  of  Medicinal 
Products and Medicinal Devices Intended for Out-
patient  Medical 
(31.10.2006), 
designating  a  range  of  conditions  (for  example, 
diabetes, cancer, mental disorders) for which drugs 
are reimbursed according to the degree of severity. 
The objective is to keep expanding the positive list 
as  well  as  to  reduce  the  level  of  co-insurance 
required  from  patients.  Patients  pay  the  full  price 
for 
prescribed 
pharmaceuticals  and  the  full  price  of  all  non-
prescription drugs in the outpatient sector. In fact, 
about  more  than  60%  of  out  of  pocket  (OOP) 
payments  in  Latvia  are  spent  on  pharmaceuticals 
and about 50% of these are related to payments for 

significant 

share 

of 

a 

Health care systems 

2.16. Latvia 

non-reimbursable  prescription  drugs  or  OTC 
drugs.  Inpatient  pharmaceutical  care  is  provided 
free of charge as the costs are included in the cost 
of inpatient services. 

There is a co-payment of €0.71 per prescription for 
outpatient  pharmaceuticals  on  the  positive  list  (if 
the pharmaceutical has 100% reimbursement level) 
and  co-insurance  of  25%  (if  the  pharmaceutical 
has  75%  reimbursement  level)  or  50%  (if  the 
pharmaceutical  has  50%  reimbursement  level). 
However, households with an income below €128 
per family member per month, as well children (up 
to the age of 18) and asylum seekers are exempted 
from user charges.  

Reference  price  system  is  in  place  in  Latvia.  The 
pharmaceuticals with the same therapeutic efficacy 
are  grouped  in  clusters  taking  into  account  the 
presentation form and dosage. The reference price 
is the price of the cheapest medicine in the cluster. 
If  more  expensive  medicine  is  prescribed,  the 
patient has to pay the difference between the actual 
price  of  a  pharmaceutical  and  the  reference  price. 
To  promote  generic  competition  and  the  use  of 
cheapest  products,  for  newly  diagnosed  patients 
only  International  Nonproprietary  Name  (not  a 
specific product) can be prescribed by a doctor and 
the  pharmacy  has  a  duty  to  dispense  the  cheapest 
reimbursable  medicinal  products,  which  conform 
to  this  name,  the  prescribed  pharmaceutical  form 
and strength. 

Pharmaceutical products are supplied to the public 
by  a  regulated  distribution  system  consisting  of 
licensed  enterprises 
that  manufacture  and/or 
distribute  them.  In  2018,  there  were  86  licensed 
wholesalers  and  32  licensed  manufacturers  of 
medicines and 7 registered manufacturers of active 
pharmaceutical substances in Latvia (State Agency 
of Medicines of Latvia, 2018). 

Wholesalers  are  private  enterprises.  The  total 
wholesale  turnover  of  pharmaceuticals  (excluding 
sales  among  wholesalers)  is  €398.12  million. 
Domestic  production  accounts  for  about  4.3%  of 
the  pharmaceutical  market.  However,  Latvian 
manufacturers export most of their pharmaceutical 
products.  Foreign  manufacturers  operate  through 
limited 
representative  offices,  subsidiaries  or 
liability  companies.  Some  of  them  perform  only 
promotion  and  marketing  activities,  while  others 

159 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

have  established  companies  and  are  licensed  as 
wholesalers. 

Hospitals purchase medicines from wholesalers or 
pharmacies.  Large  purchases  of  pharmaceuticals 
are put out to tender.  

Nearly  all  community  pharmacies  are  privately 
owned, pharmacies can be run by a pharmacist as a 
pharmaceutical  practice,  by  a  company  or  a  local 
community  government.  If  it  is  registered  as  a 
company,  at  least  50%  of  the  shares  have  to  be 
owned  by  a  pharmacist  or  at  least  half  the  board 
must  consist  of  certified  pharmacists.  In  fact,  the 
pharmacy market is dominated by five chains, with 
the  most  important  chain  being  “AS  Sentor  Farm 
Aptiekas”,  which  draws  up  33%  from  common 
small  number  of 
pharmacies 
pharmacies  exist  at  health  care 
institutions 
(hospital  pharmacies)  and,  in  rural  areas,  under 
certain  conditions  determined  by  Pharmacy  law, 
pharmacies  can  also  be  owned  by  pharmacy 
assistants. 

turnover.  A 

E-Health, Electronic Health Record 

The NHS is responsible for the implementation of 
the  e-health  policy  and  the  establishment  of  the 
necessary  infrastructure.  Financial  resources  for 
these tasks are provided by the Ministry of Health, 
but  certain  specific  projects  are  financed  by  the 
EU. 

record 

IS,  electronic  health 

In the  framework of the first  and second round e-
health projects which were finalised accordingly in 
the end of 2015 the following e-health information 
systems  are  developed  –  e-health 
integration 
platform information system (IS), e-booking IS, e-
referral 
IS,  e-
prescription 
IS,  as  well  an  e-health  portal 
(www.eveseliba.gov.lv).  The  publicly  available 
part  of  the  e-health  portal  provides  the  actual 
information  about  health  care  in  Latvia,  as  well 
information  about  health  prevention  and  other 
related  topics.  The  authorised  part  of  the  e-health 
portal  provides  the  easy  access  for  inhabitants  to 
their health data but for health care professionals - 
a virtual workplace. The publicly available part of 
the e-health portal is open since June 2016. Since 
September  12,  2016  the  authorised  part  of  the  e-
health portal is available. 

160 

On  11  March  2014  Cabinet  of  Ministers  accepted 
the  Regulations  No.  134  "Regulations  Regarding 
Unified  Electronic  Information  System  of  the 
Health  Sector",  which  determine  the  manager  of 
the  unified  electronic  health  information  system 
(hereinafter  –  E-health  system),  the  data  stored  in 
the  E-health  system  and  the  data  processing 
procedures  as  well  as  the  procedures  for  the 
issuing  of  data.  As  it  is  stated  in  the  Regulations 
No.  134  all  health  care  institutions  are  obliged  to 
use  e-  prescription  (for  pharmaceutical  products 
fully or partly compensated / reimbursed by state) 
and  e-  sick  lists  since    1  January    2018,    but 
pharmacies  are  obliged  to  accept  e-prescription 
already since December 2016.  In accordance with 
the  regulations  No.134  the  e-health  system  is 
providing  the  centralised  processing  of  person’s 
health-related 
for  medical 
treatment,  the  preparation  of  e-prescriptions,  the 
preparation of sick lists, e-booking and e-referrals 
etc. E-health system collects and stores the medical 
data of the patients regarding diagnoses, prescribed 
medications, 
and 
operations,  sick-leave,  disability  and  vaccination. 
All mentioned data is collected during doctor visits 
and  stored  in  national  data  base,  it  will  provide 
potentially valuable information for the health care 
professionals  about  their  patients,  allowing  seeing 
the  patients’  health  status  and  history  results, 
which  is  important  for  making  decision  for  future 
health  treatment  plan,  thus  improving  quality  of 
care.  

examinations 

carried  out 

necessary 

data 

etc.);  prescribe 

Health  professionals  (doctors)  can  view  and  add 
the  patient's  health  data  (diagnoses,  allergies, 
administered  medicines, 
e-
precription and e- sick leave; create an e-referral to 
the specialist or diagnostic test; create results after 
consultation;  describe  the  diagnostic  tests;  see 
another  doctor  created  e-referrals  and  the  results 
(findings);  look  at  the  results  of  diagnostic  tests; 
see  the  vaccination  data;  deny  patients  right  to 
view  certain  medical  data;  make  several  reports 
etc. 

issue 
Health  professionals 
prescribed  medicaments,  as  well  as  make  several 
reports.  

(pharmacists)  can 

The  following  information  are  available  to  the 
patients  after  authorising  in  E-health  system: 
personal  data  (address,  phone  no.,  E-mail);  GPs 
(European  Health 
data;  data  on 

the  EHIC 

 
Insurance  Card);  basic  health  data  (diagnoses  and 
allergies,  the  most  commonly  used  drugs  etc.); 
prescribed  and  issued  e-prescriptions;  issued  and 
closed e-sick-leave; referrals for consultations and 
examinations;  medical 
(results); 
diagnostic test results; vaccination data etc. 

findings 

can 

access 

patients 

this  medical 
The 
documentation  and  also  manage  (grant/refuse) 
access  to  all/part  of  their  health  data  to  health 
professionals;  mandate 
(non-health 
professional) people (relatives etc.) enabling to act 
on  behalf  of  the  patient;  check  the  audit  logs 
(every  step  and  access  is  recorded);  request  E-
consultation  from  the  health  professional;  add 
personal contact information, insurance data etc. 

other 

All functionality developed during first and second 
round  of  e-health  projects  is  available  for  health 
care  institutions,  pharmacies  and  inhabitants,  and 
NHS  is  continuing  the  development  of  E-health 
system  offering  wider 
services/ 
functionalities  /  documents.  Some  of  E-health 
system  services  are  available  also  through  state’s 
e-services portal (236). 

range  of 

E-health  user  support  service  is  available  every 
day  from  8:00  to  20:00  which    helps  to  solve 
relevant  issues  related  to  e-health  portal  and  the 
use  of  available  functionalities.  There  are  two 
support phone lines - one for citizens and other for 
professionals.  

system 

In August 2017, the Cabinet of Ministers approved 
the  objectives  and  activities  of  the  next  two  e-
health 
(1) 
development 
modernisation, development and integration of the 
health  information  systems  (registers)  with  the  e-
health 
further 
Development of the E-health  Information  System, 
linking it with personal identification. Projects will 
be co-financed by EU funds. 

information 

projects: 

system; 

(2) 

(236) www.latvija.lv. 

Health care systems 

2.16. Latvia 

Health  and  health-system 
information  and 
reporting  mechanisms/  Use  of  Health 
Technology  Assessments  and  cost-benefit 
analysis 

The main performer and coordinator of the official 
statistical  work  in  Latvia  is  the  Central  Statistical 
Bureau (CSB). The CSB is a direct administration 
body  subordinated  to  the  Ministry  of  Economics 
and is responsible for organisation of the statistical 
work  and  authenticity  of  the  data  it  has  produced 
by  summarising  the  information  obtained  from 
respondents. 

There are two main institutions responsible for the 
collection  of  health-related  information  in  Latvia: 
the  Centre  for  Disease  Prevention  and  Control 
(CDPC) and the NHS.  

is 

Injuries, 

National 

Infectious 

responsible 

CDPC  is  the  central  institution  responsible  for 
collecting  and  summarising  health  related  data  in 
Latvia.  CDPC 
for  numerous 
information  systems  and  databases  where  health 
data  are  collected  (for  example,  HIV/AIDS  Case 
Register,  The  Newborn  Register,  The  Register  of 
Patients  Suffering 
from  Diabetes,  Malignant 
Neoplasms,  Occupational  Diseases,  Congenital 
Anomalies, 
Psychiatric  Disorders, 
Tuberculosis,  Multiple  Sclerosis  and  Addiction, 
Hepatitis  C,  Death  Cause  Database  of  Latvian 
Inhabitants, 
Disease 
Surveillance  and  Monitoring  System  etc.).  The 
data  which  is  collected  in  the  named  information 
systems  is  defined  by  law  and  is  submitted  to 
CDPC  by  health  care  institutions  or  reported  by 
health 
and  microbiology 
laboratories  (cases  of  infectious  diseases).  All 
health  care  institutions  in  Latvia  have  a  legal 
obligation  to  submit  the  relevant  patient  health 
data  to  CDPC.  Data  from  the  register  of  Patients 
Suffering  from  Diabetes,  Malignant  Neoplasms, 
Occupational  Diseases,  Congenital  Anomalies, 
Injuries,  Psychiatric  Disorders,  Tuberculosis, 
Multiple  Sclerosis  and  Addiction,  are  available  in 
E-health  system  as  well.  In  accordance  with  the 
the  field  of  health 
in 
regulatory  framework 
statistics  all  health  care  institutions  in  Latvia  are 
also  obliged  to  prepare  and  submit  to  CDPC  the 
annual statistical overviews about delivered health 
care services.  

care  practitioners 

The  NHS  collects  the  data  related  to  the  use  of 
NHS paid health services. All contracted providers 

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irrespective  of  their  ownership  status  have  to 
electronically  submit  patient  information  about 
NHS paid services for payment purposes.  

lower  than  the  EU  average  (respectively  0.31% 
and 0.25% in 2015).  

Data on occupational accidents is collected by the 
State Labour Inspectorate.  In accordance with the 
Regulation  of  the  Cabinet  of  Ministers  No.  468 
“The  Approval  of  Medical  Technologies  and  the 
Implementation 
Technologies” 
(28.06.2005) the NHS is responsible for assessing 
and  approving  medical  technologies.  NHS  is  also 
responsible  for  registering  the  approved  medical 
technologies  and  maintaining  the  database  of 
approved medical technologies.  

New 

of 

In  order  to  utilise  a  new  medical  technology,  a 
health  care  institution,  medical  practitioner  or 
medical  personnel  professional  organisation  is 
required  to  provide  a  package  of  documents 
including:  a  technical  description  of  the  new 
technology;  a  summary  of  published  studies 
documenting  the  effectiveness  of  the  technology; 
the  justification  of  the  need  for  the  new  medical 
technology  (aims  and  the  provisional  results),  the 
the  medical 
necessary 
practitioners  who  will  use  the  technology;  a 
description  of  the  space  within  the  treatment 
institution in which the technology will be used.  

qualifications 

of 

Every new technology is then assessed by the NHS 
with  regard  to  safety  aspects  (risks  and  potential 
side-effects),  potential  impact  and  efficiency,  an 
assessment  of  the  influence  of  the  technology  on 
the patient’s health and quality of life, professional 
ethics.  About  50 
to  60  evaluations  of  new 
technologies are conducted each year according to 
a  methodology  that  is  specified  in  the  above-
mentioned  regulations.  A  positive  assessment  is  a 
prerequisite 
introduction  of  a  new 
the 
technology in Latvia.  

for 

to 

Since  2002,  every  new  medicine  is  evaluated 
the  Guidelines  on  Economic 
according 
Evaluation  of  Pharmaceuticals 
(approved  by 
regulations  of  the  Cabinet  of  Ministers  No.899) 
prior to being entered into the positive list of NHS 
paid medicines. 

Health  promotion  and  disease  prevention 
policies 

Total  (0.12%)  and  public  (0.11%)  expenditure  on 
prevention and public health as a % of GDP is far 

162 

Public  health  is  coordinated  by  the  Ministry  of 
Health.  Activities  are  planned  and  monitored 
mostly by CDPC, which is the main institution for 
infectious  and  non-infectious  disease  surveillance, 
control  and  prevention  and  which  coordinates 
collection  of  all  health-related  information.  The 
CDPC 
and 
implementation  of  the  State  Immunisation  Policy. 
State  paid  immunisation  is  provided  by  GPs, 
paediatricians  and  hospitals  and  financed  through 
the NHS. 

in  health  promotion 

engages 

The  implementation  of  health  promotion  and 
disease  prevention  measures  funded  by  the  EU 
funds (of a total amount of 55,4 million euros) has 
been  launched.  National  level  health  promotion 
and  prevention  measures  are implementing  by  the 
Ministry of Health in cooperation with subordinate 
institutions.  96  project  applications  for  local  level 
health  promotion  and  prevention  measures  have 
been approved and gradually are launching in local 
community.  

Recently 
reform  

legislated  and/or  planned  policy 

Recent policy response 

In order to reduce inequalities in health and health 
care  by  ensuring  the  sustainability  of  health  care 
system 
financing,  accessibility,  quality  and 
effectiveness  of  health  care  services,  the  health 
reform has been determined as a health priority in 
Government Action Plan. Health reform includes a 
strategic 
change  of  model  of 
procurement  (incl.  service  basket),  agreement 
control (quality, standards), review of functions of 
sectoral  governmental  bodies.  Implementation  of 
health  reform  will  promote  the  increase  of  health 
sector budget. 

financing, 

The Ministry of Health on the basis of World Bank 
recommendations developed the conceptual report 
“On  the  Health  System  Reform”  (adopted  on  25 
July,  2017),  which  determined  the  distribution  of 
state 
inpatient  health  care  providers 
(hospitals)  by  service  levels  (I,  II,  III  and  IV 
hospitals),  providers  of  emergency  medical 
treatment 
for 
setting 
development  of  primary  health  care  and  also 

the  ground 

services, 

funded 

 
highlighted  the  need  for  the  development  of 
cooperation areas for providers of inpatient health 
care  services.  It  also  included  plans  to  improve 
remuneration  of  the  medical  staff  and  further 
development  of  the  human  resources,  as  well  as 
defining  the  role  of  municipalities  in  the  health 
care  system,  improve  purchasing  process  of  state 
funded health care services and the reorganisation 
of  the  subordinate  institutions  of  the  Ministry  of 
Health.  The  reform  will  also  introduce  a  quality 
improvement and patient safety system, and ensure 
linking  the  register  of  healthcare  recipients  with 
tax payment information on contributions made in 
Latvia through e-health solutions. 

In 2017 €34.3 million  were granted for the  health 
the  budget  deficit 
care  system  reform  from 
deviation  allowed  by  the  European  Commission. 
This funding  was used: 1) to decrease the  waiting 
times to out-patient health care services, including 
out-patient rehabilitation services, and day hospital 
services;  2)  to  improve  the  accessibility  to  the 
diagnostics  and 
the  malignant 
treatment  of 
tumours;  3)  to  provide  the  reimbursable  drugs  for 
the  treatment  of  hepatitis  C  (for  patients  having 
F3-F4 stage of the illness). 

To continue these measures and improve access to 
the  end  of  2017  an 
healthcare  services,  at 
Informative  report  (237)  was  adopted.  It  foresees 
further  measures  in  amount  of  €113.4  million  in 
2018:  1)  to  improve  accessibility  of  health  care 
services; 2) to improve accessibility of oncological 
diseases  diagnosis  and  treatment;  3)  to  reduce  the 
spread of infectious diseases, including Hepatitis C 
and  HIV  infection  treatment;  4)  to  improve  the 
accessibility  and  quality  of  primary  health  care 
system;  5)  to  decrease  the  morbidity  rates  with 
cardiovascular  diseases  and 
the 
effectiveness of the treatment. 

improve 

to 

From  January  2018,  new  health  care  services  are 
covered  by  the  state  budget:  transcatheal  aortic 
valve  implantation  and  liver  transplantation  for 
adults,  positron  emission  tomography  services  for 
patient  with  certain  oncological  diagnosis  (PET 
services  from  01.07.2018).  As  well  the  provision 
of  diagnostics  and  consultation  for  patients  with 
rare  disease  was  improved  by  introducing  the 
specialised  Rare  Disease  Coordination  Center,  at 

(237) Informative  report  “On  implementation  of  health  reform 

measures in 2018”, 19.12.2017. 

Health care systems 

2.16. Latvia 

the  Children's  Clinical  University  Hospital.  
Diabetes  patients’  care  was 
improved  by 
introducing services of training cabinet.  

One of the priorities of the Ministry of Health is to 
tackle  difficulties  in  recruitment  and  retention  of 
staff  due  to  low  remuneration,  particularly  for  the 
middle and lower level personnel. Increases in pay 
will  continue  to  be  considered  relative  to  the 
available space in the health sector budget. 

increased,  and 

From  January  2017  the  minimal  monthly  wage 
lowest  wages  were 
the 
was 
equalised,  as  well  there  as  ensuring  that  overtime 
working  is  limited  to  a  maximum  average  of  16 
hours in a seven-day period for medical personnel 
and  emergency  medical  care  assistance  staff, 
which  is  not  medical  personnel,  by  allocating 
additional funding. 

In 2018, additional financing of €85.3 million was 
attracted  to  increase  remuneration  of  medical 
personnel and other  workers in health care sector, 
as a result percentage increase in wages for doctors 
and  functional  specialists  is  foreseen  by  44%,  for 
medical  and  patient  care  persons  and  functional 
specialists’ assistants by 38%, but for medical and 
patient care support persons by 24%. The wages of 
medical personnel working in inpatient institutions 
will 
the 
mandatory  premium  when  working  twenty-four 
hour periods and the gradual refusal from extended 
normal working time. 

increase  more  significantly  due 

to 

In order to tackle the lack of medical personnel in 
regions  outside  Riga,  measures  have  been  funded 
from  the  EU  funds  2014-2020  planning  period. 
There  are  other  measures  financed  by  EU  funds 
such  as  providing  medical  personnel  with  the 
opportunity  to  increase  their  qualifications  and 
opportunities 
their 
speciality to return to the labour market.  

for  non-practitioners 

in 

EU  funds  for  the  2014-2020  planning  period  also 
provide  support  for 
the  development  of  GP 
practice, including both the renovation of premises 
and  the  purchase  of  equipment.  Support  will  be 
provided  for  around  600  GPs'  practices  with  a 
budget  of  €4.5  million.  It  is  intended  to  provide 
support not only to individual practices but also to 
promote the development of  cooperation practices 
to  ensure  more  effective  use  of  resources  and 
improve access to primary health care. The process 

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of  development  and  harmonisation  of  the  support 
conditions  is  currently  under  way,  while  the 
implementation of the projects is envisaged to start 
in early 2019. 

There  are  also  projects  financed  by  EU  funds  to 
invest in infrastructure for tertiary health care and 
regional  hospitals,  as  well  as  for  mono-profile 
hospitals  providing  rehabilitation,  maternity  care 
and  traumatology  services.  In  2018,  the  Cabinet 
regulations  on 
implementation  conditions  for 
investments of EU funds in infrastructure for local 
hospitals  (I,  II,  III  level  hospitals)  were  approved 
and  project  implementation  will  begin  by  the  end 
of 2018. 

institution  must 

including: 1) improve 

A  large  number  measures  have  been  launched  to 
improve patient safety. Accordingly, since October 
follow 
2017  each  medical 
guidelines 
patient 
identification  (throughout  the  treatment  process 
using at least two identifiers); 2) facilitate effective 
communication  between  patient  and  health  care 
professionals,  3)  provide  risk-reduction  measures 
for surgery, anaesthesiologic procedures, as well as 
for high risk patients or groups of patients related 
to the age, medical condition and need for special 
care;  4)  establish  and  maintain  the  blame-free 
reporting  and  learning  system  on  adverse  events; 
5)  introduce  and  maintain  a  safe  drug  circulation 
regulatory 
system 
enactments 
the 
acquisition, storage, use, recording and destruction 
of  medicinal  products  in  medical  institutions  and 
social  care  institutions  and  6)  introduce  and 
maintain  a  system  for  patient  complaints  and 
suggestions analysis. 

in  accordance  with 

the  procedure 

regarding 

the 

for 

There  was  also  an  update  of  the  requirements 
for the  care  during  pregnancy,  delivery  and 
postnatal  period,  as  well  as  the  procedures  for 
new-borns,  in  order  to  ensure  the  quality  of 
service. 

Simultaneously,  the  Ministry  of  Health  developed 
and approved in January 2017 the Concept for the 
Health  Care  system’s  quality  improvement  and 
patient  safety to  improve  these  aspects,  as  well  as 
to create a common understanding of them. Within 
the  framework  of  the Concept are  activities  co-
financed  by  the  EU  Social  Fund,  such  as  targeted 
medical staff training for patient safety. Significant 
work has begun to develop clinical algorithms and 

164 

and 

health 

efficient 

patient  pathways,  which  is  critical  for  providing 
high-quality 
care 
services. Starting  from  2018,  clinical  guidelines 
and medical technologies in use are evaluated and 
updated  using  available  international  comparisons 
as  well  as  performance  indicators for  the  priority 
health  areas  (cardiovascular,  oncological  diseases, 
mental  health,  perinatal  care,  children  (from  the 
neonatal period) care). 

The  Patient  Safety  and  Healthcare  Quality 
Improvement  Unit  has  been  set  up  at 
the 
CDPC to provide supporting functions for medical 
institutions  in  patient  safety  and  quality  of health 
care area. 

The  NHS  is  working  on  the  development  of  the 
Nord-DRG  activity-based  accounting  system  in 
hospitals.  The  use  of  DRGs  has  the  potential  to 
increase  transparency  in  the  inpatient  sector,  both 
it  will  allow 
concerning  performance 
evaluating  the  complexity  of  patients  treated  in 
different  institutions)  and  resource  allocation  (as 
resources  will  be  allocated  according  to  the 
number and type of patients treated).  

(as 

is 

to 

aim 

implemented.  The 

In  order  to  change  public  attitude  towards  health 
and  improve  their  health  behaviours  and  status,  a 
number  of  changes  in  laws  and  regulations  have 
been 
limit 
consumption  of  unhealthy  products  and  habits, 
through  regulations  on  restriction  of  trans-fatty 
acid  amounts  in  food  products,  as  well  as  the 
regulations ensuring availability of healthy food in 
educational  institutions,  treatment  institutions  and 
social care and social rehabilitation institutions. In 
August  2018,  amendments  to  the  regulation  were 
approved and new nutritional norms were defined, 
with  the  addition  of  more  vegetables,  fruits  and 
milk products. In 2016 parliament adopted the law 
on the Handling of Energy drinks, which prohibits 
to  sell  energy  drinks  to  persons  under  the  age  of 
18.  Since  2000  Latvia  has  an  excise  tax  on  non-
alcoholic  beverages  and  the  tax  rate  has  been 
increased two times.  

The National Network of Healthy  Cities. The aim 
of  the  Network  aims  to  improve  the  municipal 
employees’ knowledge on public health and health 
promotion,  to  promote  the  local  governments’ 
involvement  in  the  health  promotion,  to  promote 
the  exchange  of  the  knowledge  and  good  practice 
among  local  municipalities  and  to  provide  the 

 
methodological  support  for  local  governments  on 
public  health  and  health  prevention 
issues.  
Currently there are 112 municipalities participating 
in  the  Network  (94%  of  municipalities  in  Latvia) 
(data from 2018).  

The  Plan  for  improving  health  care  services  in 
oncology  for  years  2017-2020  was  adopted  in 
2017  and  aims  is  to  improve  primary  diagnostic 
and  treatment  of  the  most  frequent  oncologic 
diseases,  quality  and  responsiveness  of  cancer 
screening  and  access  of  palliative  care.  The  Plan 
includes  the  measures  to  decrease  risk  factors  of 
oncologic  diseases,  coordination  and  surveillance 
of  cancer  screening,  to  improve  early  diagnostic, 
treatment  and  post–treatment  observation  as  well 
as  to  improve  services  of  medical  rehabilitation 
and palliative care.  

of  HIV 

the  Action  Plan  for 
Infection, 

In  October  2017, 
the 
Sexually 
Elimination 
Transmitted  Infections  and  Hepatitis  B  and  C  for 
2018-2020  was  adopted  with  the  aim  of  limiting 
the spread of these conditions.   

In  October  2017,  the  Plan  of  Rare  diseases  for 
years  2017-2020  was  adopted.  It  includes  priority 
tasks  and  measures  to  improve  early  and  timely 
diagnosis  of  rare  diseases  and  their  treatment  as 
well as information of rare diseases.  

In  June  2018,  The  Maternal  and  Child  Health 
Improvement  Plan  for  years  2018  –  2020  was 
adopted. The aim is to do this through activities of 
health promotion and disease prevention as well as 
promote  early  diagnosis,  timely  treatment  and 
medical rehabilitation. 

A  new  order  to  improve  cardiovascular  disease 
(CVD)  prevention  is  introduced  since  July  2018, 
providing additional prophylactic examinations for 
adults at a certain age (at 40, 45, 50, 55, 60 or 65 
years 
includes 
cardiovascular  risk  assessment  at  GP  practice, 
using  SCORE  method  and  necessary  diagnostic 
tests,  and  certain  measures  according  to  the 
identified risk. 

prevention 

CVD 

age). 

In December 2017, The Healthcare Financing Law 
was  adopted.  It  states  the  introduction  of  state 
health  insurance  and  two  health  care  services’ 
baskets:  (minimum  basket  and  full  basket)  from 

Health care systems 

2.16. Latvia 

2019. See above for a more detailed description of 
this policy. 

Policy changes under preparation/adoption. 

According  to  conceptual  report  “On  the  Health 
System  Reform”  there  is  ongoing  implementation 
of the reform. 

The  Ministry  of  Health  is  developing  an  Action 
plan  for  the  improvement  of  mental  health  for 
years  2019-2020.  It  will  include  issues  related  to 
the  development  of  integrated  mental  health  care; 
improvement  of 
the  knowledge,  skills  and 
competences  of  GPs;  to  promote  the  further 
education  of  nurses  working  in  GPs'  practice;  the 
improvement of efficiency and quality of in-patient 
treatment; 
improvement  of  accessibility  and 
quality  of  outpatient  psychiatric  health  care  by 
strengthening the practices of psychiatrists and by 
the creation of regional centers, where the services 
are provided by a multi-professional team. 

To continue modernisation of the  e-health system 
two  e-health  system  development  projects  (see 
above)  are  submitted  for  the  approval  to  the 
responsible institution.   

In  2017,  a  project  on  Development  of  the  Health 
System  Performance  Assessment  (HSPA)  for 
Slovenia  and  Latvia  was  launched  with  support 
from  the  EC  Structural  Reform  Support  Service 
and  in  collaboration  with  Sant’Anna  School  of 
Advanced Studies. This is a key part of substantial 
reform to improve the fiscal sustainability and the 
efficiency  of  Latvia`s  health  system,  enabling  the 
authorities  to  monitor  progress  towards  defined 
health system goals. 

New  amendments  to  the  "Law  On  Handling  of 
Tobacco  Products,  Herbal  Products  for  Smoking, 
Electronic  Smoking  Devices  and  Their  Liquids" 
have  been  prepared  including  display  ban  of 
tobacco  products,  herbal  products  for  smoking, 
electronic  smoking  devices  and  their  liquids  (this 
draft  has  been  approved  by  the  Parliament  in  the 
2nd reading and has been  notified to the European 
Commission and member states). 

Currently  under  preparation  is  a  new  national 
Action  plan  for  reduction  of  consumption  of 
alcoholic  beverages  and  limitation  of  alcoholism 
for  next  planning  period.  The  plan  includes  a 

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electronic  patient  records  in  the  future  and 
ensuring that the coverage of specialised care is 
extended to the whole of the population.  

•  To  continue  the  efforts  to  make  hospital 
budgets  more  prospective  and  costs  more 
transparent.  

•  To  continue  to  improve  data  collection  and 
monitoring  of  inputs,  processes,  outputs  and 
outcomes 
performance 
assessment  can  be  conducted  and  used  to 
improve  access,  quality  and  sustainability  of 
care.  

regular 

that 

so 

•  To  gradually 

increase 

the  use  of  cost-
effectiveness  information  in  determining  the 
basket of goods and the extent of cost-sharing.  

•  To  enhance  health  promotion  and  disease 
prevention activities i.e. promoting healthy life 
styles  and  disease  screening  given  the  recent 
pattern  of  risk  factors  (diet,  smoking,  alcohol, 
lack of exercise, obesity). The introduction of a 
smoking ban accompanied by taxes on tobacco, 
alcohol  and  soft  drinks,  stricter  regulation  of 
tobacco advertisement and labelling as  well as 
stricter  road  safety  measures  can  contribute  to 
improving  population  health  status  in  the  long 
run.  Health 
healthy 
education 
environments  in  various  settings  (school  and 
workplaces) 
cheap 
complementary policy.   

also 

and 

can 

be 

a 

variety  of  activities  regarding  the  restriction  of 
marketing  and  supply  of  alcoholic  beverages,  the 
reduction  of  harmful  alcohol  use,  treatment  and 
rehabilitation services.  

Possible future policy changes 

The Ministry of Health continues to implement the 
health care reform as described above. 

Challenges 

The  analysis  above  shows  that  a  wide  range  of 
reforms have been implemented over the years, to 
a large extent successfully (e.g. the development of 
a  strong  primary  care  system),  and  which  Latvia 
should continue to pursue. However, some policies 
have  met  with  a  number  of  obstacles  and  there 
may  be  room  for  improvements  in  a  number  of 
areas.  The  main  challenges  for  the  Latvian  health 
care system are as follows: 

•  To 

the 
improve,  as  acknowledged  by 
authorities,  the  basis  for  more  sustainable  and 
larger  financing  of  health  care  in  the  future 
(e.g.  considering  additional  sources  of  general 
budget  funds),  with  a  better  balance  between 
resources and demand, between the number of 
(including  general,  unmarked 
contributors 
taxes  etc.  contributions)  and  the  number  of 
beneficiaries  and  which  can  improve  access 
and quality of care and its distribution between 
population  groups  and  regional  areas.  If  more 
resources  are  brought  into  the  sector  it  is 
important  that  they  do  not  remain  fragmented 
but  are  pooled  together  maintaining  the  strong 
pooling mechanisms in place today.  

•  To  define  a  comprehensive  human  resources 
strategy – including higher education prospects 
–  to  ensure  a  balanced  skill-mix,  avoid  staff 
shortages  and  motivate  and  retain  staff  to  the 
sector.  

•  To  continue  to  enhance  and  better  distribute 
services  and  basic 
primary  health  care 
specialist  services  to  improve  equity  of  access 
and  the  effectiveness  and  efficiency  of  health 
care  delivery  as  well  as  ensuring  effective 
referral systems from primary to specialist care 
and improving care coordination between types 
of care. This can be helped through developing 

166 

 
 
Table 2.16.1:  Statistical Annex - Latvia 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

14

15.9

11.9

:

2006

17

15.7

12.9

14.5

2007

23

15.0

10.9

18.9

2008

24

13.8

-2.5

-10.0

2009

19

12.7

-13.0

-5.7

2010

18

13.4

-1.9

-3.5

2011

20

14.0

8.4

-0.5

2012

22

14.6

5.3

13.4

2013

23

14.9

3.5

-9.6

2014

24

15.4

2.8

5.3

2015

24

16.2

3.9

7.8

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

6.2

5.8

0.4

600

3.9

3.5

378

0.44

63.0

16.6

:

41.7

6.3

5.5

0.8

773

4.3

3.8

527

0.49

68.2

14.7

:

35.6

6.8

6.2

0.5

6.2

5.9

0.4

1,098

1,097

4.2

3.6

677

0.52

61.6

13.7

:

39.3

3.9

3.6

687

0.29

62.6

9.5

:

37.3

6.8

5.7

1.0

928

4.2

3.7

571

0.44

61.5

9.1

:

38.8

6.6

5.8

0.9

883

3.9

3.6

523

0.37

59.2

10.4

:

37.8

6.1

5.6

0.5

942

3.8

3.5

585

0.25

62.1

10.9

100.0

32.1

6.6

6.2

0.4

5.7

5.4

0.3

5.9

5.5

0.4

6.1

5.7

0.4

3.7

3.3

631

0.42

56.1

10.2

100.0

34.4

3.6

3.2

641

0.34

62.4

10.6

:

38.5

3.7

3.3

685

0.39

62.1

10.1

:

39.1

3.7

3.3

709

0.40

59.8

10.2

100.0

42.1

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2.2

76.3

64.9

53.2

50.8

199

7.7

2.2

76.1

65.0

52.5

50.8

185

7.4

2.2

76.2

65.3

54.8

51.4

168

8.5

2.2

77.5

66.5

54.3

51.6

154

6.6

2.2

77.7

67.5

56.0

52.6

144

7.6

2.1

78.0

67.9

56.4

53.1

145

5.6

2.1

78.8

68.6

56.6

53.6

371

6.6

2.0

78.9

68.9

59.0

54.6

357

6.3

2.0

78.9

69.3

54.2

51.7

353

4.4

2.0

79.4

69.1

55.3

51.5

332

3.8

2.0

79.5

69.7

54.1

51.8

326

4.1

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

1,124

1,028

1,102

1,185

2,745

2,895

2,975

3,305

Composition of total current expenditure as % of GDP

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

1.9

0.0

1.5

1.4

0.4

0.0

0.2

1.3

0.0

0.6

0.4

0.0

0.0

0.4

1.8

0.1

1.3

1.4

0.2

0.2

0.2

1.3

0.1

0.7

0.5

0.0

2.0

0.1

0.9

1.7

0.4

0.1

0.3

1.6

0.1

0.4

0.4

0.0

1.7

0.1

1.5

1.3

0.2

0.1

0.2

1.4

0.1

0.5

0.5

0.0

2.0

0.1

1.3

1.5

0.3

0.2

0.2

1.6

0.1

0.5

0.6

0.1

1.7

0.2

1.2

1.6

0.2

0.1

0.2

1.3

0.2

0.6

0.6

0.0

1.4

0.3

1.0

1.5

0.2

0.2

:

1.1

:

0.6

0.6

0.0

1.3

0.3

1.1

1.4

0.2

0.2

:

1.0

:

0.5

0.6

0.0

1.3

0.4

1.0

1.4

0.2

0.0

:

1.0

:

0.5

0.5

0.0

1.2

0.3

1.2

1.5

0.2

0.1

0.1

1.0

0.2

0.6

0.5

0.0

0.17

0.4

0.10

0.2

0.09

0.3

0.19

0.1

0.14

0.1

0.18

0.1

0.16

0.1

0.04

0.1

0.11

0.1

1.2

0.4

1.2

1.6

0.2

0.12

0.1

1.0

0.2

0.5

0.5

0.0

0.11

0.1

2.7

0.2

2.5

1.2

0.3

0.27

0.4

2.6

0.1

1.8

0.9

0.1

0.23

0.3

2.6

0.2

2.5

1.2

0.3

0.23

0.4

2.5

0.2

1.8

0.9

0.1

0.19

0.3

2.7

0.3

2.4

1.5

0.4

0.30

0.4

2.5

0.3

1.7

1.0

0.2

0.25

0.3

2.7

0.3

2.4

1.4

0.4

0.31

0.4

2.5

0.3

1.8

1.0

0.2

0.25

0.3

1
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7

2
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1
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Table 2.16.2:  Statistical Annex - continued – Latvia 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

32.1%

0.7%

25.3%

24.3%

7.1%

0.3%

2.9%

38.6%

1.2%

18.4%

12.7%

0.3%

0.3%

10.7%

2005

0.26

0.1

1.8

0.0

:

:

9.9

2006

33.0%

1.3%

24.0%

26.2%

3.1%

3.5%

3.6%

34.9%

1.6%

17.1%

12.3%

0.0%

4.5%

9.7%

2006

0.26

0.2

1.8

0.0

15.6

30.4

10.4

2005

2006

288

487

58

690

294

544

59

617

2007

31.5%

1.3%

14.3%

26.5%

6.6%

1.6%

4.0%

44.5%

1.6%

9.9%

12.1%

0.3%

2.7%

6.6%

2007

0.48

0.3

2.1

0.0

:

:

12.1

2007

304

535

60

608

2008

29.7%

1.5%

25.4%

22.0%

2.9%

1.5%

2.9%

39.3%

1.7%

14.1%

13.6%

0.0%

2.5%

8.9%

2008

0.66

0.3

2.3

0.0

18.5

27.9

11.8

2009

34.2%

1.7%

22.0%

26.5%

4.7%

3.3%

3.7%

43.0%

2.2%

14.0%

14.8%

1.3%

5.1%

3.5%

2009

0.71

0.4

2.4

0.0

:

:

9.9

2010

29.6%

4.0%

20.3%

27.0%

3.6%

2.4%

3.3%

36.2%

5.3%

17.1%

16.9%

0.0%

3.9%

3.9%

2010

0.79

0.6

2.8

0.0

15.5

:

9.8

2008

2009

2010

311

534

61

559

299

465

61

553

302

486

63

546

2005

2006

2007

2008

2009

2010

5.3

21

:

74.0

7.4

10.6

2016

3.7

3.7

2016

2.0

5.6

21

:

76.0

7.2

:

2020

3.9

4.1

2020

1.9

6.0

21

:

76.1

9.4

:

2025

4.1

4.5

2025

1.8

6.2

20

528

75.5

9.5

2.5

2030

4.2

4.8

2030

1.7

5.9

18

:

64.0

8.5

:

2035

4.3

5.1

2035

1.7

5.9

15

:

71.1

8.5

:

2040

4.4

5.3

2040

1.6

2011

24.5%

4.6%

17.8%

25.8%

3.7%

3.3%

:

2012

21.0%

4.7%

17.3%

22.5%

3.3%

2.5%

:

2013

23.8%

6.9%

18.5%

26.3%

3.6%

0.7%

:

30.3%

30.2%

32.0%

:

16.1%

16.8%

0.5%

5.1%

3.6%

2011

0.92

0.5

3.1

0.0

:

:

10.1

2011

314

496

64

535

2011

6.3

18

:

15.7%

16.9%

0.6%

4.7%

3.1%

2012

0.98

0.6

3.2

0.0

17.5

:

10.2

2012

314

486

66

528

2012

7.0

17

:

16.0%

16.3%

0.5%

1.2%

3.0%

2013

1.04

0.7

3.5

0.0

:

:

10.4

2013

319

488

67

523

2013

6.2

17

2014

21.4%

6.2%

21.6%

26.9%

3.1%

2.0%

1.6%

29.4%

5.8%

17.5%

16.0%

0.9%

3.4%

1.8%

2014

1.25

0.6

3.6

0.0

20.8

24.1

10.6

2014

322

482

70

524

2014

5.8

16

6,791

7,198

7,341

7,185

70.4

8.4

27.9

2045

4.4

5.5

2045

1.5

68.1

8.3

29.3

2050

4.5

5.6

2050

1.5

68.0

8.3

29.9

2055

4.5

5.6

2055

1.5

69.7

8.3

31.1

2060

4.4

5.6

2060

1.4

2015

21.1%

6.5%

21.4%

27.7%

2.8%

2.1%

1.9%

30.5%

5.8%

15.4%

16.6%

0.6%

3.4%

2.8%

2015

1.26

0.6

3.7

0.0

:

:

10.8

2015

320

468

70

518

2015

5.9

:

:

70.7

8.3

:

2065

4.4

5.6

2065

1.4

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

4.3

5.5

2070

1.3

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Latvia

0.6

1.8

EU

0.9

1.6

Change 2016-2070, in %

Latvia

-31.8

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.17. LITHUANIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

GDP per capita in PPS, at 19,600 PPS per capita is 
below  the  EU  average  GDP  per  capita  of  EUR 
29,600  in  2015.  Lithuania  has  a  population  of 
around  2.9  million  inhabitants.  Over  the  coming 
decades, the population of Lithuania will gradually 
decline, from 2.9 million inhabitants in 2016 to 1.7 
million  inhabitants  in  2070. This  40%  fall  is  very 
different from the EU average increase of 2%. 

Total and public expenditure on health as % of 
GDP 

Total expenditure (238) on health as a percentage of 
GDP (6.8% in 2015) is below the EU average ( 239) 
of 10.2%. Public expenditure is, at 4.7% of GDP, 
far  below  the  average  of  8%  in  2015.  Looking  at 
health  care  without  long-term  care(240)  reveals  a 
smaller gap with the EU average (4.1% vs 6.8% in 
2015). 

When expressed in per capita terms, total spending 
on  health  at  1488  PPS  in  Lithuania  is  below  the 
EU average of 3305 in 2015. So is public spending 
on  health  care:  1020  PPS  vs.  an  EU  average  of 
2609 PPS in 2015.  

Expenditure projections 

As a consequence of demographic changes, health 
care expenditure is projected to increase by 0.4 pps 
of  GDP,  below  the  average  growth  expected  for 
the  EU  (0.9)  (241),  according  to  the  Reference 
Scenario.  When  taking  into  account  the  impact  of 

(238) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(239) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(240) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

(241) I.e. considering the "reference scenario" of the projections 
Report: 
2018 

(see 
https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf). 

Ageing 

The 

future  spending 
non-demographic  drivers  on 
growth 
scenario),  health  care 
expenditure  is  expected  to  increase  by  1.2  pps  of 
GDP from now until 2070 (EU1.6). 

(AWG 

risk 

Overall, Lithuania presents low fiscal risks ( 242). 

Health status 

Life expectancy at birth (79.7 years for women and 
69.2  years  for  men  in  2015)  is  far  below  the 
respective EU averages (83.3 and 77.9 years of life 
expectancy) (243). Healthy life years, at 58.8 years 
for  women  and  54.1  for  men,  are  below  the  EU 
averages  of  63.3  and  62.6  in  2015.  The  infant 
mortality rate of 4.2‰ is above the EU average of 
3.6‰ in 2015). 

As  for  the  lifestyle  of  the  Lithuanian  population, 
there is a proportion of regular smokers of 20.4% 
in  2014  higher  than  the  EU  average  of  20.9%  in 
2014.  Alcohol  consumption  is,  at  15.2%,  higher 
than the EU average of 10.2% in 2015 according to 
Eurostat.  The  Lithuanian  Statistical  authorities 
report  a  continuous  fall  in  alcohol  consumption 
from 14.5% in 2013 to 13.2% in 2016. 

System characteristics  

Coverage 

Compulsory  statutory  health  insurance,  based  on 
compulsory insurance contributions, plus transfers 
from 
the  State  budget,  provide  health  care 
coverage to approximately 98-99% of the resident 
population.  The  National  Health  Insurance  Fund 
(NHIF)  and  its  regional  branches,  the  Territorial 
Health  Insurance  Funds  (THIFs),  contract  with 
care  providers  for  the  provision  of  services  and 
reimburse  the  insured  for  medicines.  The  set  of 
(mostly  public)  services  organised  at  municipal, 
county and national level constitute the Lithuanian 
National  Health  Systems  (LNHS).  The  services 
included  in  the  statutory  provision  are  defined  by 
law.  This  is  broad  definition  which  is  further 
detailed  by  decrees  of  the  Minister  of  Health  and 
by  contracts  among  THIFs  and  providers.  The 

(242) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(243) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

169 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

definition  of  benefit  package 
annually. 

is  not  revised 

Free  emergency  care  is  provided  to  the  all 
permanent residents. Most of the other services are 
also free for insured people, but if patients want to 
have higher service standard or additional services 
not  covered  by  compulsory  health  insurance  they 
have  to  pay  to  different  extents.  Cost-sharing 
applies to some services: for instance, the majority 
of pharmaceuticals and dental services.  

the  EU  average 

The share of private expenditure on health in total 
health  expenditure  (31.4%  in  2015)  is  far  higher 
than 
(21.6).  Out-of-pocket 
expenditure constitutes about 32.1% of total health 
expenditure, well above the EU average (15.9% in 
2015).  

of 

compulsory 

There  are  several  cost-sharing  exemptions:  19 
categories  of  population  are  exempted  from 
insurance 
payment 
contributions  as 
the 
they  are 
government. In 2015, the number of such persons 
total 
was  1.64  million  (almost  56%  of 
population). There are also two groups of people to 
whom a ceiling is applied: 

health 
insured  by 

the 

1.  various groups of self-employed people on the 
income calculated on the sum  which does not 
exceed  the  sum  of  48  amounts  of  the  taxable 
income  approved  by  the  government  of  the 
Republic of Lithuania for the current year; 

2.  people  on 

the 

from 

individual 
income 
agricultural  activities  of  the  natural  persons, 
who  engage 
individual 
activities,  for  whom  contributions  are  being 
calculated on a sum which does not exceed the 
sum of 12 amounts of the taxable income. 

type  of 

that 

in 

In  addition  to  formal  payments,  informal  (non-
official)  payments  are  still  reported. These  do  not 
encourage  a  more  effective  use  of  services  and 
constitute  an  additional  barrier  to  access  as  there 
are  no  exemptions  for  low  income  or  high  risk 
groups.  

Administrative  organisation  and 
collection mechanism  

revenue 

The  NHIF  allocates  the  budget  to  the  THIFs 
according  to  a  formula  based  on  the  number  of 

170 

through 

can  be 

residents in each county, their age and gender. As 
it  stands,  it  may  be  worth  exploring  if  additional 
gains 
resource 
achieved 
reallocation  across  the  country  to  improve  the 
geographic distribution of care (there appears to be 
an  overconcentration  of  services  in  richer  and 
urban areas and underfunding in other parts of the 
country).  The  THIFs  then  establish  contractual 
arrangements with service providers.  

is  constrained  by 

the  Compulsory  health 
Expenditure  under 
insurance  fund 
the  sums 
approved by the Law on the Approval of Financial 
Indicators  of  the  budget  of  CHIF.  The  budget  of 
the  CHIF  is  balanced  out  within  a  year.  Once  a 
month,  the  accounts  for  the  provided  health  care 
services  and  dispensed  medicines  and  minor 
medical aid equipment subject to compensation are 
being submitted by the health care institutions and 
pharmacies 
it  has 
concluded  a  contract.  Under  the  conditions  of  the 
contracts,  without 
approved 
appropriations  of  the  budget  of  the  NHIF  and  not 
later than within 30 days from the receipt of a bill, 
the  THIFs  must  settle  the  accounts  submitted  by 
institutions  and 
the 
pharmacies  wherewith 
funds  have 
concluded contracts. 

individual  health  care 

the  THIF  wherewith 

exceeding 

the  said 

the 

to 

Types of providers, referral systems and patient 
choice 

is  provided 

Primary  care  is  provided  by  general  practitioners 
(GPs) or GP teams, consisting of a district internist 
or  district  paediatrician  together  with  a  surgeon 
and an obstetrician-gynaecologist, nurses and other 
staff. Services are provided in primary care health 
centres  or  GPs  private  offices,  community  posts, 
ambulatories  and  polyclinics  around  the  country. 
Specialist  ambulatory  care 
in 
polyclinics  and  hospital  outpatient  departments, 
facilities, 
mostly  state  or  municipally-owned 
although  private  provision  of  specialist  outpatient 
care  is  growing.  Inpatient  care  is  provided  in 
general  and 
specialised  hospitals.  Providers 
establish  contracts  with  the  THIFs.  Virtually  all 
pharmacies (except for a few) and the majority of 
dental  practices  are  private.  Pharmacies  establish 
contracts  with  THIFs  and  receive  reimbursement 
for the pharmaceuticals (included into positive list) 
delivered  to  the  patients.  Dental  practices  operate 
on  a  totally  private  basis.  The  only  exception  is 
represented  by  those  dental  practices  which  are 

 
within the structure of Primary health care centres. 
The  payment  for  primary  dental  services 
is 
included into Primary Health Care capitation rate. 

The total number of practising physicians per 100 
000  inhabitants  (434  in  2015)  is  above  the  EU 
average  (344)  and  has  increased  gradually  since 
2003.  Data  on  the  physician  skill-mix  indicates 
that the number of GPs per 100 000 inhabitants (91 
in  2015),  excluding  district  internists  and  district 
paediatrician  which  are  working  very  much  like 
GPs, is above the EU average (78.3). This is due to 
a high increase throughout the last two decades as 
part  of  the  authorities'  efforts  to  improve  primary 
care  provision  (42.7  in  1998).  The  number  of 
nurses  (766  in  2015)  per  100  000  inhabitants  is 
below  the  EU  average  (833  in  2015),  having 
remained relatively flat since 2011 (753). This may 
be  associated  with  staff,  particularly  nurses, 
migrating  to  other  EU  countries  that  need  to 
provide  nursing  care  and  offer  better  wages.  This 
skill mix, coupled with non homogenous physician 
distribution  is  still  posing  some  difficulties  to  a 
well-functioning primary health care sector, which 
is acknowledged by the authorities.  

Since  the  early  1990s,  national  authorities  have 
made a significant and, to a large extent, successful 
effort  to  enhance  primary  care  provision,  to 
strengthen the referral system from primary care to 
specialist  doctors  and  to  strengthen  the  gate-
keeping role of GPs to reduce the unnecessary use 
of  specialist  and  hospital  care.  This  is  amongst 
other  things  done  through  a  financial  incentive  to 
visit, one's own GP as the first step; i.e. imposing 
an  extra  cost  for  non-referred  consultations.  All 
inhabitants  have  to  register  with  a  GP  who  acts 
like  a  family  doctor  and  refers  patients  to  other 
types  of  care.  Patients  are  able  to  choose  their 
health  centre  and  their  GP  and  choose  a  hospital 
after  referral.  To  implement  a  well-functioning 
referral  system  and  choice,  it  is  necessary  to 
continue  the  efforts  so  far  to change  the  skill  mix 
and improve the distribution of primary care across 
the  country  and  possibly  to  improve  access  to 
primary  care  /  GPs  after  normal  office  hours 
(although  office  hours  are  already  long  compared 
to  other  countries).  Shortages  of  GPs  can  lead  to 
high  waiting  times  to  visit  GPs  and  therefore 
individuals skipping the referral system and going 
straight  to  hospital,  making  unnecessary  use  of 
(free) emergency care. 

Health care systems 

2.17. Lithuania 

Lithuania  has  one  of  the  largest  numbers  of  acute 
care hospital beds per 100 000 inhabitants (608 in 
2015)  in  the  EU  (EU  average  of  402  in  2015), 
although  it  has  seen  a  large  reduction  in  the  last 
two decades (631 in 2005).  

These values were perhaps a result of the efforts to 
modernise  care  facilities  and  improve  quality  of 
care.  However,  for  a  country  spending  a  relative 
small percentage of their overall GDP on health, it 
may  be 
to 
infrastructure.  It  may  be  worth  investigating  if 
investment  in  infrastructure  is  still  necessary  and 
to  carefully  consider  what  type  of  infrastructure 
can be cost-effective given the size of the country, 
the budget for health and the economic situation. 

too  high  a  value 

to  allocate 

Treatment options, covered health services 

Health in the statutory provision basket are broadly 
defined  by  law.  This  definition  is  made  more 
detailed  by  decrees  of  the  Minister  of  Health  and 
by contracts among THIFs and their providers. The 
definition  of  the  benefit  package  is  not  revised 
annually. 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

and 

(health 

promotion 

Payment systems have evolved over the years. GPs 
(or  GP  teams)  receive  a  mix  of  capitation, 
approximately  74.5  %  of  total  payments  in  2015, 
according  to  the  number  and  age  of  their  listed 
patients (age-adjusted capitation), fees for defined 
disease 
activities 
prevention),  as  well  as  bonuses 
for  some 
performance  indicators  (the  remaining  25.5  %). 
This  mixed system  intends  to render primary care 
more attractive and provide incentives for primary 
care  provision  including  some  health  promotion 
and  disease  prevention  activities.  The  authorities 
are  considering  a  further  enlargement  of  the  non-
capitation share of GPs’ payment, and there is a set 
of  additional  performance  indicators  related  to 
reduction  of  avoidable  hospitalisations  elaborated 
for  that.  Specialists  are  paid  per  consultation, 
consisting of up to three visits for the same reason; 
if the patient needs to see specialist further on – the 
new  episode  of  consultation  is  reimbursed  to  the 
provider.  Remuneration  is  determined  by  the 
central government (Ministry of Health). 

171 

 
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

rates  are  still  high  although 
Hospitalisation 
progress 
towards  primary  care  and  reducing 
hospital capacity has been significant. The number 
of  hospital  surgery  done  as  day  cases  was  2403 
day  cases  per  100  000  inhabitants  in  2015  vs.  the 
EU average of 7635). On the contrary, the number 
of  inpatient  discharges  per  100  inhabitants  was 
23.1 in 2015, above the EU average of 16.2.  

Hospitals  are  paid  mostly  on  the  basis  of  cost  per 
case  (450  groups  of  diagnosis  –  nationally 
elaborated  DRGs)  according  to  annual  contracts. 
The  decision  was  made  to  switch  to  Australian 
Refined  DRG  system  from  2012.  Implementation 
was  delayed  until  2014  due  to  coding  problems. 
The hospital budgets are very stringent in terms of 
budget  caps.  However,  there  is  flexibility  to 
provide  more  short-term,  day  and  outpatient 
services  (so-called  priority  services)  instead  of 
ordinary hospitalisations. 

The market for pharmaceutical products 

Medicines  in  Lithuania  are  mainly  imported  from 
other EU member states. The reimbursable price is 
set on the basis of international prices of a selected 
list of countries. In order to further control overall 
expenditure,  the  authorities  have  implemented  the 
following  policies:  a)  the  reimbursable  price  is 
determined  on  the  basis  of  95%  of  the  average  of 
manufacturer prices in reference countries CZ, EE, 
HU,  LV,  PL,  SK,  RO,  BG  and  b)  there  is  a 
reference price mechanism, whereby the maximum 
reimbursement  price  of  a  new  drug  is  based  on 
other  drugs  that  have  both  the  same  active 
ingredient  and  form  and  according  to  the  disease, 
and  c)  positive  lists  (the  list  of  pharmaceuticals 
that  can  be  reimbursed)  are  based  as  much  as 
possible 
evaluation 
information.  

economic 

based 

on 

Compared  to  the  range  of  policies  used  by 
neighbouring  countries,  there  is  perhaps  room  to 
explore  other  additional  measures 
regarding 
product  price  regulation  and  direct  expenditure 
control.  On  1st  of  April  2010,  new  provisions  of 
the  Amendment  of  Law  on  Pharmacy  concerning 
regulation  of  prices  of  non-reimbursed 
the 
pharmaceuticals 
force.  The 
government  sets  the  maximum  wholesaler  and 
pharmacy  mark-ups  for  prescriptions  and  OTC. 
The representatives of manufacturers shall provide 
manufacturer  prices  for  the  Lithuanian  market,  as 

entered 

into 

172 

well as the prices at which the pharmaceuticals are 
distributed  in  the  reference  countries  in  order  to 
compare them.  

Since  2010,    a  number  of  measures  aimed  to 
reduce expenditures on pharmaceuticals have been 
adopted. The new rule about the price of generic is 
set by the Governmental Decree. The first generic 
in  the  group  shall  be  50  %  cheaper  than  original, 
the second 15 % cheaper than the first and the third 
15 % cheaper than the second generic. In the case 
when  the  group  of  reimbursed  medicinal  products 
consists  of  more  than  3  medicinal  products  of 
different  manufacturers, 
the  most  expensive 
medicinal  product  can  be  only  10%  more 
expensive  than  the  average  of  two  cheapest 
pharmaceuticals  of  the  same  INN  in  reference 
countries.  

2011, 

Since 
interchangeable 
therapeutically 
pharmaceuticals with different INN are clustered if 
they have the same therapeutic effect, indication of 
reimbursement, presentation form and are used for 
the treatment of the same age group of patients.  

Since  1st  of  May  2010  pharmacies  are  obliged  to 
show  prices  of  pharmaceuticals  to  patients  in  a 
special computer monitor.  

Since  1st  of  June,  2010  prescribing  medicinal 
product by INN is obligatory with some exceptions 
set by the Minister of Health. 

eHealth, Electronic Health Record 

Health  aims  to  improve  the  accessibility  and 
quality  of  healthcare  services  and  to  ensure  the 
the 
necessary 
information and communication technologies.  

exchange  using 

information 

three 

finished 

According to the plan of the implementation of E-
Health System Development Programme for 2009-
2015,  the  Ministry  of  Health  of  the  Republic  of 
Lithuania  has 
large  public 
investment projects: the central part of the system 
(ESPBI  IS),  e.  prescription  and  medical  image 
exchange.  According  to  the  Implementation  Plan, 
during period of 2009 – 2015 29 e-health projects 
have  been  already  implemented,  including  16 
national  and  13  regional  projects.  Information 
systems  of 
the  national-level  and  university 
hospitals,  Online  Booking  System  for  outpatient 
consultation,  and  registers  of  licenses  of  health 

 
care professionals and health care institutions, and 
register of medicines ensuring the development of 
high  quality  electronic  services  of  health  care 
institutions  (HCI)  have  been  developed  under  the 
national projects. Regional projects are focused on 
information 
regional  medical 
institutions that provide data to the central e-health 
information system. 

systems 

of 

150 HCI have already implemented the projects of 
e-health  development  information  systems  and 
currently they provide the electronic completion of 
patient  medical  records  within  the  scope  of  the 
project:  12  clinical  forms:  referrals,  epicrysis, 
description  of  visits,  e-prescriptions,  laboratory 
tests, radiological image reports and etc., as well as 
8  medical  certificates:  health  certificates  for 
students,  drivers,  holders  of  weapons,  birth  or 
death certificates, and others. 

The central e-health system (ESPBI IS) is capable 
of storing patient information from various HCI in 
one  e-health  history  (One  Resident  –  One  EHR). 
This  makes it possible to re-use health records, to 
avoid  duplication  of  diagnostics  procedures  and 
provide  health  care  services  to  patients  more 
efficiently,  safer  and  better  quality.  The  system 
will  enable  to  carry  out  disease  prevention  and 
health  promotion  programmes  more  effectively 
based on objective records, which will be available 
for  re-use.  Patient-needs-oriented  EHR  aims  to 
assure 
lifelong  and  effective  provision  of 
healthcare  services  in  Lithuania.  EHR  is  being 
developed gradually, i.e. during the first years it is 
carry  only  the  critical  patient  health  information 
and  certain  certificates.  Later  it  will  be  expanded 
and  supplemented  with  more  detailed  medical 
data. 

to 

strives 
involve  all  healthcare 
Lithuania 
institutions 
in  participation  and  secure  data 
exchange,  to  enable  successful  functioning  of  the 
ESPBI  IS  and  to  create,  store  and  transfer  data 
about  patient  health  even  between  European 
countries according to the principle “one resident – 
one EHR”. 

In  order 
to  ensure  a  coherent  policy  of 
development  of  the  eHealth  system  in  Lithuania, 
smooth  operation  of  health  care  institutions,  to 
save  the  time  of  doctors  and  patients,  to  receive 
health care services of a better quality,  the eHealth 
System Development Program for period of 2017-

Health care systems 

2.17. Lithuania 

2025  was  approved  by  Order  No  V-878  of  the 
Minister of Health of the Republic of Lithuania of 
17  July  2017,,  i.e.  it  is  aimed  that  all  health  care 
the  eHealth 
institutions  should  participate 
system  in  order  to  create  conditions  for  all  health 
care  institutions  in  Lithuania  to  provide  patient’s 
electronic  health  records  from  the  health  care 
institutions  information  systems  or  through  the 
portal (244). 

in 

Health  and  health-system 
information  and 
reporting  mechanisms/  Use  of  Health 
Technology  Assessments  and  cost-benefit 
analysis 

Data has  much improved in recent  years although 
it is still lacking in a number of areas. Information 
and  monitoring  of  physician  and  hospital  activity 
can be used for example for establishing contracts 
and prospective budgets.  

Currently  there  is  no  structure  to  conduct  health 
technology assessment in great part due to the fact 
that  it  requires  additional  administrative  capacity 
and  scientific  know-how,  currently  not  available. 
Therefore, cost-effectiveness knowledge is used in 
a limited way to determine the benefit package, the 
extent  of  cost-sharing  or  develop 
treatment 
guidelines  to  harmonise  and  rationalise  medical 
practices.  

There 
is  an  HTA  model  developed  and 
successfully deployed in Lithuania, which is based 
on  the  assessment  of  applications  submitted  to 
competent  HTA  bodies,  responsible  for  assessing 
medical devices, medical procedures, public health 
technologies  and  medicines  according 
the 
priorities  set  by  the  Ministry  of  Health.  The 
greatest  priority  is  attributed  to  the  technologies 
which  have  the  greatest  impact  on  morbidity, 
mortality and disablement. 

to 

As introduced earlier, there are indeed a number of 
risk  factors  to  health  that  deserve  attention  and 
action.  Consequently,  the  central  government  has 
set  a  number  of  public  health  objectives,  some  of 
which  are  very  detailed  and  have  been 
implemented with the help of the WHO. Currently 
there  are  six  prevention  programs  carried  out  in 
Lithuania:  Heart  and  vascular  diseases  prevention 
programme, Sealant program for children, Cervical 

(244) www.esveikata.lt. 

173 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

cancer,  Mammography,  Colorectal  cancer  and 
Prostate cancer screening programmes. 

total  (0.13%)  and  public  (0.13%) 
However, 
expenditure  on  prevention  and  public  health  as  a 
share of GDP is much lower than the EU average 
(respectively 0.3% and 0.25% in 2015).  

Recently 
reforms  

legislated  and/or  planned  policy 

In 2013 the creation of the Integrated Health Care 
and  Functional  Cluster  System  was  started,  thus 
seeking  to  start  quality  treatment  of  patients 
suffering  from  serious 
illnesses  as  soon  as 
possible, to manage patient flows more efficiently 
and optimise the activities of hospitals. 

In  order  to  achieve  a  more  effective  operation  of 
system  of  the  national  health  care  institutions,  the 
next  health  care  system  development  and  hospital 
network consolidation strategic plan was approved 
by the Minister of Health in  December 2015. The 
strategic plan foresees the directions and priorities 
system 
of 
development and optimisation. 

the  Lithuanian  national  health 

Challenges 

The  analysis  above  shows  that  a  wide  range  of 
reforms have been implemented over the years, to 
a large extent successfully (e.g. the development of 
a  strong  primary  care  system),  and  which 
Lithuania  should  continue  to  pursue.  However, 
some policies have met with a number of obstacles 
and  there  may  be  room  for  improvements  in  a 
number  of  areas.  The  main  challenges  for  the 
Lithuanian health care system are as follows: 

•  To improve, as acknowledge by the authorities, 
the  basis  for  more  sustainable  and  larger 
financing  of  health  care  in  the  future  (e.g. 
considering  additional  sources  of  general 
budget  funds),  with  a  better  balance  between 
resources and demand, between the number of 
contributors  and  the  number  of  beneficiaries 
and  which  can  improve  access  and  quality  of 
care  and  its  distribution  between  population 
groups  and  regional  areas.  If  more  resources 
are  brought  into  the  sector  it  is  important  that 
they  do  not  remain  fragmented  but  are  pooled 
together  maintaining 
strong  pooling 
the 
mechanisms in place today.  

174 

•  To  continue  to  enhance  and  better  distribute 
primary  health  care 
services  and  basic 
specialist  services  to  improve  equity  of  access 
and  the  effectiveness  and  efficiency  of  health 
care  delivery  as  well  as  ensuring  effective 
referral systems from primary to specialist care 
and improving care coordination between types 
of care. This can be helped through developing 
electronic patient records in the future.  

•  To  continue  the  efforts  to  decrease  hospital 
beds  while  increasing  day-case  surgery  and 
concentrating high-tech hospital services.  

•  To 

a 

implement 

comprehensive  human 
resources  strategy  to  ensure  a  balanced  skill-
mix,  avoid  staff  shortages  and  motivate  and 
retain  staff  to  the  sector,  especially  in  view  of 
migration and ageing. 

•  To  consider  additional  measures  regarding 
price regulation and direct expenditure control, 
including 
for  good  prescribing 
practices and a more explicit policy on generics 
and the monitoring of prescription of drugs.  

incentives 

•  To  continue  to  improve  data  collection  and 
monitoring  of  inputs,  processes,  outputs  and 
performance 
outcomes 
assessment  can  be  conducted  and  use  to 
continuously 
improve  access,  quality  and 
sustainability of care.  

regular 

that 

so 

•  To  gradually 

increase 

the  use  of  cost-
effectiveness  information  in  determining  the 
basket of goods and the extent of cost-sharing.  

to 

enhance 

continue 

•  On  the  basis  of  the  defined  public  health 
priorities, 
health 
promotion and disease prevention activities, i.e. 
promoting  healthy 
life  styles  and  disease 
screening  given  the  recent  pattern  of  risk 
factors 
lack  of 
(diet,  smoking,  alcohol, 
exercise,  obesity)  as  detailed  in  the  national 
plan,  including  the  smoking  ban  and  health 
education  in  schools  and  communities.  Taxes 
on  tobacco,  alcohol  and  soft  drinks,  stricter 
regulation  of 
tobacco  advertisement  and 
labelling  as  well  as  stricter  road  safety 
measures  and  bicycle  lanes  and  greener  areas 
are  some  of  the  measures  that  can  encourage 
healthier life-styles. 

 
Table 2.17.1:  Statistical Annex - Lithuania 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

21

15.5

9.5

:

2006

24

16.1

9.1

16.0

2007

29

17.1

12.4

12.8

2008

33

16.2

3.7

10.2

2009

27

14.1

-13.9

-1.9

2010

28

15.4

3.8

-2.3

2011

31

16.4

8.5

5.0

2012

33

17.2

5.2

2.3

2013

35

17.9

4.6

3.3

2014

37

18.8

4.4

3.8

2015

37

19.6

3.0

7.5

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

5.8

5.7

0.2

620

4.1

3.8

431

0.28

69.5

17.8

:

32.8

6.2

5.8

0.4

771

4.3

3.9

534

0.35

69.3

18.4

:

31.9

6.2

5.8

0.4

944

4.6

4.1

693

0.43

73.4

17.8

:

28.4

6.6

6.3

0.3

7.5

7.4

0.1

7.1

6.9

0.2

6.9

6.5

0.4

6.7

6.3

0.4

6.6

6.1

0.5

6.6

6.2

0.4

6.8

6.5

0.3

5.0

4.5

859

0.45

75.2

14.4

:

28.2

5.6

5.4

810

0.25

74.9

16.0

:

26.8

5.2

4.9

789

0.28

73.4

17.4

90.9

27.6

5.1

4.6

893

0.52

74.8

14.7

91.4

28.2

4.5

4.2

857

0.31

68.1

16.3

91.9

31.8

4.3

4.1

865

0.27

65.6

16.2

91.8

32.8

4.4

4.2

922

0.19

66.7

15.8

92.0

31.5

0.33

68.6

16.4

92.4

32.1

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

3.4

77.4

65.2

54.6

51.4

135

7.1

3.3

77.1

65.0

56.5

52.6

140

7.2

3.2

77.2

64.5

58.1

53.3

132

6.3

3.2

77.6

65.9

59.6

54.5

134

5.5

3.2

78.7

67.1

61.2

57.2

131

5.6

3.1

78.9

67.6

62.3

57.4

125

5.0

3.1

79.3

68.1

62.0

57.0

346

4.8

3.0

79.6

68.4

61.6

56.6

338

3.9

3.0

79.6

68.5

61.6

56.8

328

3.7

2.9

80.1

69.2

61.7

57.6

311

3.9

2.9

79.7

69.2

58.8

54.1

326

4.2

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

4.7

4.4

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

1,020

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

1,143

1,082

1,075

1,194

1,258

1,317

1,383

1,488

2,745

2,895

2,975

3,305

Composition of total current expenditure as % of GDP

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

1.8

0.1

1.0

1.9

0.2

0.1

0.1

1.6

0.1

0.7

0.7

0.0

0.1

0.1

1.8

0.1

1.2

1.8

0.2

0.1

0.1

1.7

0.1

0.8

0.7

0.1

0.1

0.1

1.8

0.1

1.1

1.7

0.2

0.1

0.1

1.6

0.1

0.8

0.6

0.1

0.1

0.1

1.8

0.2

1.3

1.7

0.2

0.1

0.2

1.7

0.2

0.9

0.6

0.1

0.1

0.2

2.1

0.2

1.5

2.0

0.2

0.1

0.2

1.9

0.2

1.1

0.8

0.1

0.1

0.2

2.0

0.2

1.4

1.8

0.2

0.1

0.1

1.8

0.2

1.0

0.7

0.1

0.1

0.1

1.9

0.2

1.4

1.7

0.2

0.1

0.1

1.8

0.2

1.0

0.6

0.1

0.1

0.1

1.9

0.1

1.3

1.8

0.2

0.1

0.1

1.8

0.1

0.8

0.6

0.0

0.1

0.1

1.7

0.1

1.4

1.7

0.2

0.1

0.1

1.6

0.1

0.8

0.6

0.0

0.1

0.1

1.7

0.1

1.4

1.7

0.2

0.1

0.1

1.6

0.1

0.8

0.6

0.1

0.1

0.1

1.8

0.1

1.5

1.7

0.2

0.1

0.1

1.7

0.1

0.8

0.6

0.1

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

1
7
5

2
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7
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1
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Table 2.17.2:  Statistical Annex - continued – Lithuania 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

31.3%

1.4%

17.2%

34.3%

3.4%

1.9%

2.1%

42.4%

2.1%

18.6%

17.8%

1.1%

2.9%

2.7%

2005

0.15

:

1.2

0.0

16.0

24.5

12.3

2006

31.4%

1.9%

19.7%

31.0%

3.9%

1.5%

1.7%

41.9%

2.5%

20.1%

16.5%

1.3%

2.3%

2.3%

2006

0.29

:

1.2

0.0

:

26.5

12.7

2005

2006

362

710

65

690

365

711

67

617

2005

2006

7.0

22

822

79.0

7.3

3.6

2016

4.1

4.1

2016

2.9

6.8

21

982

76.0

7.1

4.4

2020

4.2

4.4

2020

2.7

2007

30.4%

2.4%

19.4%

28.5%

3.4%

2.1%

2.1%

38.6%

3.4%

19.8%

15.5%

1.2%

2.9%

2.7%

2007

0.33

0.5

1.0

0.0

:

:

13.4

2007

372

705

69

608

2007

7.2

22

1,374

75.5

8.8

6.0

2025

4.3

4.6

2025

2.6

2008

29.0%

2.8%

20.7%

26.2%

3.5%

1.3%

3.2%

37.2%

3.8%

20.1%

13.7%

1.1%

1.8%

4.4%

2008

0.42

0.6

1.3

0.0

:

24.2

13.3

2008

370

711

68

559

2008

7.3

22

1,605

72.7

8.5

6.9

2030

4.4

4.8

2030

2.4

2009

28.4%

3.0%

20.6%

26.6%

3.0%

1.2%

2.0%

35.8%

3.9%

20.2%

14.3%

1.1%

1.7%

2.8%

2009

0.51

0.7

1.5

0.0

:

:

12.4

2009

365

697

69

553

2009

7.2

22

1,729

72.4

8.1

7.3

2035

4.5

5.0

2035

2.3

2010

28.4%

3.0%

20.5%

26.7%

3.5%

0.9%

2.0%

36.9%

4.3%

20.1%

14.0%

1.0%

1.2%

2.6%

2010

0.47

0.7

1.8

0.0

:

:

12.9

2010

383

716

72

546

2010

7.3

23

1,927

72.0

8.1

7.9

2040

4.6

5.3

2040

2.1

2011

29.1%

3.1%

21.7%

26.0%

2.9%

1.2%

2.0%

38.2%

4.3%

20.6%

12.6%

1.1%

1.7%

2.8%

2011

0.59

0.7

2.0

0.0

:

:

12.7

2011

409

753

85

535

2011

7.7

24

2,349

73.1

8.3

9.0

2045

4.7

5.4

2045

2.0

2012

29.7%

1.6%

21.0%

28.9%

2.9%

1.1%

1.9%

41.4%

2.1%

19.4%

13.7%

0.9%

1.7%

2.8%

2012

1.00

0.6

2.4

0.0

:

:

15.1

2012

422

759

85

528

2012

8.0

:

:

72.5

8.0

:

2050

4.7

5.5

2050

2.0

2013

28.1%

1.6%

23.0%

28.2%

2.9%

1.3%

1.8%

38.9%

2.2%

20.0%

14.3%

1.0%

2.0%

2.7%

2013

1.05

0.7

2.4

0.0

:

:

15.0

2013

428

755

86

523

2013

8.1

23

2,568

71.6

7.9

10.0

2055

4.7

5.5

2055

1.9

2014

27.5%

1.8%

21.8%

27.8%

3.2%

1.8%

2.1%

37.3%

2.4%

19.4%

13.6%

1.4%

2.6%

3.1%

2014

1.06

0.8

2.2

0.1

16.6

20.4

15.2

2015

27.8%

1.8%

22.4%

26.7%

3.4%

2.0%

2.0%

38.3%

2.5%

19.0%

13.3%

1.1%

3.0%

3.0%

2015

1.10

0.9

2.1

0.1

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2014

2015

2009

2011

2013

2015

431

760

89

524

2014

8.6

23

2,197

72.8

8.0

8.7

2060

4.6

5.4

2060

1.8

434

766

91

518

2015

8.8

23

2,403

72.2

7.9

9.4

2065

4.6

5.4

2065

1.8

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

4.5

5.3

2070

1.7

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Lithuania

0.4

1.2

EU

0.9

1.6

Change 2016-2070, in %

Lithuania

-40.3

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.18. LUXEMBOURG 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

scenario"),  health  care  expenditure  is  expected  to 
increase  by  1.7  pps  of  GDP  from  now  until  2070 
(EU: 1.6) (247).  

General  country  statistics:  GDP,  GDP  per 
capita; population 

GDP  per  capita  (68.8  thousand  PPS  in  2015)  of 
Luxembourg  is  the  highest  in  the  EU.  Despite 
having decreased since its peak in 2007, it remains 
more  than  double  of  the  EU  average  of  29.6 
thousand PPS. 

roughly  half 

a  million 
Luxembourg  has 
inhabitants,  less  than  1%  of  the  EU  population. 
Despite  its  limited  population,  it  achieves  the 
highest GDP per capita with 68.8 thousand PPS in 
2015,  which  is  almost  2.5  as  much  as  the  EU 
average  of  29.6  thousand  PPS  for  the  same  year. 
The population is projected to almost double in the 
next decades, reaching 1.0 million in 2070.  

Total and public expenditure on health as % of 
GDP 

Total  expenditure  on  health  as  a  percentage  of 
GDP  (6.1%  in  2015)  is  below  the  EU  average 
(10.2%)  and  has  remained  relatively  stable  in  last 
years, with a level of 6.1 % in 2011, reaching 7.1% 
in  2013) (245).  The  same  applies 
to  public 
expenditure  on  health  as  a  percentage  of  GDP, 
with  5%  below  the  EU  average  (8%  in  2015)  but 
relatively  stable  since  2011  (5.1%).  However, 
when expressed in per capita terms, both total and 
public  expenditure  (4,649  PPS  and  3,815  PPS  in 
2015)  are  well  above  the  EU  average  (3,305  PPS 
and  2,609  PPS).  Looking  at  health  care  without 
long-term  care ( 246)  reveals  a  similar  picture,  with 
spending  below  the  EU  average  (4%  vs  6.8%  in 
2015). 

Expenditure projections and fiscal sustainability  

As  a  result  of  population  ageing,  health  care 
expenditure  is  projected  to  increase  by  1.2  pps  of 
GDP  (below  the  average  change  in  the  EU  of  0.9 
pps  in  the  "AWG  reference  scenario").  When 
taking into account the impact of non-demographic 
drivers  on  future  spending  growth  ("AWG  risk 

(245) Note  that  figures  differ  more  before  and  after  2011.  This 
may  be  partly  due  to  a  break  in  series  due  to  the  passage 
from SHA 1.0 to SHA 2011.  

(246) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

faces 

low  medium-term 

Luxembourg 
fiscal 
sustainability risks, primarily due to the initial low 
level  of  government  debt  and  the  favourable 
budgetary  position,  which  compensate  for  the 
long  run, 
projected  ageing  costs.  Over 
Luxembourg 
fiscal 
to 
sustainability.  These  risks  are  entirely  driven  by 
the  necessity  to  meet  future  increases  in  ageing 
costs  (notably  pension,  health  care  and  long-term 
care expenditures) (248). 

the 
risks 

faces 

high 

Health status 

Life  expectancy  at  birth  (84.7  for  women  and  80 
for  men  in  2015)  is  above  the  EU  average,  but 
healthy  life  years  at  birth  are  below  the  EU 
average  for  women  (60.6)  but  above  for  men 
(63.7).  They  have  overall  increased  over  the  last 
decade, although the trend seems to be inverted in 
recent years for healthy life years, both for women 
and  men,  which  may  also  obey  to  recent  changes 
in  the  methodology  for  eliciting  self-reported 
health  status  (249).  Mortality  is  mainly  due  to 
circulatory  system  diseases  and  cancers  (250). 
Transport  accidents  are  above  the  EU  average, 
with a rate of 6.6 vs 5.2 in 2015, and death due to 
intentional  self-harm  is  higher  compared  to  EU 
average,  with  a  rate  of  13.36  (21.6  for  males  and 
6.22  for  females)  vs  11.6  for  the  EU  in  2015.  In 
addition, infant mortality is below the EU average 
thanks  to  comprehensive  and  free  antenatal  and 
postnatal  services.  Amenable  mortality,  mortality 
rates  which  are  thought  avoidable  if  appropriate 
and timely care is delivered, is below EU average 
(in  2015,  97  vs  127  at  EU  level).  As  for  the 
lifestyle  of  population,  an  increasing  trend  in  the 
share  of  overweight  population  seems  to  have 

(247) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(248) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(249) Data  on  life  expectancy  and healthy  life  years  is  from  the 

Eurostat database. 

(250) State  of  Health  in  the  EU  Luxembourg  Country  Health 
Profile  2017,  OECD,  Health  Observatory  and  European 
Commission. 
https://ec.europa.eu/health/sites/health/files/state/docs/chp_
lu_english.pdf. 

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characterised  Luxembourg  in  the  past  years.  On 
the  contrary,  alcohol  consumption  has  been 
decreasing  over  the  past  decade  and  so  has  the 
share  of  regular  smokers.  Programmes  to  prevent 
obesity  through  healthy  eating  and  sports  have 
already  been  launched,  especially  among  young 
and  children,  and,  paired  with  other  existing 
initiatives  to  promote  healthy  behaviours,  such  as 
regulations  on  alcohol  advertising,  they  should  be 
further expanded (251). 

System characteristics  

Overall description of the system 

In  2015,  about  82.0%  of  total  health  expenditure 
insurance 
was  public  expenditure 
contributions and taxation), about 10.6% was out-
of-pocket spending and the remaining 7.4% mainly 
came from voluntary private health insurance. 

(statutory 

Compulsory health insurance (252) is provided and 
managed by the National Health Insurance (Caisse 
Nationale  de  Santé,  CNS),  which  was  created  by 
merging  multiple  sickness  funds  into  one  single 
payer  in  2009.  The  CNS  is  obliged  to  maintain  a 
reserve  of  10%  of  the  total  planned  expenditure 
(253). 

insurance 

The  health 
is  mainly  financed  by 
contributions.  Contributions  are  equally  split 
between  employers  and  employees,  which  are 
calculated  as  percentage  of  gross-income  (254). 
Different  rules  apply  to  the  self-employed  and 
specific  professions.  The  central  government 
participates by paying 40% of the contributions. If 
gross-income  does  not  exceed  a  certain  level,  no 
contributions have to be paid as a means to support 
low income or disadvantaged groups.  

(251) http://www.clep.lu/code-de-deontologie/. 
(252) The  social  health  insurance  comprises  health  care,  long-

term care and accident insurance. 

(253) According to the OECD, Luxembourg scores 1 out of 6 in 
the OECD scoreboard due to the not very stringent budget 
controls.  See  Joumard,  I.,  C.  André  and  C.  Nicq  (2010), 
“Health Care Systems: Efficiency and Institutions”, OECD 
Economics  Department  Working  Papers,  No.  769,  OECD 
Publishing, 
10.1787/5kmfp51f5f9t-en 
doi: 
http://www.oecd.org/officialdocuments/publicdisplaydocu
mentpdf/?doclanguage=en&cote=eco/wkp(2010)25. 

39. 

p. 

Coverage 

compulsory  health 

Luxembourg’s  health  care  is  based  on  a  very 
comprehensive 
insurance 
package.  In  2015,  95.2%  (255)  of  all  citizens  and 
registered  residents  were  covered  by  the  statutory 
health 
the  system 
covers a high number of cross-border workers and 
their family members.  

insurance  system.  Further, 

Administrative organisation 

of 

Health system regulation is a shared responsibility 
of  the  Ministry  of  Health  and  the  Ministry  of 
Social  Security,  which  cooperate  regarding  the 
organisation,  legislation  and  financing  of  the 
system.  The  Ministry  of  Health  focusses  on  the 
planning  and  organisation  of  health  care  service 
delivery, enacting laws and regulations applying to 
health  providers  and  directly  co-finances  public 
health programmes. It is further responsible for the 
determination 
hospital 
the 
planning (256) and the scope of work of health care 
professionals.  The  Ministry  of  Social  Security 
defines  social  policy  and  oversees  the  public 
institutions  funded  by  the  health,  accident  and 
long-term 
schemes.  Public 
insurance 
expenditure  on  health  administration  and  health 
insurance as a percentage of GDP (0.26%) is close 
to the EU average (0.26%). Public expenditure on 
health  administration  and  health  insurance  as  a 
share  of  total  current  health  expenditure  is  also 
above  the  average  with  4.9%  recorded  for  2015 
(vs. EU average 3.8%). 

national 

care 

Role  of  private  insurance  and  out  of  pocket 
co-payments 

A  low  level  of  cost-sharing  applies  to  many 
services.  A  higher  level  of  cost-sharing  applies  to 
glasses  and  contact  lenses,  dental  care  and  dental 
prostheses.  Cost-sharing  exemptions  apply  for 
people  where  the  amount  of  cost-sharing  exceeds 
2.5%  of  the  gross-income.  In  fact,  out-of-pocket 
spending accounts for only a small part of private 
expenditure  and  decreased  over  the  last  decade 
(10.6% of total health spending which is less than 
the  EU-average  of  15.9%,  after  a  decrease  during 
in 
the 

last  decade  from  a 

level  of  13.4% 

(254) With  a  maximum  limit  of  five  times  the  minimum 

guaranteed income. 

(255) OECD data. 
(256) According  to  new  legislation  that  came  into  force  in  
1.4.2018:http://legilux.public.lu/eli/etat/leg/loi/2018/03/08/
a222/jo. 

178 

 
                                                           
                                                           
2006) (257). Additional voluntary private insurance 
is  taken  up  by  around  53%  of  the  population  to 
cover  out-of-pocket  payments  and  cost  sharing 
(complementary  insurance).  Note,  however,  that 
voluntary  private  health  insurance  schemes  only 
account  for  about  7.7%  of  total  expenditure  in 
2015. As a proportion of total benefits reimbursed, 
the  part  of  voluntary  insurance  remains  then  very 
low  since  the  compulsory  system  reimburses  a 
comprehensive set of services. 

Types of providers, referral systems and patient 
choice 

Primary  care  is  provided  by  general  practitioners 
(GPs)  who  are  self-employed  and  mostly  work  in 
individual  private  practices.  Specialist  outpatient 
care  is  provided  by  self-employed  individuals 
working  in  their  own  private  practices  and/or 
hospital. 

In  Luxembourg, 
the  number  of  practising 
physicians per 100 000 inhabitants (291 in 2015) is 
below  the  EU  average  (344).  The  number  of  GPs 
has  increased,  from  78  in  2005  to  87 per  100.000 
inhabitants  in  2015,  which  is  higher  than  the 
average in the EU. To practise, physicians need an 
approval of their qualifications by the Ministry of 
Health  but  there  are  no  legal  barriers  to  limit  the 
medical personnel as such, especially since the EU 
legislation  on  mutual  recognition  of  medical 
qualifications  has  been  introduced.  Considering 
that  the  system  remains  quite  attractive,  the 
number of physicians practising in Luxembourg is 
expected  to  continue  to  increase  even  if  the  high 
proportion of physicians aged 45+ (68% in 2017), 
likely  to  retire  in  the  short  to  medium  term,  will 
lessen  this  inflow.  In  comparison,  the  number  of 
nurses per 100 000 inhabitants (1,191) is one of the 
highest  of  the  EU  and  there  are  4.1  practising 
nurses  per  physician.  The  remuneration  of  nurses 
is  indeed  very  attractive  in  Luxembourg,  with  a 
ratio  of  1.4  to  the  average  wage  of  the  working 
population in Luxembourg. 

Patients are free to register with a GP but GPs have 
no  gate-keeping  role:  patients  can  directly  consult 
specialists  even  in  the  case  of  common  primary 
care.  Patients  have  the  right  to  choose  their  GP, 
specialist and hospital and there are no legal means 

(257) Note  that  this  may  be  driven  by  the  break  in  series  after 

2011 due to the shift to SHA 2011. 

Health care systems 

2.18. Luxembourg 

to  limit  the  volume  of  activity  even  if  there  are 
some  limitations  on  the  number  of  visits  to  more 
than one physician of the same speciality within a 
certain  period  of  time.  In  this  context  of  free 
choice, improving the availability and transparency 
of information about health care providers' activity 
and availability is essential to optimise the patients' 
choice.  Finally,  pharmaceuticals  are  mostly 
distributed  through  pharmacies  whose  number  is 
strictly  controlled  by  the  authorities.  Since  2011 
pharmaceuticals  delivered  by  hospitals  to  patients 
as outpatient care no longer fall under the hospital 
budget  but  are  integrated  in  the  pharmaceutical 
budget.  

Pricing,  purchasing  and  contracting  of 
healthcare 
remuneration 
mechanisms 

services 

and 

Physicians  are  paid  on  a  fee-for-service  basis. 
There  are  no  performance-related  payment 
bonuses for example to provide incentives for cost-
effective  health  promotion,  disease  prevention,  or 
disease management. The fees for medical services 
are negotiated every 2 years between the National 
Health Insurance and representatives of health care 
professionals. Every health care provider has to be 
contracted  with  the  CNS;  and  it  is  determined  by 
law that they must adhere to the fees agreed upon.  

Health care services in Luxembourg are organised 
based  on  a  reimbursement  system.  Generally,  the 
patient has to pay the costs in advance and submits 
the  receipts  to  the  CNS  for  partial  or  total 
to  hospital 
reimbursement.  Exceptions  apply 
treatments, 
and 
pharmaceuticals as well as third party payment for 
disadvantaged groups.  

laboratories 

analyses 

Hospitals  are  financed  by  the  National  Health 
Insurance.  Every 
the  government 
two  years, 
decides upon a global budget which is then divided 
annually  by  the  health  insurance  between  the 
hospitals. Hospitals ( 258) have autonomy to recruit 
their staff. The hospitals are encouraged to review 
their  quality  management  regularly.  These  efforts 
have  been  undertaken  by  the  CNS  in  order  to 

(258)

http://www.legilux.public.lu/leg/textescoordonnes/c
odes/code_securite_sociale/code_securite_sociale.pdf#page
=57. 

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European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

improve quality and cost-containment; the activity 
is combined with a financial reward.  

Hospital  discharge  rates  per  100  inhabitants  are 
below  the  EU  average  (14.57  vs  16  in  2015)  for 
inpatients  and  have  decreased  over  the  last  ten 
years (259). Conversely, after increasing all through 
the  last  decade,  day-case  discharges  per  100  000 
inhabitants are above EU average (7,921 vs 7,635). 
The  average  length  of  stay  (9.1  days  in  2015)  is 
above the EU average (7.6 days) but has been quite 
stable over the last ten years. This may partly be a 
consequence of a financing system based on global 
hospital  budgets,  which  does  not  directly 
incentivise  its  reduction.  To  tackle  this  issue,  in 
light of the relatively low bed occupancy rate, the 
current  system  based  on  the  global  budget  could 
benefit  from  including  some  elements  of  activity-
based reimbursement, to promote a  more efficient 
use of resources. 

Since 1995, for pharmaceuticals, patients must pay 
only the part of the costs to the pharmacy not being 
reimbursed by the health insurance (260). 

The market for pharmaceutical products 

Total  expenditure  on  pharmaceuticals  as  a 
percentage  of  GDP  (261)  is  well  below  the  EU 
average 
in  2015)  while 
consumption is around average.  

(0.5%  vs.  1.4% 

Luxembourg imports all pharmaceuticals products 
at  prices  based  on  those  used  in  the  country  of 
origin  which  normally  is  Belgium,  Germany  or 
France  (262).  Drugs  are  mostly  sold  in  pharmacies 
but  they  can  delivered  by  hospitals  to  patients  as 
outpatient  care,  in  which  case  they  still  fall  under 
the pharmaceutical budget. The counsellor's role of 
the pharmacist has been increased by encouraging 
the substitution of a drug by a cheaper one if they 

if 

on 

Cf 

list 

Art 

(259) Eurostat. 
(260) Positive list of pharmaceuticals, reimbursement is possible 
only 
CSS 
http://www.legilux.public.lu/leg/textescoordonnes/codes/co
de_securite_sociale/code_securite_sociale.pdf#page=57. 
(261) Expenditure  on  pharmaceuticals  used  here  corresponds  to 
category HC.5.1 in the OECD System of Health Accounts. 
Note 
records 
pharmaceuticals  in  ambulatory  care  (pharmacies),  not  in 
hospitals  and  that  over  the  counter  drugs  are  not  included 
either. 

this  SHA-based  estimate  only 

that 

22 

(262) When  determining  the  price  for  products  imported  from 
outside Europe, the price of the product in Belgium, France 
and Germany is taken into account. 

180 

the  same  qualitative  and  quantitative 
have 
fundamentals.  For 
this  purpose,  doctors  and 
pharmacists  have  a  list  of  exchangeable  products. 
The CNS maintains a comprehensive list of drugs 
approved  for  reimbursement  (positive  list).  There 
for 
are 
pharmaceuticals 
care,  with 
reimbursement rates of 40%, 80% or 100%. Drugs 
administered  at  the  hospital  fall  under  hospital's 
budget and are thus free of charge for the patient. 

three  categories  of 

reimbursement 

outpatient 

for 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

The use of Health Technology Assessment appears 
to  be  limited  in  terms  of  the  definition  of  the 
benefit basket. 

Health  and  health-system 
reporting mechanisms 

information  and 

Luxembourg  has  been  quite  active  in  this  field  in 
recent  years  and  a  number  of  projects  have  been 
established to monitor and collect health care data. 
The  Luxembourgish  government  has  adopted  a 
national  eHealth  plan  which  envisages 
the 
establishment of a national eHealth agency and the 
introduction  of  an  electronic  health 
record, 
enabling  the  exchange  and  sharing  of  health  data 
between  health  care  professionals.  The  aim  is  to 
improve  quality  and  performance  of  the  system 
and  to  control  the  development  of  expenditure, 
tests  and 
especially  by  avoiding 
examinations. Each patient can have a personal file 
containing administrative data and diagnostic data 
such  as  laboratories  results,  radiological  data  and 
medications register. 

redundant 

Health  promotion  and  disease  prevention 
policies 

Several  programmes  are  in  place  in  order  to 
promote health, including breast cancer screening, 
smoking cessation, free contraception, prenatal and 
postnatal  programmes,  and 
flu  vaccination. 
Further,  the  Ministry  of  Health  supports  school 
health  programmes,  vaccination  programmes, 
healthy  living  programmes  and  the  distribution  of 
health education material.  

Public expenditure on prevention and public health 
services  as  a  percentage  of  GDP  (0.1%  vs  EU 
0.3%)  and  as  a  percentage  of  total  current  health 

 
                                                           
Health care systems 

2.18. Luxembourg 

expenditure (2.4%) are well below the EU average 
in 2015 (3.2%). 

expenditure  shall  be  aligned  to  the  economic 
growth of the country. 

Recently 
reforms  

legislated  and/or  planned  policy 

Challenges 

Facing  the  general  economic  crisis  in  Europe,  the 
reform  of  the  health  system  from  2010  (263)  not 
only tried to tackle the negative effects of the crisis 
but provided also some structural changes in order 
to  improve  the  quality  of  care  and  to  rationalise 
expenditure. 

Measures  include  the  creation  of  the  Cellule 
d’expertise  médicale 
to  review  services  and 
medical devices proposed for introduction into the 
health  benefit  basket  or  the  modification  thereof. 
In  addition,  the  possibility  was  introduced  for 
patients,  especially  chronically  ill  persons,  to 
choose  a  doctor  as  a  reference  point  for  their 
treatments  and  follow-ups.  The  GP 
medical 
organises  the  care  path  and  manages  the  patients' 
medical  records,  for  which  the  eHealth  agency  is 
responsible.  

The standardisation of medical procedures and the 
organisation  of  hospital  networks  as  well  as  a 
better  coordination  between  primary  and  hospital 
care  were  actively  supported  to  improve  quality 
and efficiency. Further, policies promoting greater 
generic  drug  substitution  (patients  refusing  the 
substitution  proposed  by  the  pharmacist  have 
greater  proportion  of  cost-sharing)  have  been 
introduced.  Measures 
the 
introductions/strengthening of tools to monitor the 
quality  of  care  and  to  increase  transparency  (at 
patient,  hospital  and  physician  level,  as  well  as  at 
the health insurance level). In particular, the law of 
2010  scheduled  the  creation  of  an  electronic 
patient file to be used in all health care sectors and 
containing all the information related to the health 
status of a patient. 

included 

also 

the 

legislative  period  2013-2018 

For 
the 
government  intends  to  strengthen  health  care 
promotion  and  prevention  of  diseases  by 
integrating health questions in all policies (“health 
in all policies”). The ongoing growth of health care 

(263)

http://www.legilux.public.lu/leg/a/archives/2010/02

42/a242.pdf#page=2. 

The  analysis  above  has  shown  that  a  range  of 
reforms  have  been  implemented  in  recent  years  – 
e.g.  improvements  regarding  hospital  efficiency, 
improved  data  collection  and  monitoring  and  the 
control of pharmaceutical expenditure – and which 
Luxembourg should continue to pursue. The main 
challenges  for  the  Luxembourgish  health  care 
system are as follows: 

•  To improve the basis for more sustainable and 
efficient  financing  of  health  care  in  the  future 
(e.g.  considering  additional  sources  of  general 
budget  funds),  aiming  at  a  better  balance 
between resources and spending. 

to 

•  To  continue  to  enhance  and  better  distribute 
primary  health  care  services 
improve 
effectiveness  and  efficiency  of  health  care 
delivery.  To  continue 
to  shift  excessive 
capacity  and  activity  of  acute  inpatient  care 
towards  ambulatory  and  outpatient  care 
services,  and  strategically  directing  more 
resources  towards  providers  of  lower  levels  of 
care.  

•  To implement a monitoring of human resources 
in the health care sector that ensures a balanced 
skill-mix,  that  avoids  staff  shortages  and  that 
motivates  and  retains  staff  to  the  sector  in  the 
future.  In  addition,  to  consider  enhancing 
financial and  institutional incentives  for health 
care professionals to provide adequate levels of 
services to patients based on quality indicators, 
performance-based 
reporting  and  payment 
bonuses.  

•  To 

increase 

the  use  of  cost-effectiveness 
information, such as HTAs, in determining the 
basket of goods.  

•  To improve the systems for data collection and 
monitoring  of  inputs,  processes,  outputs  and 
outcomes 
performance 
assessment can be conducted.  

regular 

that 

so 

•  Promote  the  use  of  the  recently  deployed 
including  electronic  patient 

eHealth 

tools 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

records  can  help  ensuring  effective  referral 
systems  from  primary  to  specialist  care  and 
improving  care  coordination  between  types  of 
care. 

•  To  foster  public  action  in  the  area  of  health 
promotion  and  disease  prevention  on  the  basis 
of  the  defined  public  health  priorities  (diet, 
smoking,  alcohol,  lack  of  exercise),  given  the 
pattern of risk factors.  

182 

 
 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.18.1:  Statistical Annex – Luxembourg 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

1
8
3

EU- latest national data

2005

30

68.7

1.6

:

2006

34

71.4

3.6

0.6

2007

37

75.4

6.6

0.9

2008

38

71.9

-3.0

-5.1

2009

37

64.8

-6.1

1.3

2010

40

65.4

2.9

-1.0

2011

43

66.1

0.2

-17.5

2012

44

64.4

-2.6

5.3

2013

46

64.0

1.0

7.8

2014

50

67.2

3.3

1.0

2015

52

68.8

0.9

-11.7

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

8.0

6.7

1.3

7.8

7.0

0.8

7.4

7.3

0.0

7.2

7.2

0.0

7.8

6.7

1.1

7.5

6.2

1.2

6.1

6.1

0.0

6.6

6.6

0.1

7.1

6.6

0.6

6.9

6.3

0.7

6.1

6.1

0.0

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

4,311

4,632

4,750

4,689

4,807

4,941

4,287

4,620

5,082

5,218

4,649

2,745

2,895

5.9

5.9

5.6

5.5

5.2

5.2

5.8

5.8

6.6

6.5

6.2

6.1

5.1

5.1

5.5

5.5

5.5

5.4

5.2

5.2

5.0

5.0

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,441

2,487

2,505

2,701

2,821

2,835

2,556

2,727

3,923

3,902

3,815

2,153

2,263

2,324

2,609

0.02

74.2

11.4

98.7

12.9

0.02

71.5

11.5

98.2

13.4

0.01

70.8

11.5

97.9

10.3

0.01

81.2

11.8

97.2

10.1

0.07

85.1

11.1

97.2

9.9

0.06

82.5

10.9

97.2

10.2

0.04

83.3

11.3

97.2

10.9

0.08

83.2

11.6

97.0

10.4

0.08

77.2

11.4

96.5

10.3

0.03

74.8

10.9

96.0

10.5

0.03

82.1

10.3

95.2

10.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0.5

82.3

76.7

62.4

62.3

65

2.6

0.5

81.9

76.8

62.1

61.2

66

2.5

0.5

82.2

76.7

64.6

62.3

63

1.8

0.5

83.1

78.1

64.2

64.8

59

1.8

0.5

83.3

78.1

65.9

65.1

61

2.5

0.5

83.5

77.9

66.4

64.4

57

3.4

0.5

83.6

78.5

67.1

65.8

104

4.3

0.5

83.8

79.1

66.4

65.8

101

2.5

0.5

83.9

79.8

62.9

63.8

112

3.9

0.5

85.2

79.4

63.5

64.0

87

2.8

0.6

84.7

80.0

60.6

63.7

91

2.8

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

1.9

:

2.1

0.7

0.2

0.2

0.1

1.7

:

1.8

0.6

0.1

0.2

0.1

1.7

:

2.1

0.7

0.2

0.1

0.1

1.6

:

1.7

0.6

0.1

0.1

0.1

1.6

:

2.0

0.7

0.2

0.1

0.1

1.4

:

1.6

0.6

0.1

0.1

0.1

1.7

0.1

2.2

0.7

0.2

0.1

0.1

1.6

0.1

1.8

0.6

0.1

0.1

0.1

1.9

0.2

2.4

0.8

0.2

0.2

0.1

1.7

0.2

2.0

0.6

0.1

0.2

0.1

1.8

0.2

2.4

0.7

0.2

0.1

0.2

1.6

0.1

1.9

0.6

0.1

0.1

0.1

1.7

0.2

1.5

0.5

0.1

0.1

0.3

1.5

0.2

1.1

0.4

0.1

0.1

0.3

1.9

0.2

1.6

0.6

0.1

0.1

0.3

1.6

0.2

1.2

0.5

0.1

0.1

0.3

1.9

0.2

1.5

0.6

0.1

0.2

0.3

1.6

0.2

1.1

0.4

0.1

0.1

0.3

1.7

0.2

1.5

0.5

0.1

0.2

0.3

1.4

0.2

1.1

0.4

0.1

0.1

0.3

1.5

0.2

1.5

0.5

0.1

0.2

0.3

1.3

0.2

1.1

0.4

0.1

0.1

0.3

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

2
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1
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Table 2.18.2:  Statistical Annex - continued – Luxembourg 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

28.2%

:

31.8%

10.8%

2.4%

2.4%

1.8%

2006

25.0%

:

2007

22.0%

:

29.4%

26.9%

9.8%

2.3%

1.9%

1.3%

9.0%

2.0%

1.9%

1.2%

28.7%

28.5%

27.3%

:

30.4%

10.3%

1.3%

2.7%

1.3%

2005

1.07

1.1

2.8

0.2

18.6

23.0

11.8

2005

255

1097

78

690

2005

6.0

16

:

30.5%

10.5%

1.4%

2.3%

1.3%

2006

1.06

1.7

2.8

0.2

20.4

21.0

12.0

2006

261

1094

77

617

2006

5.9

16

:

31.2%

10.6%

1.5%

2.5%

1.3%

2007

1.04

1.7

2.7

0.2

20.0

21.0

11.8

2007

268

:

82

608

2007

6.0

16

2008

23.0%

2.0%

29.9%

9.5%

2.2%

1.7%

1.3%

26.6%

2.5%

30.9%

10.1%

1.4%

2.1%

1.4%

2008

1.23

1.6

2.7

0.2

20.3

20.0

11.5

2008

272

:

81

559

2008

6.1

16

2009

28.5%

2.5%

36.1%

11.2%

2.5%

2.7%

1.8%

26.6%

2.5%

30.7%

9.8%

1.4%

2.8%

1.4%

2009

1.41

1.6

2.6

0.2

20.3

19.0

11.4

2009

270

1112

79

553

2009

6.1

15

2010

28.1%

2.4%

37.7%

11.1%

2.7%

2.2%

3.4%

26.1%

2.4%

31.5%

9.7%

1.5%

2.3%

1.3%

2010

1.38

1.6

2.6

0.2

22.1

18.3

11.4

2010

277

1105

82

546

2010

5.9

15

2011

28.2%

2.6%

24.4%

8.8%

2.3%

2.3%

4.9%

29.7%

3.1%

22.0%

8.7%

1.4%

2.8%

5.3%

2011

1.35

1.5

2.5

0.2

22.5

16.9

11.5

2011

276

1127

82

535

2011

6.0

15

2012

28.5%

2.7%

23.6%

8.5%

2.1%

2.1%

4.6%

29.9%

3.1%

21.5%

8.4%

1.3%

2.4%

5.1%

2012

1.32

1.5

2.5

0.2

23.5

16.8

11.3

2012

278

1192

83

528

2012

6.0

14

2013

28.9%

2.6%

23.2%

8.4%

2.1%

2.4%

4.4%

30.0%

3.0%

21.1%

8.1%

1.3%

2.4%

5.4%

2013

1.29

1.5

2.2

0.2

23.0

15.7

11.0

2013

281

1193

86

523

2013

6.0

14

2014

26.6%

2.9%

23.8%

8.3%

2.2%

2.4%

4.3%

27.7%

3.3%

21.9%

8.1%

1.4%

2.5%

5.0%

2014

1.26

1.6

2.2

0.2

15.1

15.3

11.1

2014

286

1197

88

524

2014

5.9

13

4,475

5,065

5,685

6,364

6,493

6,671

6,983

7,403

7,642

7,921

69.0

7.2

21.7

2016

3.9

3.9

2016

0.6

70.0

7.4

24.5

2020

4.0

4.1

2020

0.6

72.3

9.1

26.9

2025

4.0

4.2

2025

0.7

72.7

9.2

:

2030

4.2

4.4

2030

0.8

73.7

9.4

29.9

2035

4.3

4.5

2035

0.8

72.5

9.1

30.3

2040

4.4

4.7

2040

0.9

72.4

8.8

32.2

2045

4.6

4.9

2045

0.9

73.2

8.8

34.2

2050

4.7

5.1

2050

0.9

71.6

8.9

35.8

2055

4.8

5.3

2055

1.0

71.1

8.9

37.5

2060

4.9

5.4

2060

1.0

2015

25.3%

3.1%

24.3%

8.6%

2.3%

2.5%

4.3%

26.2%

3.6%

22.4%

8.5%

1.4%

2.4%

5.2%

2015

1.23

1.6

1.8

0.2

:

15.0

:

2015

291

1191

87

518

2015

5.8

:

:

71.6

9.1

:

2065

5.0

5.5

2065

1.0

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

5.1

5.6

2070

1.0

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Luxembourg

1.2

1.7

EU

0.9

1.6

Change 2016-2070, in %

Luxembourg

79.7

EU

2.0

Source:  EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.19. MALTA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

In  2017,  the  GDP  at  market  prices  in  PPS  per 
capita  stood  at  28,700,  which  is  below  the  EU 
average of 29,900. Population was estimated at 0.5 
million in 2017. It is expected to stay within half a 
million  in  the  coming  decades,  with  the  fastest 
expansion occurring in the next years.   

Total and public expenditure on health as % of 
GDP 

Total  expenditure  on  health  as  a  percentage  of 
GDP  (9.8%  in  2014)  has  increased  over  the  last 
decade  (from  9.0%  in  2005) and  is  below  the  EU 
average  of  10.2%  in  2015.  Throughout  the  last 
decade, total public expenditure has first decreased 
then  increased  as  a  share  of  GDP:  from  5.2%  in 
2005 down to 4.5% in 2010, and then up to 6.4% 
of  GDP  in  2014  (EU:  8.0%  in  2015).  Looking  at 
health  care  without  long-term  care (264)  reveals  a 
similar picture with public spending below the EU 
average (MT: 5.6% in 2014 vs. EU: 6.8% in 2015). 
When  expressed  in  per  capita  terms,  also  total 
spending  on  health  at  2,566  PPS  in  2014  was 
below  the  EU  average  of  2,975  in  2014.  So  was 
public spending on health care: 1,675 PPS in 2014 
vs. an average of 2,324 PPS in 2014 (265). 

Expenditure projections and fiscal sustainability  

to 

is  projected 

As a consequence of population ageing, health care 
expenditure 
increase  by  a 
considerable  2.7  pps  of  GDP  between  2016-2070, 
high  above  the  average  growth  expected  for  the 
EU  of  0.9  pps  of  GDP,  according  to  the  "AWG 
reference scenario". When taking into account the 
impact  of  non-demographic  drivers  on  future 
spending  growth  ("AWG  risk  scenario"),  health 

(264) To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(265) Note  that  these  PPS  figures  reflect  current  plus  capital 
health  expenditure  in  contrast  to  EUROSTAT  data  series, 
which reflect current expenditure only. 

care expenditure is expected to increase by 4.3 pps 
of GDP from now until 2070 (EU: 1.6 pps) (266). 

Medium fiscal sustainability risks appear for Malta 
over the long run. These risks are primarily related 
to the strong projected impact of age-related public 
spending  (notably  pensions,  healthcare  and  long-
term care) (267). 

Health status 

Life expectancy at birth, 84.0 years for women and 
79.7  years  for  men,  is  above  the  respective  EU 
averages  of  83.3  and  77.9  years  in  2015.  Healthy 
life  year  expectancy  is  very  high  with  74.6  years 
for women and 72.6 for men in Malta versus 63.3 
and  62.6  in  2015  in  the  EU  (268).  The  infant 
mortality rate of 5.8‰ is above the EU average of 
3.6‰ 
relatively 
consistent  throughout  the  last  decade,  however 
caution  needs  to  be  exercised  when  interpreting 
such figures in view of the fact that termination of 
pregnancy is illegal in Malta. 

in  2015,  having 

remained 

As  for  the  lifestyle  of  the  Maltese  population,  the 
data  indicates  a  proportion  of  regular  smokers  of 
18.9%  in  2014,  being  below  the  EU  average  of 
20.9%.  The  proportion  of  the  obese  population  is 
far  above  EU  level.  In  2014,  one  in  four  adults 
(25%  of  the  population)  were  reported  as  being 
obese,  in  comparison  with  EU  average  of  15.4%, 
rising  marginally  from  23%  in  2009  (EU  average 
15.5%).  Overweight  and  obesity  rates  among  15-
year old children has increased by 36% since 2001, 
and currently stand at 30% which is more than one 
and  a  half  times  the  EU  average.  There  are 
differences in obesity rates between girls and boys, 
these  being  26%  and  34%  respectively  (269).  The 
alcohol consumption is below the EU level. 

(266) The 

2018 

Ageing 

Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(267) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(268) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

(269) Health at a Glance: Europe 2016. State of Health in the EU 

cycle, OECD. 

185 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

System characteristics  

condition  in  a  system  which  is  separate  from  the 
one mentioned above. 

Overall description of the system 

A National Health Service (NHS), managed by the 
Ministry  of  Health  and  funded  through  taxation, 
provides  coverage  for  a  comprehensive  range  of 
services  (preventive,  curative  and  rehabilitative 
care).  

Coverage 

The  Maltese  health  care  system  is  based  on  the 
principle  of  equity  and  solidarity  with  universal 
coverage. The public healthcare system provides a 
comprehensive  basket  of  services  to  all  persons 
residing in Malta  who are covered by the Maltese 
legislation  and  also  provides 
social  security 
necessary  care 
irregular 
to  groups  such  as 
immigrants  and  foreign  workers  who  have  valid 
work  permits.  There  are  no  user  charges  or  co-
payments  for  health  services.  The  private  sector 
acts as a complementary mechanism for healthcare 
coverage and service delivery. 

Administrative  organisation  and 
collection mechanism  

revenue 

The  budget  for  the  public  health  sector  is  defined 
annually in Parliament when the general budget is 
approved.  A 
financial 
management and control at the Ministry of Health 
monitors and controls the financial management of 
the public health system.  

specific 

unit 

for 

Role  of  private  insurance  and  out  of  pocket 
co-payments  

(28.9%  of 

Private  expenditure  constituted  a  relatively  high 
share,  with  34.7%,  of  total  health  expenditure  in 
2014, which is above the EU average of 23.5% in 
2015. A large part of private expenditure is out-of-
pocket  expenditure 
total  health 
expenditure  in  2014  and  much  higher  than  the 
respective  EU  average  of  15.9% 
in  2015). 
Authorities  ensure  means-tested  entitlement  (for 
people  with  low  incomes)  to  pharmaceuticals, 
dental  and  optometric  care,  i.e.  benefits  mostly 
excluded  from  the  free  public  healthcare  basket. 
The  remainder  is  left  to  private  health  insurance 
whose  share  of  private  expenditure  has  remained 
steady  over  the  last  few  years.  The  chronically  ill 
are provided with free medicines according to their 

186 

Types of providers, referral systems and patient 
choice 

The public healthcare system is the key provider of 
health  services.  The  private  sector  complements 
the provision of health services, in particular in the 
area  of  primary  health  care.  In  2016,  a  public- 
private partnership agreement was signed between 
the Maltese government and a private international 
health  care  provider  to  operate  three  hospitals  in 
the  Maltese  islands.  In  addition,  some  services, 
especially for long-term and chronic care, are also 
provided  by  the  private  sector,  the  Church  and 
other voluntary organisations. 

Increasing 

effectiveness 

The  state  health  service  and  private  general 
practitioners  (GPs)  provide  primary  health-care 
and 
the 
services. 
consolidation of the position of the primary health 
care  system  is  the  cornerstone  of  the  National 
health  care  system.  To  this  effect  a  number  of 
actions  have  been  implemented  to  strengthen 
quality  and  efficiency  of  services  such  as  new 
referral  systems  in  liaison  with  the  private  family 
doctor.  Private  family  doctors  are  empowered  to 
refer  patients  with  musculoskeletal 
directly 
problems  for  physiotherapy  services  in  primary 
health  care  settings.  Both  public  and  private 
doctors  also 
for  bone 
densitometry  and  X-rays.  A  number  of  public 
health  centres  are  equipped  with  digital  X-ray 
facilities,  enabling  X-rays  to  be  taken  on  site  and 
accessed  remotely  by  hospital  specialists 
in 
secondary care.  

their  patients 

refer 

teaching  hospital 

Secondary and tertiary care is mainly provided by 
specialised  public  hospitals  of  varying  sizes. 
Hospital care is mostly delivered in NHS hospitals. 
The  main  acute  general  services  are  provided  by 
one 
(Mater  Dei  hospital) 
incorporating  specialised,  ambulatory,  inpatient 
care and intensive care services. There has been a 
significant amount of investment in public-private 
partnerships,  in  order  to  improve  the  capacity  in 
terms  of  surgical  operations  as  well  as  diagnostic 
and  emergency  services.  Some  minor  procedures 
have  recently  been  partly  relocated  to  primary 
health  centres  to  alleviate  the  burden  on  the  main 
hospital. Anticoagulation monitoring services have 
also been partly devolved to health centres. 

 
Health care systems 

2.19. Malta 

Under the NHS, primary care is delivered through 
a  network  of  public  health  centres,  provided  by 
general  practitioners  (GPs),  nurses  and  some 
is 
specialists.  NHS  outpatient  specialist  care 
centred  in  the  hospitals  outpatient  departments,  in 
which most of the specialists work, with a number 
of  ambulatory  specialist  clinics  being  held  in 
primary health centres.  

In addition to NHS provision, there is also private 
outpatient  primary  care  and  specialist  care 
practice,  given  mostly  from  the  private  doctor’s 
office,  for  private  patients.  Doctors  are  allowed 
part-time after-hours private clinics when in public 
employment.    This  applies  mostly  to  specialities 
other  than  family  medicine,  where  there  seems  to 
be  a  better  uptake  of  the  option  that  the  public 
sector  offers  for  a  better  paid,  exclusive  contract, 
which bars private practice. 

There  is  a  compulsory  referral  system  from 
primary  care  to  specialist  doctors.  GPs  act  like 
gatekeepers 
to  specialist  and  hospital  care. 
However,  this  system  is  very  often  bypassed  by 
patients attending specialist health care directly in 
the  private  sector.  One  reason  is  the  degree  of 
choice  of  GP,  or  specialist,  in  the  private  sector 
and the other is that in certain specialist areas there 
are still relatively long waiting times for outpatient 
appointments in the busier specialities. 

As a rule, patients consult more frequently GPs in 
the  private  sector  than  GPs  in  the  public  sector, 
mostly due to the continuity of care that the same 
GP in the private sector can provide, as opposed to 
the  GP  on  call  in  the  public  sector.  However,  not 
all  GPs  in  the  private  sector  are  well-equipped  to 
deal  with  any  sort  of  emergency,  especially  those 
requiring  urgent  investigations  such  as  specific 
blood tests and radiography. 

Some  of  the  health  centres  are  equipped  to  deal 
with minor emergencies for 24 hours and 7 days a 
week. The Accident and Emergency department at 
Mater Dei Hospital is equipped to deal  with  more 
serious  emergencies.  The  Maltese  tend  to  make 
unnecessary  use  of  hospital  emergency  care, 
particularly since they  would not want to risk that 
they  might  need  specialised  investigations  or 
admission  to  hospital,  for  which  the  public  GP 
would refer them to A&E. This peaks in weekends 
when  private  practitioners  tend  to  have  their  days 
off. 

alleviate 

A number of initiatives are being adopted in Malta 
to  help 
this  problem.  European 
investment  is  being  sought  to  create  a  major 
primary care hub (to become operational in 2023) 
which  should  alleviate  the  congestion  at  the 
hospital.  Indeed,  according  to  this  plan,  a  number 
of services, particularly those that are ambulatory, 
elective  in  nature,  and  not  dependent  on  other 
hospital  infrastructure,  would  be  moved  towards 
the primary care hub, in addition to other primary 
care  functions.  It  would  be  desirable  that  this 
would  be  accompanied  by  a  cultural  shift  within 
the  population  to  visit  the  primary  care  facilities 
for  emergency  care,  encouraged  by  a  clear-cut 
organisational  and  financial  regulation  aiming  at 
avoiding  duplication  of  emergency 
services 
between the hospitals and the primary health hub.. 
Further investment is being sought for setting up of 
an integrated IT infrastructure which would bridge 
between primary and secondary care, together with 
public  and  private  care.  This  should  also 
increase  continuity  of  care  and, 
significantly 
consequently, 
increased 
engagement  of  the  public  with  primary  care 
services. 

hopes, 

one 

the 

The  density  of  physicians  in  Malta  is  slightly 
above the average density in the EU. In 2015, there 
were  379  practising  physicians  per  100,000 
inhabitants,  compared  to  344  in  EU.  The  number 
of  general  practitioners  is  also  slightly  above  the 
EU  average  (81  per  100,000  inhabitants  vs.  78  in 
the  EU).  The  number  of  nurses  per  100,000 
inhabitants (794 in 2015) is slightly below the EU 
average of 833.  

In  2015,  the  number  of  acute  care  beds  was 
relatively  low  with  324  compared  to  402  per 
100,000  inhabitants  in  the  EU.  With  this  capacity 
Malta  achieves  discharge  rates  of  15.3  per  100 
inhabitants (EU: 16.2). 

Treatment options, covered health services 

The  public  healthcare  system  offers  primary, 
secondary  and  tertiary  health  care  services.  The 
private sector acts as a complementary mechanism 
for health care coverage and is now also involved 
in  a  number  of  public-private  partnerships  related 
to healthcare provision. 

The  state  health  service  and  private  general 
practitioners  comprise  primary  health  care  in 

187 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Malta.  However,  the  two  systems  of  primary  care 
practice function independently of one another and 
the  latter  account  for  two-thirds  of  the  workload. 
Secondary and tertiary care is mainly provided by 
specialised  public  hospitals  of  varying  size  and 
function.  The  main  acute  general  services  are 
provided  by  one  main 
teaching  hospital 
incorporating  specialised,  ambulatory,  inpatient 
care  and  intensive  care  services.  A  new  oncology 
hospital was opened in September 2015 providing 
oncology  and  haematology  care  (270).  Malta  has 
become almost self-sufficient in terms of providing 
most tertiary care. When it comes to the provision 
of  highly  specialised  care,  there  are  cases  where 
this  is  provided  by  visiting  consultants  from 
specialised centres abroad who periodically attend 
local  hospitals  for  outpatient  consultations  and/or 
perform operations.  For certain conditions patients 
are sent overseas because it would neither be cost-
effective  nor  feasible  to  conduct  such  treatments 
locally.  

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

in 

GPs and specialists are paid on a salary basis when 
working for the NHS, while they receive a fee-for-
service 
the  private  sector.  The  collective 
agreement with the Medical Association of Malta, 
concluded  by  the  Government  in  2007,  includes 
job  plans  for  doctors  in  senior  posts  resulting  in 
better  pay  per  performance.  The  possibility  of 
exclusivity  contracts  with  the  NHS  has  been 
introduced, remunerated at a higher rate. Such job 
plans  and  exclusivity  contracts  have  also  been 
extended  to  various  levels  within  the  general 
practice  profession  with  the  revision  of  the  said 
collective  agreement  in  2013,  and  to  resident 
specialists in the 2017 agreement. 

Hospital budgets are defined by the government on 
a  prospective  global  budget  basis,  but  managers' 
decision-making  autonomy  assists  in  increasing 
hospital efficiency.  

The market for pharmaceutical products 

While  there  is  no  direct  product  price  regulation, 
there is a tendering system to control the prices of 

(270) Azzopardi-Muscat  N,  Buttigieg  S,  Calleja  N,  Merkur  S 
(2017).  Malta:  Health  system  review.  Health  Systems  in 
Transition, 2017; 19(1):1–137. 

188 

NHS covered medicines and a cost/benefit analysis 
is conducted prior to the inclusion of a medicine in 
the  Government  Formulary  List.  Authorities 
promote  the  rational  prescribing  of  physicians 
through 
treatment  guidelines.  Education  and 
information campaigns on the prescription and use 
of medicines are also organised from time to time. 
Within  the  NHS  prescribing  is  done  by  active 
ingredient  and  pharmacists  dispense  the  products 
procured by the public system  which  may  include 
generics.  For  private  patients  generic  substitution 
is voluntary.  

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

is 

The  use  of  health  technology  assessment  (HTA) 
for  decision-making  purposes 
increasing 
(including the development of treatment guidelines 
or  for defining  the  benefit  package  or  medicines). 
Since  HTA  requires  scientific  know-how  and 
administrative  capacity  which  for  a  small  country 
may  represent  a  significant  cost,  local  authorities 
are  engaging  with  initiatives  such  as  EUnetHTA. 
Authorities  are  encouraging  providers  to  set  up 
patient  care  protocols  to  enhance  safety  and 
clinical outcomes.  

eHealth, Electronic Health Record 

(e.g. 

clinical 

providers' 

eHealth  and  electronic  hospital  records  empower 
patients  by  introducing  access  to  their  medical 
data.  While  hospital  activity  data  is  available  in 
certain detail, even from parts of the private sector, 
there  are  still  information  gaps  in  a  number  of 
areas 
outcomes, 
appropriateness  of  processes,  outputs,  patient 
experiences  and  satisfaction).  Malta’s  National 
Health  System  Strategy  gives  particular  attention 
to  the  use  of  information  technology  and  the 
creation  of  a  healthcare  information  system.  The 
roll  out  of  myHealth  service  since  2012  allows 
patients  and  doctors  to  access  electronic  medical 
records through a nominated doctor of their choice 
and  an  eID,  thus  strengthening  continuity  of  care 
for patients. Developments are continuously being 
deployed  on  this  platform  connecting  more  and 
more  services  over  time.  A  number  of  eHealth 
initiatives 
underway  with 
currently 
procurement procedures already in place.   

are 

 
                                                           
Health care systems 

2.19. Malta 

Health;  Food 
reformulation;  Tobacco;  Food 
Safety;  Health  Enhancing  Physical  Activity 
(HEPA);  Antimicrobial  Resistance  and  Medical 
Genetics  services.  Additionally,  a  consultation 
document  on  a  Transgender  Healthcare  Strategy 
for Malta was launched in April 2018. At the same 
time, 
implementation  and 
evaluation of earlier strategies that are approaching 
the  end  of  their  lifespan  in  2020,  including  the 
Healthy  Weight  for  Life,  Non-communicable 
Disease, Tuberculosis Communicable Disease and 
Sexual Health strategies.  

is  ongoing 

there 

In  2018,  a  Social  Determinants  Unit  within  the 
Superintendence  of  Public  Health  was  set  up 
following  the  award  of  a  large  European  Social 
Funds  project.  The  work  carried  out  by  the  unit 
will 
training  and  policy 
implementation,  recognising  the  profound  impact 
of social determinants on health. 

research, 

include 

Health  promotion  and  disease  prevention 
policies 

health 

public 

include 

objectives 

The  central  government  has  set  a  number  of 
strongly 
relevant 
associated  with  the  risk  factors  and  pattern  of 
mortality  and  disease.  Priorities 
the 
prevention  and  control  of  obesity  and  diabetes 
through  a  national  platform  that  promotes  healthy 
diet  and  exercise,  decrease  smoking  and  alcohol 
use.  Authorities  also  see  the  education  and  sports 
sector  as  an 
the 
important  partner 
inclusion  of  health  promotion  and  disease 
prevention  in  school  curricula  and  the  training  of 
health  staff.  Such  public  health  objectives  are 
clearly  defined  in  strategy  and  policy  documents 
published  over  the  past  five  years,  including 
obesity,  diabetes,  non-communicable  disease, 
cancer and sexual health, among others. 

through 

Recently 
reforms  

legislated  and/or  planned  policy 

Healthcare services 

Recent policy response 

Health promotion and disease prevention  

initiatives  are  key 

The  National  Health  System  Strategy  (NHSS) 
recognised  that  health  promotion  and  disease 
improving 
prevention 
population 
the 
sustainability of the health care system in the long 
term.  A  number  of  sectoral  strategies  have  been 
launched since 2014, including: 

and  maintaining 

health 

to 

•  a  new  National  Cancer  Plan  (2017-2021)  that 
builds  on  a  previous  National  Cancer  Plan 
(2011-2015); 

•  a Diabetes strategy (2015-2020); 

•  a Hepatitis strategy (2018-2025); 

•  a national Breastfeeding Policy (2015-2020);  

•  a  Food  and  Nutrition  Policy  and  Action  Plan 

(2015-2020); 

•  a Healthy Lifestyle in Schools: Healthy Eating 

and Physical Activity Policy (2015). 

Other  strategies  are  at  an  advanced  stage  of 
development,  including  those  related  to  Mental 

Since  the  launch  of  the  NHSS,  new  healthcare 
services have been introduced, whereas established 
services  which  have  been  operating  successfully 
have been expanded.  

Screening:  Since  2014  there  has  been  a  gradual 
expansion  of 
the  National  Cancer  Screening 
Programmes. 

Primary  care:  The  relocation  of  services  from 
hospital  to  primary  care  is  key  to  long-term 
sustainability  of  the  health  care  system.  This  is 
being supported by investment in various ongoing 
infrastructural  projects.  These  capital  projects  are 
being  accompanied  by  a  restructuring  of  elective 
care  services  away  from  the  acute  hospital,  with 
the  aim  of  placing  more  of  these  interventions 
within  the  community  setting.  The  paradigm  shift 
in care from one of hospital medical professionals’ 
dominance  to  the  inclusion  of  highly  qualified 
health  care  professionals  across  disciplines  in 
primary  and  chronic  care  settings  has  been 
evidenced  in  diabetes  care  in  Malta,  as  well  as 
other  aspects  of  chronic  illness.  A  range  of 

189 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

specialist  clinics  are  now  organised  through  the 
primary health care centres (271).  

Secondary and tertiary care: Several initiatives in 
the  area  of 
tertiary  care 
secondary  and 
implemented  since  2014  include  improvement  the 
patient care experience. 

recruitment, 

Health  workforce 
training  and 
specialisation:  Efforts  at  healthcare  workforce 
capacity  building  have  been  largely  successful, 
with the number of physicians increasing from 346 
per  100,000  in  2013  to  382  per  100,000  in  2015; 
and the number of nurses increasing from 744 per 
100,000 in 2013 to 840 per 100,000 in 2015 (273).  

New  model  for  capital  investment  in  hospitals:  A 
public-private  partnership  between 
the  public 
healthcare sector and an international provider was 
announced in 2016.  

Equitable access and patient rights: Patient rights 
and  responsibilities  have  been  enshrined  in  a 
National  Patients’  Charter,  launched  in  2016, 
which  sets  out  key  rights  and  responsibilities  of 
people  receiving  care  within  the  Maltese  health 
system  and  provides  information  that  underpins 
their  right  to  safe  and  high-quality  care.  Several 
initiatives to enhance provision of equitable access 
to healthcare have been implemented. The rights of 
marginalised  groups  and  minorities  were  also 
given specific attention. 

reducing  waiting 

Ensuring quality of care: Concern about excessive 
waiting 
time  for  outpatient  appointments  or 
inpatient (e.g. elective surgical) care – which may 
negatively  impact  patient  health  –  has  led  to 
initiatives  aimed  at 
lists, 
including  a  ‘fast  tracking’  system  (guided  by  the 
newly established position of ‘fast-track nurse’) for 
colonoscopy  patients.  Other  initiatives  have  also 
contributed to a reduction in waiting list times for 
various services, especially for surgery. There was 
also  an  increase  in  acute  care  hospital  beds  from 
255  per  100,000  in  2013  to  324  per  100,000  in 
2015 (272).  There  are  also  agreements  for  specific 
surgical  procedures  with  the  private  sector  to 
increase surgical capacity and bring  waiting times 
in  line  with  the  requirements  of  the  Charter  of 
Patient  Rights.  The  efficient  sourcing  and  supply 
of  medicines is a particular concern for the health 
system.  Business  process  re-engineering  and  new 
IT  infrastructure  has  enabled  the  eradication  of 
out-of-stock situations on a number of medicines. 

(271) Source: 

https://deputyprimeminister.gov.mt/en/phc/Pages/Home.as
p. 

infrastructures  within 

IT systems: EU and national investment in IT and 
e-health 
the  healthcare 
system have increased in recent years. The national 
e-health  programme 
includes  various  projects 
planned  for  the  period  2017–  2021,  such  as  a 
‘converge’ project, that aims to establish a unified 
e-health  infrastructure,  pulling  together  existing 
vertical  systems, 
thus  facilitating  a  national 
electronic health record and better intelligence for 
informing  policy  decisions; 
introduction  of 
electronic card scheme and electronic prescriptions 
(currently  being  piloted)  to  manage  patients’ 
medicines  entitlement;  a  revised  Digital  Health 
strategy  is  currently  at  an  advanced  stage  of 
development.  

Challenges 

The analysis shows that a number of reforms have 
been  implemented  in  recent  years  notably  to 
reduce  waiting  times  for  elective  surgery  and  to 
establish  public  health  priorities.  The  main 
challenges  for  the  Maltese  health  care  system  are 
as follows:  

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the increasing health care expenditure over the 
coming  decades.  To  evaluate  whether  the 
ongoing  strategy  of  health  system  reform  is 
sufficient  to  cope  with  the  challenge  of  future 
spending growth. 

•  To  monitor  health  systems  performance  and 

enhance its functioning as needed.  

•  To  continue  to  include  more  elements  of 
activity-related  payment  in  primary  care  and 
specialist outpatient care. 

•  To continue to enhance primary care provision. 
To make the referral system more effective and 
improve care coordination.  

(272) Malta HSPA 2018. 

(273) Malta HSPA; data from Eurostat. 

190 

 
 
                                                           
                                                           
•  To investigate if additional measures regarding 
price regulation, expenditure control, and good 
prescribing  practices  are  needed  to  ensure  a 
more cost-effective use of medicines. 

•  To  improve  data  collection  on  primary  and 
outpatient  care  utilisation.  To  continue  efforts 
to improve the IT infrastructure and sustain the 
use  of  health 
in 
decision-making.  

technology  assessment 

•  To  further  enhance  health  promotion  and 
disease  prevention  activities  i.e.  promoting 
healthy  life  styles  and  disease  screening  given 
the recent pattern of risk factors (diet, smoking, 
alcohol, obesity) in various settings (at work, in 
school). 

•  To  ensure  acceptable  standards  in  public-
robust 
private  partnership  hospitals.  A 
is 
legislative  and  governance 
needed 
to  ensure  careful  monitoring  and 
evaluation of this new arrangement. This would 
allow the regulator to assess the quality of care 
and  value  for  money  being  provided  to  the 
population. 

framework 

Health care systems 

2.19. Malta 

191 

 
1
9
2

Table 2.19.1:  Statistical Annex – Malta 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

5

21.9

3.1

:

2006

5

21.7

1.5

2.8

2007

6

22.5

3.6

-3.6

2008

6

22.1

2.7

-1.3

2009

6

20.6

-3.2

-1.1

2010

7

21.3

3.0

2.6

2011

7

21.1

0.9

16.7

2005

2006

2007

2008

2009

2010

2011

9.0

7.1

1.9

9.1

7.4

1.8

8.5

7.1

1.4

8.2

7.6

0.5

8.3

7.9

0.5

8.3

7.9

0.4

9.6

9.1

0.5

2012

7

21.3

1.7

5.4

2012

10.0

9.4

0.5

2013

8

21.5

3.2

2.6

2014

8

22.5

5.9

4.4

2015

9

24.2

7.3

:

2013

2014

2015

9.9

9.3

0.6

9.8

9.1

0.7

1,537

1,621

1,609

1,637

1,663

1,768

2,114

2,282

2,391

2,566

5.2

3.4

895

1.89

58.2

15.0

100.0

28.8

5.3

3.5

941

1.76

58.1

13.9

100.0

29.6

4.7

3.4

900

1.38

56.0

13.6

100.0

31.1

4.5

4.0

896

0.45

54.8

12.1

100.0

32.8

4.5

4.2

899

0.32

54.1

13.5

100.0

31.9

4.5

4.3

968

0.27

54.8

13.6

100.0

32.9

5.2

4.9

5.4

5.1

5.5

5.0

1,141

1,243

1,320

0.30

54.0

14.0

100.0

30.2

0.37

54.5

14.2

100.0

29.9

0.46

55.2

15.1

:

30.3

6.4

5.8

1,675

-0.20

57.5

13.8

:

28.9

:

:

:

:

:

:

:

:

:

14.1

100.0

:

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

0.4

81.4

77.3

70.4

68.6

78

5.4

0.4

82.0

77.0

69.5

68.3

80

3.7

0.4

82.2

77.5

71.1

69.2

76

6.6

0.4

82.3

77.1

72.1

68.8

70

8.5

0.4

82.7

77.9

71.0

69.4

72

5.5

0.4

83.6

79.3

71.3

70.1

56

5.6

0.4

83.0

78.6

70.7

69.9

158

6.5

0.4

83.0

78.6

72.2

71.5

151

5.3

0.4

84.0

79.6

72.7

71.6

125

6.7

0.4

84.2

79.8

74.3

72.3

123

5.0

0.4

84.0

79.7

74.6

72.6

110

5.8

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

1.3

1.4

1.4

1.4

1.5

1.5

1.9

1.8

1.8

1.6

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

0.4

0.4

0.4

0.4

0.4

0.4

0.5

0.4

0.4

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

1.8

0.2

0.7

0.4

0.4

0.2

0.8

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

EU- latest national data

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,745

2,895

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

r

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2.19.2:  Statistical Annex - continued – Malta 

Composition of total as % of total current health expenditure

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

18.1%

19.0%

19.3%

18.7%

18.7%

18.9%

20.4%

18.9%

19.2%

18.2%

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

10.5%

11.2%

10.8%

9.9%

10.0%

9.1%

9.7%

7.3%

7.6%

:

:

:

2005

:

:

:

:

:

:

6.4

:

:

:

2006

0.74

0.5

2.5

0.0

:

:

8.8

:

:

:

2007

0.73

0.7

2.7

0.0

:

:

7.5

:

:

:

2008

0.73

1.0

3.2

0.0

22.9

19.2

7.1

:

:

:

2009

0.72

1.0

3.1

0.2

:

:

7.4

:

:

:

2010

0.72

1.0

3.1

0.2

:

:

7.9

:

:

:

2011

0.48

1.0

2.9

0.2

:

:

6.9

:

:

:

2012

0.72

1.0

2.9

0.2

:

:

7.7

:

:

:

2013

0.94

0.9

1.9

0.5

:

:

8.6

:

:

:

31.5%

2.9%

11.9%

6.1%

7.1%

2.6%

13.6%

2014

1.17

0.9

2.1

0.5

25.2

18.9

8.5

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2015

1.16

0.9

1.9

0.5

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

:

550

:

690

2005

2.6

8

:

561

:

617

2006

3.6

8

:

584

:

608

2007

2.6

7

:

643

72

559

2008

2.4

9

304

618

66

553

2009

2.5

11

308

647

67

546

317

669

76

535

329

669

80

528

346

702

80

523

366

798

81

524

379

794

81

518

2010

2011

2012

2013

2014

2015

:

12

:

14

:

14

:

14

:

15

:

15

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

3,461

3,458

3,427

3,578

3,957

6,759

7,145

7,639

7,763

8,454

8,612

6,362

6,584

87.5

4.7

30.5

2016

5.6

5.6

2016

0.4

89.6

5.3

:

2020

6.0

6.2

2020

0.5

80.4

4.8

31.8

2025

6.4

6.9

2025

0.5

78.0

4.9

27.4

2030

6.8

7.5

2030

0.5

82.3

6.6

26.6

2035

7.1

8.1

2035

0.5

81.5

6.8

35.4

2040

7.3

8.5

2040

0.5

83.2

7.6

34.4

2045

7.4

8.7

2045

0.5

83.2

7.8

35.2

2050

7.5

8.9

2050

0.5

80.7

8.6

35.7

2055

7.7

9.1

2055

0.5

81.8

7.9

36.6

2060

7.8

9.3

2060

0.5

81.7

8.0

37.6

2065

8.1

9.6

2065

0.5

77.1

8.0

28.0

2070

8.3

9.9

2070

0.5

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Malta

2.7

4.3

EU

0.9

1.6

Change 2016-2070, in %

Malta

19.9

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

H
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a

1
9
3

2
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1
9
.

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2.20. THE NETHERLANDS 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  country  statistics:  GDP,  GDP  per 
capita; population 

GDP  per  capita  (35,996  PPS)  in  the  Netherlands 
was  well  above  the  EU  average  (29,610  PPS)  in 
2015, with an overall increase since 2005 (34,415 
PPS).  Population  stood  at  17.0  million  people  in 
2016  and  has  been  increasing  throughout  the  last 
decade. According to projections, the increase will 
continue, reaching 19.5 million in 2070.  

Total and public expenditure on health  

Total  expenditure  on  health  as  a  percentage  of 
GDP  (10.6%  in  2015)  has  increased  since  2005, 
when  the  share  was  9.4%.  This  level  is  slightly 
above the EU-average (10.2% GDP in 2015). The 
same  applies  to  public  expenditure  on  health  as  a 
percentage  of  GDP,  recorded  as  8.5%,  which  is 
higher  than  the  EU  average  for  the  same  period 
(8.0%  in  2015).  Total  (3,836  PPS  in  2015)  and 
public (3,097 PPS in 2015) per capita expenditure 
in  2015  were  also  above  the  EU  average  in  the 
same year (respectively 3,305 PPS and 2,609 PPS). 
Looking at health care without long-term care (274) 
reverses  the  picture,  with  spending  going  below 
the EU average (5.9% vs 6.8% in 2015). 

Expenditure projections and fiscal sustainability  

Public  expenditure  on  health  care  is  projected  to 
increase  by  0.8  pps  of  GDP  ("AWG  reference 
scenario")  (275),  broadly  in  line  with  the  projected 
valued  of  0.9  pps  for  the  EU.  When  taking  into 
account the impact of non-demographic drivers on 
future spending growth ("AWG risk scenario"), the 
increase  reaches  1.4  pps  of  GDP  from  now  till 
2070,  slightly  below  the  EU  average  of  1.6  pps. 
The  long-term  fiscal  sustainability  risk  indicator 
S2,  which  shows  the  adjustment  effort  needed  to 
ensure that the debt-to-GDP ratio is not on an ever-
increasing  path,  is  at  3.0%  of  GDP.  In  the  long 
term,  the  Netherlands  therefore  appears  to  face 
is 
sustainability 
medium 

risks.  This 

fiscal 

(274) To  derive  this  number,  the  aggregate  HC.3  is  subtracted 

from total health spending. 
(275) The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

194 

primarily  related  to  the  projected  increase  in  the 
costs  of  ageing  where  in  particular  the  projected 
increase in long-term care costs contribute 2.0% of 
GDP to the indicator (276). 

Health status  

Whereas life expectancy for women in 2015 was in 
line with the average with 83.2 years (83.3 for the 
EU  in  the  same  year),  men  live  longer  in  the 
Netherlands  than  in  the  EU  as  a  whole:  79.9  vs 
77.9  in  2015.  Notably,  healthy  life  years  have 
decreased  for  Dutch  women,  from  63.5  years  in 
2005, 
the 
Netherlands  under  the  EU  average.  However  this 
has  methodological  reasons  (277).  For  men  the 
picture  is  slightly  better.  Years  spent  in  good 
health  are  still  less  than  in  2005  (65.4),  but  are 
with 61.1 closer to the EU average of 61.6 in 2015 
(278).  

in  2015,  which  brings 

to  57.2 

Data  show  an  increase  in  the  proportion  of  the 
population which is obese (from 10.7% in 2005 to 
12.8% in 2015). There has been a steady reduction 
of the proportion of the population that is a regular 
smoker,  going  from  25.3%  in  2005  to  19%  in 
2015,  under  the  EU  average  (20.9).  Alcohol 
consumption  is  decreasing  too  and  was  in  2015 
with 8 litres under the EU average (10.2 litre). 

System characteristics 

System financing 

The  healthcare  system  in  the  Netherlands  is 
insurance  based.  In  2015,  80.7%  of  total  health 
expenditure  funding  was  generated  from  public 
sources. 

Revenue collection mechanism 

Health insurance organisations operating under the 
health insurance act, have the obligation to accept 

(276) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(277) The definition of Healthy Life Years used in the European 
Survey on  Income and Living Conditions is different than 
that  of  Statistics  Netherlands  (CBS).  CBS  and  the  OECD 
instead  show  that  the  percentage  of  women  older  than  65 
who  feel  healthy  or  very  healthy  is  very  stable  in  the 
Netherlands. 

(278) Data  on  life  expectancy  and healthy  life  years  is  from  the 

Eurostat database. 

 
                                                           
 
                                                           
Health care systems 

2.20. The Netherlands 

in 

alternative 

publish  comparative  standardised  information  on 
premiums,  benefits,  performance 
claim 
processing  and  patient  satisfaction.  The  annual 
switching  rate  of  the  insured  between  funds  (the 
insured  can  decide  before  the  beginning  of  each 
calendar  year  whether  they  want  to  switch  health 
care  insurer)  is  between  6%  and  7% (279).  As  a 
issue  characterising  patients  choosing 
general 
between 
information 
providers, 
asymmetries, technical complexity and uncertainty 
as  to  future  needs  make  switching  between  funds 
more  difficult.  In  addition,  four  insurers  account 
for  about  90%  of  the  market.  Whether  this 
concentration  in  the  insurance  market  reduces  the 
expected benefits of competition between insurers 
is  unclear.  It  may  also  increase  the  bargaining 
insurers  over  care  providers  and 
power  of 
pharmaceutical companies which may lead to cost-
savings.  

expenditure 

on 
insurance 

total 
and  health 

health 
and 
Public 
administration 
a 
as 
percentage  of  GDP  were  broadly  in  line  with  the 
EU average in 2015, though slightly above (0.33% 
vs. 0.26% for the EU for public and 0.41 vs. 0.38% 
for the EU for total)  which is probably due to the 
fact  that  the  system  is  based  on  multiple  insurers. 
The  higher  than  average  can  be  explained  by  the 
supervise  costs,  prices,  quality, 
efforts 
contractual  terms  and  market  developments  in  the 
health market as well as ensuring risk-equalisation 
and  prevent  risk-selection,  which  are  necessary  in 
the context of competition in health insurance (280). 

to 

is 

de 

facto 

The  current  healthcare  system  is  open-ended, 
although 
the  Cabinet  uses  annual  budget 
projections for public spending. However, if faced 
with  overspending,  the  Ministry  in  charge  has  the 
possibility to resort to a macro budgetary cap tool, 
which 
a 
clawback/payback mechanism, whereby the excess 
spending  needs  to  be  returned  by  providers.  The 
most  influential  decisions  are  taken  at  the  start  of 
the cabinet; in the (max. 4) years the cabinet is in 
power, adjustments are made to the path set out at 
the  start.  Note,  though,  that  for  some  treatments 
the government still defines budgets and for other 
health  care  provision  the  government  decides  on 

equivalent 

to 

to 

is  not  allowed 

every  citizen  requesting  a  basic  health  insurance. 
In  addition,  risk  selection  is  forbidden,  i.e.  the 
insurer 
request  different 
premiums  from  different  clients  applying  for  the 
same  policy  and  they  are  obliged  to  accept  all 
enrolees for all policies. As the cost profiles of the 
individual insured differ, a system has been set up 
to  compensate  insurers  for  those  cost  differences 
(risk equalisation scheme), to create a level playing 
field for all insurers. 

their 

income.  This  contribution 

The  funding  of  statutory  health  insurance  comes 
from  different  sources.  Through  their  employer, 
citizens  pay  a  tax-based  insurance  contribution, 
based  on 
is 
distributed  to  the  different  health  insurers  on  the 
basis  of  the  above  described risk  equalisation  and 
counts for roughly 50% of the total revenue of the 
health  insurers).  The  distribution  is  based  on  the 
risk  profile  of  the  population  in  each  health 
insurance organisation. Indicators such as age, sex, 
medication use, healthcare use and socio-economic 
status  of  the  insured  play  a  role  in  the  risk 
equalisation  scheme.  A  good  functioning  risk 
equalisation scheme is vital, to prevent insurers to 
select  citizens  with  a  specific  risk  profile.  The 
Dutch  risk  equalisation  scheme  has  both  ex  ante 
and ex post risk equalisation mechanism, although 
ex-post measures are being cancelled. That means 
that insurers will run a bigger risk, but a lack of ex-
post  measures  forms  an  incentive  for  insurers  to 
purchase  healthcare  more  effectively.  In  addition, 
health  insurance  organisations  collect  a  nominal 
premium  from  each  person  insured.  The  level  of 
this  premium  differs  between  health  insurance 
organisations  depending  on  the  policy  of  the 
organisation, 
their 
reserves  etc.  Further,  as  of  2016,  every  insured 
person over age 18 must pay an annual deductible 
of  €385  ($465)  for  health  care  costs,  including 
costs of hospital admission and prescription drugs 
but excluding some services, such as GP visits. An 
additional source of funding that insurers receive is 
a state contribution for the insured under the age of 
18  (10%  of  total  revenue).  Altogether,  nominal 
premium, deductible and 18-  contribution account 
for the remaining 50%. 

internal  organisation, 

their 

Insurers  collect  insurance  premiums  and  the  risk-
equalisation scheme between insurers applies to all 
funds for the basic benefit package. The content of 
the  basic  benefits  package  is  decided  on  by  the 
Ministry  of  Health.  Private  and  public  authorities 

(279)

http://www.vektis.nl/downloads/Publicaties/2016/Zo

rgthermometer%20nr17/#5/z. 

(280) A  system  based  on  "regulated"  competition  inherently 

needs more regulatory capacity. 

195 

 
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

infrastructure 

to  decide  on 

the  remuneration  methods  for  providers  or  sets 
prices for treatments. For the major part individual 
insurers  negotiate  prices  with  health  care 
providers.  Insurers  also  can  negotiate  about 
resource  allocation  /  financing  between  sectors  of 
care  (primary  care  services,  specialists  outpatient 
care,  hospitals  current  spending)  and  for  private 
and 
hospitals 
equipment. Almost all hospitals in the Netherlands 
are private, but not for profit. Since the healthcare 
system is open-ended, total health expenditure may 
exceed  the  budget-projections  (281).  However,  in 
the  recent  years  expected  growth  of  health 
expenditure  turned  out  to  be  lower  instead,  but 
according to the Netherlands Bureau for Economic 
Policy  Analysis  (CPB)  latest  projections,  health 
care  expenditure  is  expected  to  increase  over  the 
period  2018-2021(282).  Possible  ways  to  finance 
the  expected  increase  of  health  expenditure  are 
increasing  employer  taxes  and  health  insurance 
premiums,  or  increasing  cost-sharing  mechanisms 
or removing increased interventions from the basic 
benefit package.  

organisation: 

of 
Administrative 
government, levels and types of social security 
settings 
involved,  other 
institutions 

involved,  Ministries 

levels 

As mentioned above, all health insurers are obliged 
to  accept  all  applicants  and  to  charge  each 
individual applicant the same nominal premium for 
the  same  policy (283).    For  groups,  the  premium 
may  differ.  Applicants  are  free  to  choose  an 
insurer.  A  Health  Insurance  Income  Support 
scheme  provides  means-tested  subsidies  to  help 
those below a certain income threshold (about 60% 
of  the  households  receive  such  a  subsidy)  to  pay 
for their insurance premiums ( 284). 

(281) According to the OECD, The Netherlands scores 2 out of 6 
in  the  OECD  scoreboard  due  to  the  not  very  stringent 
budget controls. 

(282) In  these  projections,  health  care  expenditure  is  rising  as  a 
percentage of GDP as the projection is based on the long-
term trend excluding policy measures and on demographic 
developments. 

(283) The voluntary deductible can then influence the price paid 
for  a  specific  policy,  even  though  the  benefits  package  is 
the same. 

(284) The  law  on  the  health  insurance  income  support  scheme 
states  that  no  household  should  pay  more  on  their  health 
care  premiums  paid to  insurers  than a  fixed percentage  of 
their  income.  Any  costs  for  health  insurance  premiums 
above  this  percentage  are  compensated  through  the  health 

196 

Coverage (population) 

Since  2006,  a  mandatory  universal  health 
insurance  scheme  operated  by  private  health 
insurance  funds  (for  profit  and  not-for-profit) 
provides  100%  population  coverage, 
through 
contracts with providers. 

Treatment options, covered health services 

The basic (but comprehensive) benefits package is 
fixed  by  law.  Health  insurers  set  a  nominal 
premium 
community-rated 
corresponding to that package. 

insurance 

Role  of  private  insurance  and  out  of  pocket 
co-payments 

In  2015,  private  health  expenditure  was  about 
19.3%  of  total  health  expenditure,  slightly  below 
the EU average for the same year (21.6%). Out-of-
pocket expenditure (285) was 12.3% of total health 
in  2015.  Out-of-pocket  payments 
expenditure 
apply 
limited. 
to  certain  services  but  are 
Eyeglasses,  contact  lenses  and  certain  dental 
prostheses,  for  example,  are  not  covered  by  the 
basic  benefits  package.  In  2008,  the  government 
introduced  an  annual  mandatory  deductible  of 
€150  for  insured  people  18  and  over  (which  has 
since  been  increased  to  €385  in  2017) (286).  GP 
services (287)  are  exempted  from  the  mandatory 
deductible,  as  a  means  to  encourage  primary  care 
services  vis-à-vis  specialist  consultations  and 
hospital  care  (indeed,  to  be  able  to  go  to  a 
specialist,  one  needs  a  referral  from  the  GP).  In 
addition,  this  exemption  is  intended  not  create  a 
financial barrier for individuals to access this type 
of primary care, thereby supporting the role of the 
GP  as  gatekeeper  in  the  Dutch  healthcare  system. 
Some  services  have  recently  been  excluded  from 
the basic package of care,  while others have been 

care  allowance.  In  2013  approximately  60%  received  an 
allowance. 

(285) Note that the €150 mandatory deductible is not included in 
the 5.7% out-of-pocket-payments. In 2010 the total amount 
of OOP caused by the mandatory deductible is nearly €1.5 
billion. The actual amount of OOP is therefore higher than 
the 5.7% reported here. 

(286) By law, the deductible is periodically adjusted in line with 
an 
for  health  expenditures.  Households  are 
compensated  for  the  growth  of  the  deductible  with  a  tax 
subsidy mentioned above. 

index 

(287) Other  services  such  as  maternal  care,  district  nursing  and 
healthcare  for  children  up  to  the  age  of  18  are  also 
exempted. 

 
                                                           
                                                                                   
Health care systems 

2.20. The Netherlands 

specialist  and  hospital  care.  In  addition,  GP 
services are free. Free choice of GP is allowed but 
given  the  number  of  GPs  and  their  capacity 
constraints,  choice  may  be  limited  in  some  areas. 
Free  choice  of  a  specialist  or  hospital  is  also 
allowed  (291).  Moreover,  authorities  have  planned 
to  introduce  preconditions  for  and  stimulate  the 
usage  of  ICT  and  e-  health  solutions  to  allow  for 
electronic  exchange  of  medical  data  (e.g.  e-
prescribing  or  e-appointments  and  e-health 
records), to support and render the referral system 
and  care  coordination  more  effective,  reduce 
medical errors and increase cost-efficiency. 

The  number  of  acute  care  beds  per  100  000 
inhabitants (518 in 2015, latest available year) has 
decreased  over  time  (from  690  in  2005),  though 
remaining  above  the  EU  average  until  2015  (407 
and 402 for the EU in 2013 and 2015 respectively). 
Hospitals  have  autonomy  to  recruit  medical  staff 
their 
and  other  health  professionals 
remuneration  level,  although  a  pay  scale  is  set  at 
national  level  in  a  collective  labour  agreement  by 
employers and trade unions. 

and 

Pricing,  purchasing  and  contracting  of 
healthcare 
remuneration 
mechanisms 

services 

and 

GPs are paid a mix of a capitation (€58 per patient 
minimum, with increments for age and deprivation 
index) and a consultation fee (€9) (292). Specialists 
are paid either a salary or a fee for service or a mix 
of  the  two.  GPs  are  eligible  to  receive  bonuses 
regarding  their  activity  or  performance;  these 
bonuses  may  relate  to  all  kinds  of  agreements 
between 
the 
the 
prescription of generics. 

the  GP,  e.g. 

insurer  and 

added (288).  About  84%  of  the  population  buy 
supplementary  private 
this 
figure  seems  to  be  declining  over  time  (289).  It  is 
possible to reinsure the mandatory deductible. 

insurance, 

thought 

Types of providers, referral systems and patient 
choice 

Provision is mostly private but publicly regulated. 
Primary  care  is  provided  by  independent  general 
practitioners (GPs), often working in private group 
(290).  Outpatient  specialist  care 
is 
practices 
in  outpatient  hospital  departments. 
provided 
Almost  all  hospitals  are  non-profits  while 
university  hospitals  are  public.  Providers  have  to 
establish contracts with health insurers. 

The  number  of  practising  physicians  per  100  000 
inhabitants  (347  in  2015)  is  in  line  with  the  EU 
average  (344),  showing  a  gradual  increase  since 
2005  (271).  The  number  of  GPs  per  100  000 
inhabitants  (82  in  2015)  is  slightly  above  the  EU 
average  (78  in  2015),  with  a  consistent  increase 
over the past decade (66 in 2005). The number of 
nurses  per  100  000  inhabitants  (1,047  in  2015)  is 
well  above  the  EU  average  (833  in  2015)  though 
recording  a  slight  decline  compared  with  2013 
(1,210).  This  fits  with  authorities'  objective,  in 
recent  years,  to  increase  the  supply  of  staff.  The 
numbers  above  suggest  that  the  skill  mix  is 
improving in the direction of a more primary care 
oriented  provision  (which  the  authorities  wish  to 
continue to pursue). Staff supply is regulated: there 
are  quotas  for  medical  students  and  for  publicly 
financed training for  medical specialties, although 
there  is  no  regulation  in  terms  of  physician 
is  some 
location.  Perhaps  as  a  result 
some 
in 
concentration 
regions/areas and staff shortages in others.  

of  medical 

there 

staff 

Authorities  have  made  strong  efforts 
to  use 
primary care vis-à-vis specialist and hospital care. 
Residents have to register with a GP and there is a 
compulsory  referral  system  from  primary  care  to 
specialist  doctors  i.e.  GPs  act  like  gatekeepers  to 

Hospitals  are  paid  on  the  basis  of  DBC’s,  the 
descriptions  of  which  are  set  by  the  Dutch 
Healthcare  Authority  (NZa),  and  the  prices  are 
negotiated by the hospital and the insurer. A small 
part (30%) is fixed and set by NZa,  whereas 70% 
is  set  through  negotiations  between  insurers  and 

(288) Some  of  those  removed  include  examples  such  as  special 
chairs,  allergen-free  mattress  covers,  medication  for 
erectile  malfunction,  whereas  methadone  treatment  and 
treatment of dyslexia for children have been added to those 
included. 

(291) Indeed,  according  to  the  OECD,  the  level  of  choice  of 
provider in The Netherlands has a score of about 3 out of 6, 
while gatekeeping scores 6 out of 6. 

(292) Note that there are also salaried GPs, most of them working 

for another GP. 

(289)

https://www.nza.nl/1048076/1048181/Marktscan_Z

orgverzekeringsmarkt_2015.pdf, page 51. 

(290) There are also a not insignificant number of salaried GPs. 

197 

 
                                                           
 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

hospitals.  Hospital  and  mental  healthcare  fees  are 
based on Diagnosis Treatment Combinations (293).  

looking  at  hospital  activity, 

inpatient 
When 
discharges, based on available figures (2012 latest) 
are lower than the EU average (11 in 2012 vs. 16 
in 2013, and 16 in 2015 for the EU) but day case 
the  contrary,  are  significantly 
discharges,  on 
higher, i.e. more than double, than the EU average 
(16,201  in  2012  vs.  7,143  in  2013  in  the  EU  and 
7,635 
in  2015).  The  proportion  of  surgical 
procedures  conducted  as  day  cases  (60%  in  2012, 
latest  available  figure)  appears  to  be  considerably 
higher  than  the  EU  average  (30.9%  in  2013  and 
32.3%  in  2015).  Hospital  average  length  of  stay 
seems  to  be  below  the  EU  average  (7.6  days  in 
is 
latest 
2015), 
considerably outdated (6.6 in 2006 to be compared 
with  the  EU  average  of  8.0  in  2009).  All  these 
figures  point  to  a  high  hospital  throughput  and 
high hospital efficiency (294). 

reported  value 

thought  he 

The market for pharmaceutical products 

Since the 1980s, the authorities have implemented 
a  number  of  policies  to  control  expenditure  on 
pharmaceuticals. Although pricing is free there is a 
maximum  price  (295)  set  for  each  product  with  a 
given  active  substance,  strength  and  formulation 
which  is  based  on  the  prices  of  medicines  in  four 
reference  countries  (BE,  DE,  UK  and  FR)  the  so 
called external reference pricing, and (since 2004) 
price  negotiations  between  healthcare  insurers, 
pharmacists  and  producers (296). 
  Externally 
dispensed  pharmaceutical:  the  authorities  also 
apply  internal  reference  pricing  (297),  whereby  the 
maximum  reimbursement  level  of  a  medicine  is  a 
weighted  average  price  of  the  products  in  each 
cluster  of  products  that  a  medicine  belongs  to, 
using  1998  prices.  New  products  introduced  after 
1998 can get a premium price if the  manufacturer 
demonstrates  cost-effective  added  value,  and  the 

(293) The  OECD  score  for  remuneration  incentives  to  raise  the 
volume  of  care  in  The  Netherlands  is  therefore  about  3.5 
out  of  6  as  a  result  of  the  mix  remuneration  systems  for 
physicians and hospitals. 

(294) Though  this  may  be  partly  due  to  the  broad  coverage  for 

long-term care. 

(295) The system was laid down in the Pricing Act of 1996. 
(296) A  maximum  price  is  only  set  for  pharmaceuticals  within 
the  GVS.  For  pharmaceuticals  which  are  used  by  medical 
specialists  (usually  for 
is  no 
maximum price. 

inpatient  care), 

there 

(297) The reference pricing system, introduced in 1993, is called 

the Medicine Reimbursement System (GVS). 

198 

price  of  this  new  product  becomes  the  maximum 
reimbursement  level  for  all  the  products  that 
followed and are added to the initial drug to form a 
cluster.  Clusters  of  pharmaceuticals  define 
"therapeutic  equivalents",  where  pharmaceuticals 
are  equivalent  if  they  have  comparable  clinical 
characteristics,  a  more  or  less  similar  indication, 
route of administration, targeted age group and for 
which no clinically relevant differences in income 
apply.  For  externally  dispensed  pharmaceutical: 
only pharmaceuticals included in GVS are covered 
by  basic  health 
though 
insurance 
-  even 
sometimes  be  obtained 
reimbursement  may 
through complementary voluntary health insurance 
(298). 

The  authorities  promote  rational  prescribing  of 
physicians  by  stimulating  the  development  of 
treatment  guidelines,  set  up  by  medical  experts, 
and the monitoring of prescribing behaviour. They 
also promote education and information campaigns 
on  the  prescription  and  use  of  medicines  and 
regional  platforms  of  physicians  and  pharmacists 
exist  to discuss the use of  medicines and improve 
its  effective  use.  Some  insurers  have  started  to 
offer financial incentives to GPs based on efficient 
prescription of some drugs. Prescribing is done by 
active  ingredient  as  part  of  medical  training.  A 
number  of  insurers  initiated  a  policy  of  selective 
contracting  of  generic  medicines;  as  of  the  1st  of 
July  2008,  these  insurers  reimburse  only  the 
cheapest  generic  product  (more  precisely,  those 
that  are  at  the  same  price  level  as  the  cheapest 
pharmaceutical  plus  5%)  within  a  number  of  big-
selling  therapeutic  classes.  Producers  of  generics 
responded  by  substantially  lowering  their  generic 
list prices. Insurers and their enrolees benefit from 
lose  some 
the  system,  but  pharmacists  may 
revenues  as  a  result  of  diminishing  discounts  and 
rebates provided by generic producers. As a result 
of these policies, the average prices of prescription 
medication have dropped considerably in the past. 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

The National Institute for Health Research and the 
Health  Care  Insurance  Board  (ZiNL)  conduct  and 

(298) Note  that  free  choice  is not  excluded;  if  patients  opt  for  a 
more  expensive  pharmaceutical  in  the  same  group,  they 
have to pay the excess themselves, except if the physician 
decides  that  the  more  expensive  one  is  clinically  relevant 
for that particular individual case. 

 
                                                           
                                                           
It 

health 

system. 

is  used 

information 

to  determine 

gather 
technology 
on 
assessment  (HTA).  Based  on  this  HTA,  the  ZiNL 
advises the central government on what should be 
covered  under  the  basic  benefit  package  of  care 
and  the  extent  of  reimbursement  /cost-sharing  in 
the 
the 
reimbursement  of  medicines  and  applied  to  new 
high-tech  equipment,  while  prices  are  mainly  set 
by the healthcare authority (NZa). The HTA helps 
defining  clinical  guidelines  which  are  compulsory 
and 
to  meet  with  effective  monitoring  of 
compliance. The ultimate decision on what should, 
and  what  should  not  be  covered  in  the  basic 
package  is  made  by  the  central  government.  The 
central  role  of  specialists  in  the  absorption  of 
treatment into the basic package should not be left 
unmentioned.  New  treatments  or  methods  of 
diagnosis-setting  adopted  by  medical  specialists 
are more or less automatically covered in the basic 
package,  since  the  basic  package  covers  health 
care  "according  to  the  latest  developments  in 
science and technology". Only after ZiNL research 
shows that some methods or treatments are (cost-) 
ineffective  the  ZiNL  may  advise  that  type  of 
treatment to be removed from the basic package. 

E-health (e-prescription, e-medical records) 

In the Netherlands, there is no national system for 
the  exchange  of  data  on  e-prescription  or  e-
medical  records.  The  exchange  of  medical  data  is 
facilitated  mainly on a regional level. Most of the 
medical records are updated electronically and are 
no longer available in paper. A survey shows that 
93%  of  general  practitioners  and  66%  of  medical 
specialists  update 
records  mainly  or 
their 
exclusively  electronically.  Furthermore,  many 
doctors  exchange  patient  data  electronically. 
Nearly  all  (90%)  of  the  general  practitioners 
exchange  patient  data  electronically  with  public 
pharmacies, 
practitioner 
services  and  hospitals.  Almost  half  (46%)  of 
medical 
data 
electronically with general practitioners. There are 
also  systems  which  connect  medical  specialists  or 
other  healthcare  providers  who  are  active  in  the 
same  chain  of  care  (for  example  cancer  or 
diabetes).  Recently  national  policy  has  been 
introduced  which  states  that  the  majority  of 
chronically  ill  patients  must  have  access  to  their 
own  medical  data 
(for  example  prescribed 
pharmacy), within the period 2014-2019. With this 
policy the Dutch government aims for more patient 

emergency 

specialists 

exchange 

general 

patient 

Health care systems 

2.20. The Netherlands 

empowerment,  higher  quality  and  more  effective 
care. 

Health  and  health-system 
reporting mechanisms 

information  and 

In order to improve access and reduce the waiting 
time  for hospital  surgery, authorities  have obliged 
hospitals  and  mental  healthcare  providers  to  give 
information to an integrated central and nationwide 
information  system  on  patients  on  a  waiting  list. 
This information can be used by insurers and their 
to  choose  between  hospitals.  The 
insured 
publishing  of  this  information  is  designed  to 
encourage providers to increase activity and reduce 
waiting times. Data on patients' experience of care 
is  published  by  the  government,  the  insurers  and 
NGOs.  This  improved  information  transparency 
has  certainly  contributed  to  reduce  waiting  times 
and  lists,  even  though  the  major  factor  was  most 
probably  the  implementation  of  pay-per-volume 
systems for most health care providers. 

exists,  which 

Comprehensive  data 
enables 
information on physician and hospital activity and 
quality and patient care utilisation to be published. 
This information is used by insurers and patients to 
choose providers and by providers to improve their 
own  activity.  Surveys  are  conducted  on  patient's 
experience and satisfaction with the care provided. 
A general health care sector performance report is 
published 
a 
regular 
comprehensive set of indicators. 

using 

basis 

on 

a 

Health  promotion  and  disease  prevention 
policies 

The  central  government  has  set  a  number  of 
relevant  public  health  objectives,  set  in  terms  of 
processes  and  the  reduction  of  health  inequalities. 
The ambition is to decrease or at least stabilise the 
difference in life expectancy by 2030 compared to 
now,  which,  given  the  expected  developments  on 
social determinants of health and the international 
position  of  the  Netherlands,  is  an  ambitious  goal. 
With  regards  to  healthy  life  expectancy,  the 
ambition  is  that  of  a  significant  decrease  in 
differences  by  2030.  The  2015  level  of  public 
expenditure  on  prevention  and  public  health 
services  as  percentage  of  GDP  is  in  line  with  the 
average  (0.29  vs.  0.25  for  the  EU  in  2015).  In 
terms  of  total  expenditure,  it  is  a  bit  more 

199 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

markedly above the average (3.9% vs 3.4% for EU 
in 2015). 

Recently 
reforms 

legislated  and/or  planned  policy 

Measures  to  control  health  care  costs  have  been 
implemented  by  the  government  since  2008  for 
acute care. The breach of the Stability and Growth 
Pact  criteria  in  2010  reinforced  the  government’s 
recognition that an effective control of public costs 
(including  health  care  costs)  was  needed.  The 
political drive of the current government (in office 
since 2012) to reduce the national debt to no more 
than  3%  of  the  national  budget  has  led  to 
significant  reductions  in  the  health  care  budget. 
The  measures that  have been implemented can be 
grouped into four categories:  

(1) shifting costs from public to private sources; 

(2) shifting costs between various statutory sources 
(e.g. transfer of care from the exceptional medical 
expenses  act  (AWBZ)  to  the  municipalities), 
mostly  in  combination  with  major  cuts  in  the 
budgets;  

(3) substitution of institutional care with home care 
and secondary care with primary care;  

(4)  increased  focus  on  improving  efficiency  and 
eliminating fraud. 

Initially,  from  2009,  the  measures  were  mainly 
targeted  at  reducing  overspending,  shifting  costs 
from public to private sources by limiting the basic 
package  and  efforts  to  prevent  improper  health 
the 
care  consumption.  From  2011  onwards, 
measures  focused  more  on  structural  changes  in 
the  area  of  acute  care,  with  the  government 
seeking  to  reach  a  consensus  with  stakeholders  to 
agree on further cost containment. 

The  future  policy  agenda  for  the  Dutch  health 
system  commits  itself  to  the  promotion  of  high 
quality  and  sustainable  care.  In  2011,  the  first 
outline agreements between the Minister of Health, 
health care providers and insurers were concluded, 
which  form  a  base  for  less  growth  of  healthcare 
consumption  and  more  high  quality  healthcare. 
These  agreements  work,  because  the  use  of 
agreements  between  parties  is  part  of  Dutch 
political culture, and because for providers there is 

200 

the 

latent 

threat  of 

always 
the  government 
imposing  measures,  such  as  tariff  cuts,  when  the 
agreed  terms  are  not  met.  Also,  the  healthcare 
purchasing  market  provides  sufficient  incentives 
for  both 
to  produce 
insurers  and  providers 
healthcare of good quality at acceptable prices. 

These  objectives,  moderate  growth  and  improved 
quality of care, need to be anchored into the Dutch 
healthcare system. The following policy objectives 
will  be  aimed  for  in  doing  so:  Primary  healthcare 
(PHC).  The  Dutch  healthcare  system  is  widely 
known  for  its  well-functioning  PHC  system.  The 
aim  is  to  further  improve  coordination  between 
general  practitioners,  pharmacies,  district  nurses, 
and  paramedics.  Especially  the  district  nurse  will 
become  more  important;  as  from  2015  it  will  be 
reimbursed  by  the  insurer  (without  usage  will  be 
subject to own risk), with a central role for care in 
districts.  A  central  role  of  PHC  will  also  make  it 
possible  for  healthcare  to  become  more  patient-
oriented, as more care can be provided at or near a 
patient's home. 

Regarding  innovation,  this  is  regarded  as  an 
important  feature  of  the  system,  which  should 
remain  available  to  patients  to  safeguard  high 
quality  care.  New  and 
innovative  healthcare 
services  will  therefore  be  adopted  into  the  basic 
package,  under  strict  conditions  of  proven 
therapeutic  effect  and  cost-efficiency.  In  addition, 
innovation  has  the  potential  to  empower  patients 
and  to  increase  self-reliance,  as  well  as  unburden 
healthcare  providers.  Both  aspects,  again,  make  it 
possible  for  healthcare  to  become  more  patient-
oriented. 

On  transparency,  insurers  need  to  know  what  the 
outcome of  healthcare provision is, as a  means of 
purchasing care based on quality. This also means 
that they are not obliged to remunerate inefficient 
healthcare. For the system to work efficiently, it is 
therefore 
takes  up 
responsibility  to  solely  provide  sensible  and  cost-
conscious  healthcare.  Care  provision  receipts 
therefore need to become more understandable for 
patients  and  quality  of  healthcare  provision  will 
become more widely available by ZiNL ( 299). This 

that  everyone 

important 

(299) Regarding  patient  information,  ZiNL  has  set  up  a  website 
support  informed  patient  choice:  kiesbeter.nl;  furthermore 
it is also among the responsibilities of the insurer to make 
quality of care available to their enrollees, in a transparent 
and comparable manner. 

 
                                                           
will empower patients, and it also provides a base 
for  insurers  to  select  care  providers,  mainly 
through  selective  contracting  of  healthcare  by  the 
insurer.  The  effect  aimed  for  is  that  non-sensible 
use  of  care  will  be  cut  back,  while  it  can  also 
improve 
safety  and,  again,  patient-oriented 
healthcare. 

Challenges 

The  analysis  above  shows  that  a  wide  range  of 
reforms have been implemented over the years, to 
a  large  extent  successfully  (e.g.  the  policies  to 
control  pharmaceutical  expenditure;  to  strengthen 
primary  care;  to  reduce  hospital  use;  to  improve 
data  collection  and  monitoring;  and,  to  improve 
life-styles),  and  which  The  Netherlands  should 
continue  to  pursue.  The  challenges  for  the  Dutch 
health care system are as follows: 

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the increasing health care expenditure over the 
coming decades, which is a risk to the medium-
term sustainability of public finances.  

•  To  continue  to  enhance  and  better  distribute 
primary  health  care 
services  and  basic 
specialist  services  to  ensure  equity  of  access 
and  the  effectiveness  and  efficiency  of  health 
care  delivery;  To  ensure  an  effective  referral 
systems from primary to specialist and hospital 
care  and  improving  care  coordination  between 
types  of  care,  notably  by  ensuring  that  users 
register  with  their  GP  and  by  exploring  the 
development of electronic patient records in the 
future. 

•  To find a balance between possible economies 
of  scale  and  consumer  choice  between 
providers  and  insurers.  Possible  economies  of 
in  health  care  provision  and 
scale  exist 
insurance; and the challenge is to balance these 
economies of scale with the need for sufficient 
user choice between providers/insurers, so that 
providers/insurers  will  also  in  the  long-run 
optimise the mix between quality and costs. 

•  To  ensure  that  the  gains  expected  to  be 
achieved through competition between insurers 
the 
providers 
as  well 

outweigh 

as 

Health care systems 

2.20. The Netherlands 

administrative costs associated with the need to 
monitor 
different 
dimensions of the health care market. 

regulate  many 

and 

•  To  continue  to  improve  accountability  and 
governance of the system and identify possible 
cost-savings in the health sector administration. 
To further the existing efforts, such as financial 
incentives  for  GPs  in  smaller  areas,  to  ensure 
that  resource  allocation,  including  that  of 
medical 
is  not 
detrimental to poorer regions. 

staff,  between 

regions 

so 

•  To  continue  to  improve  data  collection  and 
monitoring  of  inputs,  processes,  outputs  and 
outcomes 
performance 
assessment  can  be  conducted  and  use  to 
continuously 
improve  access,  quality  and 
sustainability  of  care  and  serve  as  a  tool  of 
patient empowerment. 

regular 

that 

•  To  further  the  efforts  to  support  public  health 
priorities  and  enhance  health  promotion  and 
disease  prevention  activities,  i.e.  promoting 
healthy  life  styles  and  disease  screening  given 
the  recent  pattern  of  risk  factors  (smoking, 
alcohol) and the pattern of both infectious and 
non-infectious diseases. 

201 

 
                                                                                   
 
 
2
0
2

Table 2.20.1:  Statistical Annex – The Netherlands 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

EU- latest national data

2005

546

34.4

1.9

:

2006

579

35.6

3.4

0.9

2007

613

37.2

3.5

4.2

2008

639

36.7

1.3

4.3

2005

2006

2007

2008

9.4

9.4

0.0

9.2

9.2

0.0

9.3

9.2

0.0

9.5

9.5

0.0

2009

618

33.8

-4.3

3.1

2009

10.3

10.2

0.0

2010

632

34.1

0.9

2.7

2010

10.4

10.4

0.0

2011

643

34.7

1.2

2.1

2011

10.5

10.5

0.0

2012

645

34.8

-1.4

2.1

2012

10.9

10.9

0.0

2013

653

34.7

-0.5

0.7

2013

11.0

10.9

0.1

2014

663

34.7

1.0

-0.3

2014

10.9

10.9

0.0

2015

683

36.0

1.8

-1.1

2015

10.6

10.6

0.0

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,825

2,922

3,109

3,325

3,443

3,562

3,643

3,770

3,848

3,847

3,836

2,745

2,895

6.7

6.7

7.6

7.6

7.7

7.7

7.8

7.8

8.5

8.4

8.6

8.6

8.7

8.7

9.0

8.9

8.9

8.8

8.8

8.8

8.5

8.5

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,004

2,416

2,581

2,718

2,838

2,945

2,996

3,093

3,086

3,096

3,097

2,153

2,263

2,324

2,609

0.01

70.9

16.5

97.9

7.8

0.02

82.7

16.0

98.5

9.2

0.01

83.0

16.1

98.6

8.7

0.02

81.7

16.6

98.8

10.7

0.02

82.5

16.1

98.8

5.8

0.04

82.7

16.1

98.8

5.8

0.01

82.2

17.1

99.9

5.9

0.01

82.0

17.0

99.8

10.4

0.01

80.2

17.2

99.8

11.7

0.01

80.5

17.0

99.8

12.2

0.01

80.7

16.9

99.9

12.3

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

16.3

81.7

77.2

63.5

65.4

60

4.9

16.3

82.0

77.7

63.5

65.2

57

4.4

16.4

82.5

78.1

64.3

66.1

55

4.1

16.4

82.5

78.4

59.9

62.5

52

3.8

16.5

82.9

78.7

60.1

61.7

50

3.8

16.6

83.0

78.9

60.2

61.3

49

3.8

16.7

83.1

79.4

59.0

64.0

100

3.6

16.7

83.0

79.3

58.9

63.5

99

3.7

16.8

83.2

79.5

57.5

61.4

95

3.8

16.8

83.5

80.0

59.0

63.3

88

3.6

16.9

83.2

79.9

57.2

61.1

91

3.3

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.7

0.3

1.8

1.0

0.5

0.4

0.4

2.1

0.2

0.8

0.6

0.2

0.2

0.2

2.0

0.2

2.2

1.0

0.5

0.4

0.5

1.9

0.2

1.6

0.8

0.2

0.3

0.4

1.9

0.2

2.2

1.0

0.4

0.4

0.5

1.8

0.2

1.6

0.8

0.2

0.3

0.4

1.8

0.3

2.4

1.0

0.5

0.4

0.4

1.7

0.3

1.8

0.7

0.2

0.3

0.3

2.0

0.4

:

1.0

0.5

0.5

0.5

1.9

0.3

2.0

0.8

0.2

0.3

0.3

2.0

0.4

:

1.0

0.5

0.5

0.5

1.9

0.4

1.9

0.8

0.2

0.3

0.3

2.0

0.4

:

1.0

0.5

0.4

0.5

1.9

0.4

2.0

0.7

0.2

0.3

0.3

2.0

0.5

2.8

0.9

0.5

0.4

0.4

1.9

0.4

2.0

0.6

0.2

0.3

0.3

2.1

0.5

2.8

0.9

0.5

0.4

0.4

2.0

0.4

2.1

0.6

0.2

0.3

0.3

2.1

0.4

2.8

0.8

0.5

0.4

0.4

1.9

0.4

2.1

0.5

0.2

0.3

0.3

2.2

0.5

2.7

0.8

0.5

0.4

0.4

2.1

0.5

1.9

0.5

0.2

0.3

0.3

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

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Table 2.20.2:  Statistical Annex - continued – The Netherlands 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

28.5%

2.9%

19.1%

10.9%

4.9%

3.9%

4.7%

31.5%

2.3%

12.6%

8.8%

2.5%

2.8%

3.4%

2005

0.66

:

0.8

0.1

10.7

25.2

9.7

2006

21.2%

2.6%

24.2%

10.9%

4.9%

4.2%

5.0%

25.3%

2.8%

21.2%

10.8%

2.8%

3.4%

4.7%

2006

0.78

:

0.8

:

11.3

25.2

9.8

2007

20.2%

2.6%

23.8%

11.0%

4.8%

4.3%

4.9%

23.7%

2.9%

20.7%

11.0%

2.7%

3.5%

4.7%

2007

0.76

0.7

0.8

0.2

11.2

23.1

9.5

2008

18.7%

3.2%

25.4%

10.3%

4.9%

4.1%

4.3%

22.0%

3.5%

22.7%

9.5%

2.6%

3.7%

4.2%

2008

1.04

1.0

1.0

0.2

11.1

23.3

9.6

2005

2006

2007

2008

271

819

66

690

2005

5.4

10

280

820

68

617

2006

5.6

10

279

830

68

608

2007

5.7

11

287

840

70

559

2008

5.9

11

2009

19.0%

3.5%

:

10.0%

4.6%

4.5%

4.8%

21.9%

4.0%

23.1%

9.0%

2.8%

3.8%

3.9%

2009

1.09

1.0

1.1

0.3

11.8

22.6

9.2

2009

292

:

72

553

2009

5.7

11

2010

19.3%

3.9%

:

9.8%

4.6%

4.4%

4.8%

22.2%

4.5%

22.5%

8.8%

2.8%

3.8%

3.7%

2010

1.22

:

1.2

0.2

11.4

20.9

9.3

2010

296

:

73

546

2010

6.6

12

2011

18.7%

4.2%

:

9.5%

4.8%

4.1%

5.0%

21.7%

4.8%

22.9%

8.5%

2.8%

3.6%

3.8%

2011

1.29

:

1.3

0.3

11.4

20.8

9.0

2011

313

:

73

535

2011

6.6

12

2012

18.5%

4.4%

25.6%

8.3%

4.7%

3.9%

3.9%

21.4%

5.0%

22.8%

7.0%

2.6%

3.6%

3.7%

2012

1.18

:

1.1

0.3

12.0

18.4

9.3

2012

325

1190

77

528

2012

6.2

11

8,817

9,602

10,324

10,987

11,766

12,509

12,618

16,201

67.0

7.2

46.5

2016

6.2

6.2

2016

17.0

67.0

6.6

48.0

2020

6.4

6.5

2020

17.4

55.9

:

49.3

2025

6.6

6.7

2025

17.9

54.5

:

50.1

2030

6.7

6.9

2030

18.4

52.7

:

51.1

2035

6.8

7.0

2035

18.8

52.8

:

51.8

2040

6.9

7.2

2040

19.0

47.5

:

51.4

2045

6.9

7.3

2045

19.2

45.6

:

60.0

2050

7.0

7.4

2050

19.2

2013

19.4%

4.4%

25.9%

7.8%

4.4%

3.8%

3.9%

22.3%

5.0%

23.2%

6.2%

2.4%

3.4%

3.7%

2013

1.15

:

1.2

0.3

11.1

18.5

8.7

2013

331

1210

79

523

2013

6.2

:

:

:

:

:

2055

7.0

7.5

2055

19.3

2014

19.4%

4.0%

26.2%

7.6%

4.4%

4.0%

4.0%

22.0%

4.5%

23.4%

6.2%

2.4%

3.7%

3.9%

2014

1.29

:

1.3

0.4

12.9

19.1

8.0

2014

343

1034

82

524

2014

8.0

:

:

:

:

:

2060

7.0

7.6

2060

19.3

2015

21.2%

4.7%

25.3%

7.8%

4.8%

3.7%

3.9%

24.4%

5.3%

22.5%

6.3%

2.8%

3.4%

3.9%

2015

1.25

:

1.4

0.4

12.8

19.0

8.0

2015

347

1047

82

518

2015

8.2

:

:

:

:

:

2065

7.0

7.6

2065

19.4

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

7.0

7.6

2070

19.5

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Netherlands

0.8

1.4

EU

0.9

1.6

Change 2016-2070, in %

Netherlands

15.1

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

2
0
3

2
.
2
0
.

T
h
e
N
e
t
h
e

r
l

a
n
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2.21. POLAND 

General 
context: 
sustainability, demographic trends 

Expenditure, 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

In 2015, GDP per capita in Poland was 18,500 PPS 
and  below  the  EU  level  of  29,600  PPS.  Poland 
remained  with  positive  growth  rates  of  real  GDP 
during  the  crisis.  In  2016,  population  is  estimated 
is 
at  38  million 
characterised  by  declining  growth  with  an  ageing 
population and a rising share of older age cohorts. 
The  population  is  projected  to  decrease  to  31 
million until 2070.  

(300).  Poland's  population 

Total and public expenditure on health as % of 
GDP 

Total expenditure on health was at 6.6% of GDP in 
2015 (EU: 10.2% in 2015). Total public spending 
on  health  was  at  4.7%  of  GDP  (EU:  8.0%). 
Looking at health care without long-term care (301) 
reveals  a  similar  picture  with  public  spending 
below the EU average (PL: 4.3% vs. EU: 6.8% in 
2015).  Spending  relative  to  GDP  was  increasing 
steadily  between  2003  and  2009  and  has  slightly 
decreased since. In 2015, 11% of total government 
towards  health 
expenditure  was  channelled 
spending  (EU:  15%).  In  per  capita  terms,  total 
(1,264  PPS)  and  public  spending  (900  PPS)  were 
well below the respective EU averages (3,305 PPS 
and 2,609 PPS) (302).  

Expenditure projections and fiscal sustainability  

Public  expenditure  on  health  care  is  projected  to 
increase  by  0.8  pps  of  GDP  ("AWG  reference 
scenario"),  below  the  average  increase  of  0.9  pps 
for the EU. When taking into account the impact of 
non-demographic  drivers  on 
future  spending 
risk  scenario"),  health  care 
growth 
expenditure  is  expected  to  increase  by  1.7  pps  of 
GDP  from  now  till  2070  compared  to  the  EU 

("AWG 

(300) According  to  the  Central  Statistical  Office  of  Poland,  the 

population on 31st June 2015 was 38.45 million. 

(301) To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(302) Note  that  these  PPS  figures  reflect  current  plus  capital 
health  expenditure  in  contrast  to  EUROSTAT  data  series, 
which reflect current expenditure only. 

average  of  1.6  pps  (303).  Overall,  projected  health 
care  expenditure  poses  a  risk  to  the  long-term 
sustainability  of  public  finances.  There  are  no 
short-term  risks  and  the  medium-term  risks  are 
low. Over the long run, however Poland does face 
medium  risks  to  fiscal  sustainability.  These  risks 
are largely due to an unfavourable initial budgetary 
position,  but  also  to  the  necessity  to  meet  future 
increases  in  ageing  costs  (notably  healthcare  and 
long-term care) (304).  

Health status  

In 2015 life expectancy at birth was 81.6 years for 
women  and  73.5  years  for  men,  below  the  EU 
averages (EU: 83.3 for women and 77.9 for men). 
However,  in  2015  healthy  life  years  were  slightly 
at the EU average for women (63.2 vs. 63.3 years), 
but  below  the  EU  average  for  men  (60.1  vs.  62.6 
years).  Amenable  mortality  rates,  i.e.  deaths  that 
should  not  occur  with  timely  and  effective  care, 
are  well  above  the  EU  average  (169  deaths  in 
Poland  versus  127  deaths  in  the  EU  per  100,000 
inhabitants).  Infant  mortality  was  at  the  level  of 
4.0‰ in 2015 (EU: 3.6‰). 

System characteristics  

Administrative  organisation,  system  financing, 
revenue collection mechanism  

(NHF).  Rules  pertaining 

The  health  care  system  in  Poland  is  described  by 
two basic acts. Details of the operation of general 
health insurance system are defined by the  Act of 
27  August  2004  on  healthcare  services  financed 
from  public  funds.  The  insurer  is  the  National 
Health  Fund 
to 
therapeutic activity in Poland are regulated by the 
Act  of  15  April  2011  on  therapeutic  activity.  The 
act defines the rules for the therapeutic activity, in 
particular  the  conditions  to  be  met  by  entities 
carrying  out  therapeutic  activity,  as  well  as  the 
categories  of  entities  and  kinds  of  therapeutic 
activity.  

Since  2003,  a  centralised  National  Health  Fund 
the  financial  resources  and 
(NHF)  manages 

(303) The 

2018 

Ageing 

Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(304) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

204 

 
                                                           
                                                           
them  between  providers  based  on 
allocates 
the 
individual  contracts.  Moreover, 
Agricultural 
Fund  was 
Insurance 
established  in  order  to  perform  tasks  connected 
with  full  servicing  of  farmers'  social  insurance 
(305). 

in  1990 

Social 

the  population 

Funds  are  coming  mostly  from  universal  health 
insurance  contributions  collected  by  the  NHF. 
Moreover,  government  budgets  (state,  regional  or 
local authorities) contribute for specified purposes, 
such as health insurance contributions  for specific 
(e.g.  unemployed 
groups  of 
receiving 
security  benefits,  persons 
receiving  social  pensions,  farmers,  war  veterans, 
etc.),  capital  expenditure  in  public  health  care 
tertiary  care 
institutions,  highly 
procedures  (such  as  organ 
transplants,  heart 
surgery,  treatments  abroad)  and  very  expensive 
drugs (in total around 10%). 

specialised 

social 

The NHF contributions are calculated on the gross 
income  base,  which  makes  it  a  sort  of  earmarked 
type of personal income tax (PIT). The base differs 
slightly  for  some  defined  social  groups:  farmers 
(depending on the size of the farm), self-employed 
(depending on income, but with a lower limit) and 
beneficiaries  of  social  security  (depending  on  the 
gross  amount  of  benefits).  The  contribution  rate 
amounts  currently  to  9%  of  the  base,  7.75%  of 
which are subtracted from PIT and 1.25% are paid 
directly by the insured person.  

In  2011,  a  major  reform  was  introduced  allowing 
for  the  possibility  of  direct  transformation  of 
public health care units, including public hospitals 
into  corporate  units  (corporatisation).  The  law 
regulates  that  both  public  and  private  hospitals 
contracted  by  NHF  will  function  according  to  the 
same  rules.  Also  public  hospitals 
that  were 
transformed into corporate units will be allowed to 

(305) The  main  regulation  defining  farmers'  social  insurance 
obligations  and  entitlements  to  benefits  is  the  act  of  20 
December  1990  on  social  insurance  for  farmers.    The 
current regulation of farmer’s health insurance is included 
in  the  act  of    2  December  2016  to  amend  the  act  on 
healthcare services financed from public funds (pol. ustawa 
z  2  grudnia  2016  r.  o  zmianie  ustawy  o  świadczeniach 
opieki 
środków 
publicznych). 

finansowanych 

zdrowotnej 

ze 

Health care systems 

2.21. Poland 

offer  for  fees  services  outside  the  contracts  with 
NHF (306). 

thus 

improve 

The  laws'  purpose  is  to  increase  the  efficiency  of 
health  care  providers  and 
the 
functioning  of  health  care  system.  If  the  financial 
report  on  public  hospital  activity  indicates  a  net 
loss,  then  hospital  or  his  owner  has  3  months  to 
cover  it.  Otherwise,  the  owner  makes  a  decision: 
transformation  into  corporate  unit  or  liquidation. 
Since  July  2011,  62  public  hospitals  were 
corporatised  (one  of  them  was  privatised)  (307).  It 
will  be  interesting  to  observe  the  law's  further 
impact in the coming years. 

Coverage  and  role  of  private  insurance  and 
out of pocket co-payments 

Public  health  insurance  covers  91.6%  of  the 
population  (308).  Practically  all  social  groups  are 
covered  by  mandatory  health  insurance.  There  is 
no  legal  possibility  to  opt-out  from  the  system  on 
the  grounds  of  income,  social  group  or  source  of 
means of living. The law identifies the package of 
insurance 
health  services  provided  under 
scheme,  as  well  as  a  limited  list  of  excluded 
services. A number of services, defined by law, are 
provided  with  co-payments.  The  level  of  co-
payments  is  legally  limited  and  depends  on  the 
income of an insured person (309). For dental care, 
a precise system of point pricing with respect to a 
standard basket of dental procedures and materials 
is established (310). 

the 

(306) Please,  notice  that  the  Act  of  15  April  2011  on  medical 
activity regulates the transformations of public independent 
health  care  provider  (pol.  samodzielny  publiczny  zakład 
opieki zdrowotnej (SPZOZ) – specific name for health care 
provider).    In  accordance  with  this  act,  if  the  heath  care 
provider  is  not  able  to  finance  its  own  deficit,  then  its 
founder  can  defray  the  negative  balance  or  is  obliged  to 
transform    this  provider  into  corporate  unit  (or  budgetary 
unit) or decide on liquidation of the unprofitable provider. 
(307) By  today,  191 hospitals  have  changed their  organizational 
form    (into  corporate  unit).  Majority  of  them,  (ca.  70%,) 
are  owned  or  controlled  by  public  body  (mainly  local 
government). 

(308) The guaranteed benefit baskets are stored in the regulations 

of the Minister of Health, not in the act. 

(309) Only  charges  for  accommodation  and  catering  in  the  care 
and  treatment  facility,  nursing  and  care  facility  or  in 
medical  rehabilitation  facility  that  provides  twenty-four 
hour services are dependent on the income. 

(310) As a result, Poland scores about 5.9 out of 6 on the breadth, 
6  in  the  scope  and  around  5.3  on  the  depth  of  basic 
coverage according to the OECD scoreboard. 

205 

 
                                                           
                                                           
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for  a 

Shares  of  public  and  private  expenditure  in  total 
health care spending have been stable over the last 
decade:  71%  of  expenditure  being  publicly  and 
29%  privately  financed  in  2015  (EU:  78%  public 
and  22%  private).  As  such,  health  financing  is 
based to a higher degree on private sources than in  
other  EU  countries.  Out-of-pocket  spending 
large  majority  of  private 
accounts 
expenditure (23.3% of total current expenditure on 
health  in  2015;  EU:  15.9%).  As  there  are  no 
patient  charges  for  medical  treatment  by  general 
practitioners, specialists or in hospitals, private co-
outpatient 
foremost 
payments 
pharmaceuticals.  This 
relative 
underdevelopment  of  other,  more  institutionalised 
patterns  of  financing  (such  as  supplementary 
insurance schemes).  

for 
suggests 

are 

a 

Private  expenditure  also  includes  the  pre-payment 
schemes, of which main components are "medical 
subscriptions"  and  different  insurance  policies 
protecting against the risk of high expenditures on 
health  care.  The  former  ones  are  mainly  the 
expanded  packages  of  health  services  offered  by 
their  employees.  They  usually 
employers 
include  services  that  the  employers  are  obliged  to 
provide  in  accordance  with  law  and  cover  mostly 
outpatients services. The latter ones are still in the 
early  stage  of  development  and  concern  a  minor 
number of patients. 

to 

Types of providers, referral systems and patient 
choice   

Health  care  services  are  provided  by  public  and 
non-public therapeutic entities and private medical 
practitioners 
(individual  or  group  medical 
practice). All providers are independent in terms of 
organisation, personnel, assets and finances.  

(or 

Family 

physicians 

Primary  health  care  is  provided  in  outpatient 
clinics  and  at  home  (with  doctors  obliged  to 
provide  home  services  when  required  for  medical 
reasons). 
general 
practitioners  –  GPs)  act  as  gatekeepers  for 
specialist  and  hospital  care.  Patients  have  a  free 
choice  of  the  GP,  with  a  limited  number  of 
changes  available  per  year.  Also,  there  is  free 
choice  of  and  direct  access  to  certain  specialists 
(e.g.  gynaecologists,  psychiatrists,  oncologists, 
dentist  and  venereologist).  Specialist  outpatient 
care  is  based  mostly  on  private  medical  practices 
or  specialised  health  centres  (mainly  in  the  big 

206 

cities), which developed on the basis of the former 
public  specialised  health  care  centres.  Inpatient 
hospital  care  is  provided  predominantly  in  public 
hospitals.  The  number  of  non-public  hospitals 
increased  over 
last  decade  (428  private 
hospitals of 1013 in 2016).  In terms of the number 
of  hospital  beds  the  public  sector  dominates. 
Private  hospitals  are  relatively  small  in  size  and 
have fewer beds. 

the 

While the insurance coverage should practically be 
universal,  the  supply  of  health  care  is  seemingly 
not sufficient to provide the whole population with 
timely  and  adequate  care.  The  number  of 
practising physicians per 100,000 inhabitants (233 
in 2015) is one of the lowest in the EU (EU: 344). 
The  same  is  true  for  GPs  (22  per  100,000 
inhabitants  in  Poland  vs.  78  in  the  EU  in  2015). 
The number of nurses is also low (520 per 100,000 
inhabitants in 2015), and below the EU average of 
833. Staff shortages are particularly perceptible in 
some  regions  and  for  some  specialisations  as  the 
regional  and  sub-sectorial  discrepancies  in  care 
availability are significant. 

A  characteristic  feature  of  the  Polish  health  care 
system  is  the  widespread  phenomenon  of  double 
(or  multiple)  employment:  physicians  keep  part-
time  salaried  job  in  (mostly  public)  health  care 
units and simultaneously act as individual medical 
practitioners.  Indeed,  only  for  a  small  minority  of 
individual  practitioners  (with  the  exception  of 
dentists)  this  occupation  is  reported  as  their  main 
or  only  job.  Such  practice  may  have  a  strong 
negative effect on the quality of services provided 
by  the  health  care  units  and  their  economic 
situation, as their equipment and facilities are often 
their  secondary 
used  by 
activities. 

the  physicians  for 

Total expenditure on inpatient care as a % of GDP 
was  below  the  EU  average  (2.2%  vs.  2.8%  in 
2015),  as  was  public  expenditure  (2.0%  vs.  2.5% 
in 2015). Inpatient care accounts for roughly 46% 
of  public  expenditure  on  health 
in  Poland 
compared  to  32%  in  the  EU.  High  expenditure 
may be a sign of a health system, which is oriented 
away  from  ambulatory  and  towards  hospital  care, 
providing  potential  to  increase  the  relative  cost-
effectiveness  of  care,  by  shifting  away  from 
hospital centric health care provision. 

 
The  capacity  of  Polish  hospitals  (491  beds  per 
100,000 inhabitants in 2015) is higher than the EU 
average  of  402,  while  the  average  length  of  stay 
with 7.3 days in 2015 is below the EU average of 
7.6  days.  However, 
the  number  of  hospital 
inpatient  discharges  increased  from  14  in  2005  to 
16 in 2015 per 100 inhabitants (EU: 16 in 2015).  

Total and public expenditure on outpatient care as 
a % of GDP were below the EU average (1.5% and 
0.8% vs. 2.4% and 1.8% in 2015). Total and public 
expenditure  on  outpatient  care  as  a  %  of  current 
health  expenditure  were  roughly  around  the  EU 
average  (23%  and  18%  vs.  24%  and  22.5%  in 
2015).  

remunerated  according 

Physicians  employed  by  the  health  care  units  can 
be 
to  a  number  of 
contractual  arrangements,  although  salary  is  the 
most  widespread  pattern.  Individually  practising 
physicians  are  generally  paid  according  to  the 
capitation principle, on the basis of patient lists.  

Hospitals  are  financed  on  the  basis  of  contracts 
concluded  between  individual  entities  and  the 
National Health Fund. A  uniform classification of 
hospital  services,  mainly  based  on  defining 
individual  groups  of  procedures  and  prices  for 
basic units serves as a basis for those contracts. 

The market for pharmaceutical products 

The  pharmaceutical  market  in  Poland  is  divided 
into two segments: open (through pharmacies) and 
closed  (through  hospitals)  markets.  Over  the  last 
decade,  the  value  of  drugs  sold  has  increased  in 
both  markets,  while  the  quantity  has  decreased  in 
hospitals and remained stable in pharmacies. These 
developments  suggest  a  sharp  increase  in  the 
average price of hospital drugs, driven mainly by a 
growing use of original drugs. In the open market, 
the  shares  of  reimbursed  and  over-the-counter 
(OTC) drugs were broadly equal until 2004. Since 
then  a  significant  increase  in  the  quantity  of 
prescribed  and  reimbursed  drugs  has  exceeded 
significantly  that  of  the  OTC  drugs.  However,  in 
terms of value the gap between the growth rates of 
the  two  groups  has  been  much  narrower,  which 
suggests a much higher price dynamics of the OTC 
pharmaceuticals, resulting  from  high effectiveness 
of 
insufficient 
campaigns 
competition  between  the  OTC  drugs  producers. 
the  structure  of 
More  detailed  analysis  of 

advertising 

and 

Health care systems 

2.21. Poland 

pharmaceutical  market  allows  observing 
the 
increase  in  the  share  of  imported  drugs,  linked  to 
the fall in their relative price, as well as the growth 
in  the  total  value  of  sold  generics,  driven  mainly 
by the relative increase in their prices, rather than 
quantities sold. 

New drug reimbursement regulations and changes 
to  the  official  list  of  subsidised  drugs  have  been 
introduced  in  2012.  Now  the  Ministry  of  Health 
can  negotiate  the  fixed  refundable  price  of  a  drug 
directly  with  manufacturers.  Thus,  prices  of 
reimbursed  drugs  are  identical  in  all  pharmacies. 
Under  the  reimbursement  law,  the  list  is  updated 
every two months. 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

The  Centre  for  Health  Care  Quality  Monitoring 
provides independent accreditation on the basis of 
a published set of standards. Quality requirements, 
national  guidelines  and  standards  are  developed 
based  on  independent  expertise.  Further  schemes 
include  developing  a  better  system  to  evaluate 
services.  The  use  of  technology  assessment  is 
increasing,  leading  to  evidence-based  contracting 
of services.  

technology 

assessment 

The  Agency  for  Health  Technology  Assessment 
and  Tariff  System  was  established  in  2005  as  an 
advisory  body  to  the  Ministry  of  Health.  It  is 
technology 
for  preparing  health 
responsible 
information  on 
assessment  reports,  collecting 
health 
and 
methodologies.  The  main  task  of  the  agency  is  to 
prepare 
of  Health 
the  Minister 
recommendations  on  financing  all  health  care 
services  from  public  funds  (especially  in  relation 
to  drug  reimbursement  list,  national  and  local 
government  health  care  programs, 
therapeutic 
drugs  programs  (high-cost,  innovative  drugs)  and 
hospital's chemotherapy drugs list).  

results 

for 

E-health (e-prescription, e-medical records) 

In 2013, an electronic verification of beneficiaries’ 
rights  was  introduced  (so-called  eWUŚ  system). 
This  allows  for  verification  whether  the  person  is 
entitled  to  benefits  financed  from  public  means. 
Also an individual health e-account (so-called ZIP) 
was introduced in July 2013, on which the insures' 
data are collected. 

207 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

its 

The  following  legal  regulations  were  adopted 
aiming at the  modernisation  of the current system 
of  gathering,  processing  and  usage  of  information 
in healthcare. Those regulations are deriving from 
the Act of 28 April 2011 on information system in 
healthcare.  The  act  and 
implementing 
legislation  provide  the  legal  framework  for  the 
functioning  of  information  systems  in  healthcare. 
It  is  also  a  foundation  for  implementation  of 
solutions supporting the exchange of medical data, 
which  need  to  be  used  in  treatment  process  in 
Poland. Under this act there are IT solutions being 
developed  currently,  through  which  it  will  be 
possible  to  prepare  tools  for  implementation  of 
healthcare  information  as  well  as  to  conduct 
electronic  medical  records  (documentation)  in 
medical entities. 

Currently, the following projects are ongoing: 

includes 

1.  Electronic  Platform  for  Collection,  Analysis 
and  Dissemination  of  Digital  Resources  on 
Medical  Events  (P1).  Information  systems 
which will be launched within this project will 
become  electronic  platform  of  medical  data. 
The aim of this project is to build an electronic 
platform  for  public  services  in  healthcare, 
enabling  different  stakeholders 
to  collect, 
analyse  and  share  their  digital  resources  on 
the 
medical  events.  The  project 
necessity 
level  of 
to  ensure  appropriate 
security  as  regards  data  and  services.  Due  to 
high  sensitivity  of  data  being  processed 
(medical  data),  feeding  the  data,  as  well  as 
their  processing  will  be  done  with  the  full 
knowledge  of  patient,  in  compliance  with  the 
required security and confidentiality measures. 
Projects  allow  to  implement  ePrescription, 
referral,  Online  Patient  Account  as  well  as  to 
exchange  electronic  medical  documentation. 
The  platform  will  be  connected  with  local 
information  systems  of  healthcare  providers 
and  with  the  data  being  processed,  which 
makes  the  functioning  of  the  system  to  be 
liable to high requirements of security level. 

2.  Domain-specific 

information 

and 
communication  systems  in  healthcare  (P4)  – 
and 
the  project  will 
and 
implementation 
communication  systems  supporting  specific 
business 
follows:  Healthcare 
Statistics  System;  Risks  Monitoring  System; 

enable  building 

information 

areas, 

of 

as 

Integrated  System  of  Monitoring  Trade  in 
Medicinal  Products;  System  Monitoring 
Education  Medical  Professionals,  System  of 
Registration of Healthcare Resources. 

in  electronic 

3.  Platform P2, i.e. Platform for sharing services 
and  resources  of  digital  medical  records  with 
on-line  businesses  was  established  and 
launched  at 
the  beginning  of  2013.  P2 
platform  is  a  universal  IT  tool  used  to  keep 
registers  and  provide  electronic  services.  P2 
platform  enables  electronic  registration  and 
updating of register data (e.g. it is possible to 
apply for permission to run a pharmacy), gives 
healthcare providers the opportunity to submit 
their applications to the register electronically, 
form, 
to  keep  documents 
provides  wider  usage  if  digital  signature  and 
assists  public  administration  in  downloading 
registry  data.  During  integration  with  the  P2 
platform  the  registers  are  rebuilt  so  that  they 
are  consistent  with  the  reference  architecture 
of  a  medical  register.  The  following  registers 
were integrated with the P2 platform: Register 
of  permits  for  running  commonly  available 
pharmacies,  pharmacy  points  and  Register  of 
permits  for  running  hospital  pharmacies, 
company  pharmacies  as  well  as  hospital 
pharmacy departments; Register of permits for 
running  pharmaceutical  warehouses;  Coding 
Systems  Register;  Register  of  Medicinal 
Products  Authorised  for  the  Market  on  the 
territory of the Republic of Poland; Register of 
Medically  Assisted  Procreation;  Residency  IT 
System (SIR). 

Full operation of the system will be possible when 
the above mentioned projects are finalised. 

Feeding 
the  system  with  medical  data  and 
electronic  medical  documentation  is  the  vital 
requirement  for  full  operation  of  the  system.  For 
this  purpose  healthcare  providers  were  obliged  to 
keep  medical  documentation  in  electronic  form 
starting  from  1  January  2018.  Until  that  time 
healthcare  providers  can  develop  and  process 
medical documentation in traditional (paper) form 
as  well  as  in  electronic  one.  Due  to  the  solution 
implemented  in  Poland  as  regards  exchange  of 
medical  documentation,  medical  documentation 
will  be  held  by  healthcare  providers  in  the 
information  and  communication  system  and  its 
dissemination  will  be  possible  through  Medical 

208 

 
Health care systems 

2.21. Poland 

Information  System  (MIS), 
i.e.  P1  platform, 
mentioned  above.  Healthcare  provider  will  feed 
into MIS the data or medical electronic documents 
possible  to  be  downloaded  by  other  healthcare 
provider  when  necessary  for  the  continuity  of 
treatment  and  providing  patients  with  medical 
products  and  devices.  Sharing  the  data  is  possible 
only with the consent of patient. E-prescription and 
e-referral  will  be  specific  documents  available 
during  data  sharing.  It  will  be  possible  to  provide 
those  documents  within  P1  platform  directly, 
through special application.    

the  computerisation  of 
As  mentioned  above, 
is  developing 
healthcare  system 
dynamically. 
current 
regulations,  healthcare  information  system  will 
eventually include databases functioning within: 

in  Poland 
accordance  with 

In 

and 

information 

information 
domain-specific 

Medical  Information  System  (MIS),  which  is 
information  and  communication  system  used  for 
processing  data  on  provided,  being  provided  and 
planned  healthcare  services  shared  by  healthcare 
communication 
providers’ 
and 
systems, 
communication  systems  (Register  of  Medical 
Services  System  of  the  National  Health  Fund, 
Healthcare 
of 
of  Health  Resources,  Risks 
Registration 
Monitoring  System,  Accessibility  to  health  care 
services Monitoring System, Register of Medicinal 
Products Authorised for the Market on the territory 
of  the  Republic  of  Poland,  Integrated  System  of 
Monitoring  Trade  in  Medicinal  Products,  System 
Monitoring  Education  Medical  Professionals, 
Reimbursement  List  Operation  System)  and 
Medical registers. 

Statistics 

System, 

System 

Health  and  health-system 
reporting mechanisms 

information  and 

The collection and processing of statistical data on 
health care is governed by the Council of Ministers 
on  the  programme  of  statistical  surveys.  In  2016, 
as well as planned for 2017, the program foresees 
the  following  tests,  which  consist  of  dozens  of 
statistical  forms,  as  e.g.  health’s  status  of  the 
population,  health’s  monitoring,  hospitalisation, 
prevention,  vaccination,  economic  aspects  of 
health  care,  the  National  Health  Account  and 
others. A separate branch of IT-systems is used by 
the  National  Health  Fund  as  the  primary  payer. 
These systems  include E-health (e-prescription, e-

medical  records,  e-referrals),  a  system  for  billing 
services,  in  which  data  are  collected  both  on  the 
number  of  benefits,  types  of  benefits  and  costs  of 
benefits.  Together  with  the  characteristics  of 
this  creates  a 
patients 
(age, 
comprehensive  source  of 
information  for  an 
effective allocation of resources. 

region) 

sex, 

Health  promotion  and  disease  prevention 
policies 

to 

Public  health  has  gained  a  large  momentum  in 
2015.  The  Parliament  adopted  the  law  on  public 
health  (from  September  11th),  which  entered  into 
force 
this 
in  December  2015.  According 
legislation  new  governance, 
inter-ministerial 
coordination  and  financing  mechanisms  are  in 
place.  Overall 
spending  on  public  health 
programmes  will  increase  in  2016,  compared  to 
2015. Before 2016 total and public expenditure on 
prevention  and  public  health  services  as  a  %  of 
GDP were below the EU average (0.2% and 0.1% 
vs.  0.3%  and  0.3%  in  the  EU).  Public  and  total 
expenditure  on  prevention  and  public  health 
services as a % of current health expenditure were 
slightly below the EU average (2.7% and 2.7% in 
Poland vs. 3.1% and 3.2% in the EU in 2015). 

Transparency and corruption 

in 

regulations 

Regarding  anti-corruption 
the 
functioning  of  the  Ministry  of  Health,  this  area  is 
particularly  vulnerable  to  issues  of  lobbying, 
informal  pressures  and  corruption  proposals  in 
meetings  with  external  stakeholders,  in  particular 
with representatives of the pharmaceutical industry 
involved  in  creating  the  list  of  reimbursed  drugs. 
In  view  of  the  need  to  normalise  the  above 
mentioned  contacts,  a  special  procedure  was 
adopted on how to receive visitors in the Ministry 
of  Health.  The  procedure  provides  transparency 
rules  for  meetings  with  external  stakeholders, 
especially  in  the  context  of  possible  lobbying 
activities. The Ministry of Health collaborates with 
the  European  Healthcare  and  Corruption  Network 
(EHFCN)  since  2006.  This  cooperation  relies 
mainly  on  exchange  of  experiences,  information, 
data  and  best  practices.  The  Network  is  the  only 
international  organisation  in  Europe,  dedicated  to 
combating  corruption,  fraud  and  losses  in  health 
care systems. The Ministry of Health also took part 
in  the  awareness-raising  campaign  organised  by 
the  EHFCN,  the  aim  of  which  was  to  show  the 

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European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

scale  of  corruption  in  the  healthcare  sector  in 
Europe, by pointing to what the lost funds could be 
allocated  due  to  fraud  and  corruption  in  health. 
the 
The  Ministry  of  Health 
takes  part 
implementation  of 
“Government  Anti-
the 
Corruption  Programme  for  years  2014-2019”, 
aiming  at  reducing  the  level  of  corruption  in 
Poland. 

in 

Recently 
reforms 

legislated  and/or  planned  policy 

in 

services 

include:  1)  Changes 

Since 2012, many amendments have been made to 
basic governance laws of the health care insurance 
system.  These  related  to  the  provision  of  health 
care 
the 
contracting of health care services by the National 
Health Fund – with emphasis on the complexity of 
the services and experience of service provider; 2) 
Changes  in  primary  health  care  -  by  changing 
eligibility  requirements  for  doctors  which  could 
serve  as  a  family  physician;  3)  Changes  in  the 
financing of cross-border treatment in a State other 
than 
- 
the  Member  State  of 
implementation of EU legislation.  

affiliation 

Related  to  pharmaceuticals,  the  reimbursement 
system  was  changed.  Medicinal  products  are 
reimbursed on the basis of administrative decision 
issued by the Minister of Health. Furthermore, the 
system of fixed prices and margins was introduced. 

In  2015,  the  Act  on  public  health  was  adopted.  It 
defines specific tasks of public health and indicates 
institutions  involved  in  providing  these  tasks  and 
these  activities.  The  act 
rules  of  financing 
promotes  health  and  enhances 
the  disease 
for 
prevention 
implementation  of  these  tasks  is  the  National 
Health Programme. 

activities. 

baseline 

The 

An  amendment  to  the  provisions  of  the  Act  on 
health care services financed from public funds has 
been adopted. It sets a minimum amount of public 
expenditure  on  financing  health  care 
the 
in 
the  current 
upcoming  years.  According 
regulations, public expenditure on health care is to 
be  increased  every  year,  to  reach  at  least  6%  of 
GDP  in  2024.  Next,  the  amendment  included  the 
possibility  of  special  supplement  payments  to 
doctors, who specialise in primary care and make a 
commitment to work in Poland for a certain period 
after  completion  of  their  training  and  settled 

to 

210 

minimum  wages  for  specialists  who  meet  the 
formulated in the act criteria. 

Moreover,  changes  to  the  Act  on  healthcare 
services  financed  from  public  funds  introduced  in 
2017 a new legal institution in the form of a basic 
hospital  security  system  for  healthcare  services, 
which became the main form of securing access to 
healthcare  services 
the  field  of  hospital 
treatment and outpatient care specialist carried out 
at  hospital  outpatient  clinics.  In  the  scope  of 
services  covered  by  the  contract  concluded  under 
the  security  system,  a  new  form  of  settling  the 
costs  of  benefits  provided  was  accepted,  in  the 
form of a lump sum for a given settlement period. 

in 

From  2016  onwards,  people  aged  75  or  more 
receive certain medicines, foodstuffs for particular 
nutritional  purposes  and  medical  devices  included 
in the reimbursement list of the Ministry of Health 
for free. 

Pharmacovigilance - a key element of the adopted 
amendments  has  remodelled  the  definition  of 
"adverse  reaction  of  medicinal  product".  It  has 
basically expanded the group of people entitled to 
report  adverse  reaction  of  pharmaceuticals  (for 
instant:  patients,  nurses,  midwives,  paramedics, 
introduced  possible 
laboratory  diagnosticians), 
requirements  for  post-authorisation  studies  and 
obligation 
to 
EudraVigilance by stakeholders. 

reaction 

adverse 

report 

to 

introduced.  Until 

Moreover,  the  obligation  to  pay  health  insurance 
premiums  by  farmers  operating  in  farms  over  6 
acres  conversion  was 
the 
adoption  of  the  Act,  for  all  farmers,  premiums 
were  paid  from  the  state  budget.  In  2018,  the 
provisions  of  the  Act  amending  the  act  on  social 
insurance  for  farmers  and  some  other  acts  that 
regulate  the  issue  of  social  security  for  farmers' 
helpers  at  harvest  on  an  agricultural  holding  by 
introducing  a  new  type  of  civil  law  agreement 
came into force. Farmers have to health insurance 
premiums  for  farmer's  assistants  performing  at 
their farm activities specified in the aid agreement 
at harvest. 

The  Ministry  of  Health  prepared  a  Regional 
Healthcare  Needs  Maps  of  Poland  in  order  to 
analyse  current  and  projected  demographic  trends 
and  the  health  status  of  the  society.  The  analysis 
was  conducted  at  a  regional  level  with  respect  to 

 
Health care systems 

2.21. Poland 

available  healthcare  resources  and  infrastructure, 
identifying  needs  for  policy  reform.  Regional 
Healthcare  Needs  Maps  of  Poland  are  created  for 
each  voivodeship  and  includes  projections  of 
healthcare  needs  of  the  society  at  a  county  and 
voivodeship  level.  These  documents  provide  the 
basis  for  the  Healthcare  Needs  Map  of  Poland, 
which  additionally  contains  analysis  of  healthcare 
provided  at  national  level  (ex.:  transplantology). 
This  approach  identifies  fields  of  the  healthcare 
system,  which  require  coordinated  intervention  of 
more  than  one  voivode  or  appropriate  State 
authorities.  Identified  priorities  for  healthcare 
policy  at  regional  level  and  Regional  Healthcare 
Needs  Maps  of  Poland  should  be  taken  into 
account by the National Health Fund at the process 
of contracting of healthcare providers. This should 
lead  to  more  rational  financing  of  healthcare 
investments  and  healthcare  system,  decrease  the 
risk  of  strictly  arbitral  decisions  and  increase  the 
transparency of the system.  Until the end of 2015 
Healthcare  Needs  Maps  in  the  fields  of  oncology 
and cardiology were prepared. 

In  addition,  in  2015  the  Ministry  of  Health 
introduced  fast-track  waiting 
lists  for  cancer 
patients. They are now guaranteed diagnostics and 
treatment  within  specified  times,  and  there  are  no 
treatment.  Health  care 
limits 
financing 
providers,  who 
and 
timeliness 
ensure 
comprehensiveness of health care services, face no 
financing ceilings. 

for 

In  2016,  a  new  instrument  was  introduced  to  the 
health  care  system  that  enables  proper  assessment 
of investment projects before their implementation. 
Evaluation of the purposefulness of the investment 
is  made  on  the  basis  of  a  questionnaire  covering 
several  criteria,  including  the  implementation  of 
maps  of  health  needs  and  priorities  for  regional 
health  policy,  taking  into  account  the  desired 
directions of development of health care in Poland. 
The  provisions 
Investment 
concerning 
Applications  Assessment  Instrument  in  Health 
Care  were  amended 
in  2018,  among  others 
expanding  the  scope  of  entities  that  can  apply  for 
issuing  an  opinion  as  well  as  the  types  of 
investments that are the subject of these opinions. 

the 

In  2017,  the  Act  on  basic  health  care  was  passed, 
the  provisions  of  which  are  to  improve  the 
organisation  and  functioning  of  basic  health  care, 
as  well  as  create  conditions  for  increasing  its 

in  particular 

effectiveness.  In  particular,  it  is  important  to 
improve the coordination of care and teamwork in 
the  field  of  the  separate  competences  of  primary 
care physicians, primary care nurses and midwifes, 
and 
the 
organisation  of  patient  care  management.  By  the 
end  of  2019  a  pilot  programme  for  "Preparation, 
testing  and  implementation  of  coordinated  care 
organisation  in  the  healthcare  system"  will  be 
completed. 

improvement  of 

the 

legal  regulation  regarding 

In  2018,  the  Act  amending  the  act  on  the 
information system in health care and certain other 
acts  ware  adopted.  Together  they  constitute  a 
comprehensive 
the 
Patient's Internet Account. Thanks to this solution, 
beneficiaries  will  have  access  to,  among  others, 
the  provided  and  planned 
information  on 
healthcare  services  collected 
the  Medical 
in 
Information System, reports on the sharing of data 
concerning  them  and  the  amount  of  public  funds 
spent  on 
the  healthcare  services 
provided. 

financing 

The Act on State Emergency Medical Services was 
amended  in  2018  to  transfer  to  the  Minister  of 
Health  the  maintenance  and  technical  service  of 
the  System  for  Supporting  Command  of  the  State 
Medical  Rescue,  previously  implemented  by  the 
Minister of Public Administration. 

Challenges 

The  Polish  government  has  continued  in  recent 
years  to  tackle  the  pervasive  inefficiencies  of  the 
health system. The  main challenges for the Polish 
health system currently are as follows: 

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the increasing health care expenditure over the 
coming  decades,  as  this  is  a  risk  to  the  long-
term sustainability of public finances.   

•  To improve the basis for more sustainable and 
larger  financing  of  health  care  in  the  future. 
This  can  improve  access  and  quality  of  care 
and  its  distribution  between  population  groups 
and regional areas.  

•  To  develop  a  comprehensive  human  resources 
strategy that tackles spatial/regional disparities, 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

ensures  sufficient  numbers  of  staff  in  general, 
aims  at  increasing  the  number  of  general 
practitioners  relative  to  specialist  clinicians, 
and in the future in view of staff and population 
ageing  and  motivates  and  retains  staff  to  the 
sector and to the country.  

•  To  foster  the  reallocation  of  resources  aiming 
at  reducing  the  high  share  of  spending  on 
inpatient care and increasing the relatively low 
share  of  spending  on 
typically  more  on 
outpatient care services.  

•  To  strengthen  the  role  of  primary  health  care 
that  of  general 

within 
practitioners in their role as gatekeepers. 

the  system  and 

•  To carry out the  mapping of  health care needs 
aiming at identifying priorities for resources re-
allocation  and 
for 
investments in the health system. 

serving  as  a  basis 

•  To 

tackle 

employment 
the  multiple 
phenomenon, affecting accessibility and quality 
of  public  health  services,  and  the  widespread 
illegal use of public equipment and facilities by 
the individual practitioners.  

•  To  pursue  the  restructuring  and  reorganisation 
of  the  hospital  sector,  aiming  at  rationalising 
existing  hospital  bed  capacity  and  improving 
the  cost-efficiency  within  hospitals,  ensuring 
that  care  is  provided  in  the  most  clinically 
appropriate 
for 
example  by  maximising  the  proportion  of 
elective care provided on a day case basis, day-
of-surgery  admission;  to  closely  monitor  the 
effects on access to and quality of care related 
to  possibility  of  voluntary  transformation  of 
public 
units 
into 
hospitals 
(corporatisation).  

cost-effective  way, 

corporate 

and 

•  To  foster  a  wide  use  of  Health  Technology 
and 

Assessment 
communication technologies in health care. 

information 

and 

•  To  enhance  health  promotion  and  disease 
prevention 
disease 
screening given the most recent pattern of risk 
factors (circulatory system diseases, cancers).  

promoting 

activities, 

212 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.21.1:  Statistical Annex – Poland 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2
1
3

1,109

1,134

1,189

1,169

1,191

1,264

2,745

2,895

2005

246

13.7

3.5

:

2006

275

14.2

6.3

4.7

2007

314

15.2

7.1

8.3

2008

366

15.3

4.2

13.4

2009

317

14.8

1.8

5.3

2010

362

15.9

3.5

0.8

2011

380

16.5

5.0

2.2

2012

389

16.8

1.6

4.1

2013

395

16.9

1.5

-1.6

2014

411

17.5

3.3

0.9

2015

430

18.5

3.9

5.4

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

6.3

6.1

0.2

689

4.2

4.0

464

0.23

67.3

11.5

97.3

27.8

6.2

6.0

0.2

756

4.3

4.1

523

0.24

69.2

11.3

99.3

27.1

6.3

5.9

0.4

875

4.4

4.2

614

0.26

70.2

13.3

98.1

26.3

6.8

5.8

1.0

1,111

5.0

4.6

808

0.36

72.7

9.7

97.8

24.4

7.1

5.8

1.3

995

5.1

4.8

723

0.31

72.6

12.4

97.8

24.4

6.9

5.9

1.0

6.7

6.4

0.3

6.9

6.6

0.3

6.7

6.4

0.3

6.5

6.3

0.3

6.6

6.3

0.3

5.0

4.7

811

0.34

73.1

10.6

97.8

23.7

4.8

4.5

817

0.30

72.1

10.6

96.6

24.0

4.7

4.4

816

0.28

68.6

10.8

91.0

24.3

4.8

4.5

839

0.28

71.8

11.2

91.6

23.7

4.7

4.4

856

0.25

71.9

10.8

91.3

23.1

4.7

4.4

900

0.26

71.2

11.0

91.0

23.3

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

38.2

79.3

70.8

66.9

61.2

102

6.4

38.2

79.7

70.9

62.9

58.4

97

6.0

38.1

79.8

71.0

61.5

57.6

94

6.0

38.1

80.0

71.3

63.0

58.6

91

5.6

38.1

80.1

71.5

62.5

58.3

87

5.6

38.0

80.7

72.2

62.3

58.5

83

5.0

38.1

81.1

72.5

63.3

59.1

197

4.7

38.1

81.1

72.6

62.8

59.1

192

4.6

38.1

81.2

73.0

62.7

59.2

184

4.6

38.0

81.7

73.7

62.7

59.8

170

4.2

38.0

81.6

73.5

63.2

60.1

169

4.0

EU- latest national data

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

1.8

0.1

1.1

1.7

0.2

0.1

0.1

1.7

0.1

0.6

0.7

0.1

0.1

0.1

1.8

0.1

1.2

1.7

0.2

0.1

0.1

1.7

0.1

0.7

0.7

0.1

0.1

0.1

1.9

0.1

1.2

1.6

0.2

0.1

0.1

1.8

0.1

0.7

0.6

0.1

0.1

0.1

2.2

0.1

1.4

1.6

0.2

0.2

0.1

2.1

0.1

0.8

0.6

0.1

0.1

0.1

2.2

0.1

1.5

1.7

0.2

0.2

0.1

2.2

0.1

0.9

0.6

0.1

0.1

0.1

2.2

0.1

1.4

1.6

0.1

0.1

0.1

2.1

0.1

0.8

0.6

0.1

0.1

0.1

2.1

0.1

1.4

1.5

0.1

0.1

0.1

2.0

0.1

0.8

0.6

0.1

0.1

0.1

2.1

0.1

1.4

1.4

0.2

0.1

0.1

2.0

0.1

0.8

0.5

0.1

0.1

0.1

2.2

0.1

1.4

1.4

0.1

0.2

0.2

2.1

0.1

0.8

0.4

0.1

0.1

0.2

2.1

0.1

1.4

1.3

0.2

0.2

0.1

2.0

0.1

0.8

0.5

0.1

0.1

0.1

2.2

0.1

1.5

1.3

0.2

0.2

0.1

2.0

0.1

0.8

0.5

0.1

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
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Table 2.21.2:  Statistical Annex - continued – Poland 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

29.0%

1.9%

18.6%

28.6%

2.6%

2.3%

1.5%

42.3%

2.8%

15.9%

16.4%

1.7%

2.5%

2.2%

2005

0.20

:

0.8

:

:

:

9.5

2005

214

509

14

690

2005

6.3

14

2006

30.0%

1.6%

19.5%

28.3%

2.7%

2.3%

1.5%

42.7%

2.4%

16.3%

16.0%

2.0%

2.5%

2.2%

2006

0.19

:

0.9

:

:

:

10.4

2006

218

509

14

617

2006

6.6

14

2007

32.5%

1.8%

20.6%

26.8%

2.9%

2.4%

2.0%

44.3%

2.5%

16.9%

14.2%

1.9%

2.4%

2.9%

2007

0.27

:

1.0

:

:

:

10.9

2007

219

518

16

608

2007

6.8

14

2008

37.4%

2.2%

23.6%

27.2%

3.1%

2.6%

1.9%

45.6%

2.8%

17.8%

13.2%

1.7%

2.2%

2.4%

2008

0.29

0.7

1.1

0.1

16.4

23.8

11.4

2009

38.4%

2.4%

25.7%

28.4%

2.8%

2.8%

1.7%

44.6%

2.9%

18.9%

13.3%

1.2%

2.1%

2.1%

2009

0.37

0.8

1.2

0.0

15.8

23.8

10.7

2008

2009

216

519

22

559

2008

6.8

14

217

525

21

553

2009

6.8

16

2010

37.5%

2.5%

24.2%

27.1%

2.4%

2.4%

1.5%

45.0%

3.0%

17.7%

13.4%

1.1%

2.1%

1.9%

2010

0.47

0.9

1.4

0.0

:

:

10.6

2010

217

524

21

546

2010

6.6

15

2011

33.1%

2.2%

22.0%

24.2%

2.2%

2.2%

1.7%

44.4%

3.0%

17.7%

13.5%

1.1%

2.0%

2.2%

2011

0.48

1.0

1.3

0.0

:

:

10.9

2011

219

521

20

535

2011

6.8

16

2,105

2,685

2,818

2,894

3,770

4,050

4,362

:

7.9

13.7

2016

4.3

4.3

2016

38.0

:

7.6

16.2

2020

4.3

4.5

2020

37.9

:

7.8

17.2

2025

4.4

4.7

2025

37.7

:

7.9

:

2030

4.5

4.9

2030

37.2

:

7.7

19.4

2035

4.7

5.2

2035

36.6

:

7.6

20.7

2040

4.8

5.4

2040

35.8

:

7.4

21.8

2045

4.9

5.6

2045

35.1

2012

32.0%

2.0%

21.9%

21.4%

2.3%

2.0%

1.2%

45.6%

3.0%

18.5%

10.6%

1.4%

2.0%

1.8%

2012

0.55

1.1

1.5

0.0

:

:

10.8

2012

223

:

22

528

2012

7.0

:

:

:

7.1

:

2050

5.0

5.8

2050

34.4

2013

33.7%

2.2%

22.1%

21.6%

2.2%

2.5%

2.7%

45.6%

2.9%

18.0%

9.8%

1.3%

2.7%

3.8%

2013

0.68

1.1

1.7

0.0

:

:

11.6

2013

224

527

22

523

2013

7.1

16

2014

33.8%

2.2%

22.4%

21.4%

2.4%

2.7%

2.2%

45.5%

2.9%

17.9%

10.2%

1.4%

2.7%

3.2%

2014

0.66

1.1

1.6

0.1

16.7

22.7

10.7

2015

33.9%

2.2%

23.2%

21.0%

2.4%

2.7%

1.6%

45.9%

2.9%

18.0%

10.1%

1.6%

2.7%

2.3%

2015

0.76

1.2

1.7

0.1

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2014

2015

2009

2011

2013

2015

231

524

22

524

2014

7.2

17

233

520

22

518

2015

7.4

16

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

4,328

4,547

4,437

6,362

6,584

76.4

7.8

29.1

:

7.0

21.1

2055

5.1

5.9

2055

33.6

:

6.9

21.5

2060

5.2

6.0

2060

32.8

:

7.3

21.0

2065

5.2

6.1

2065

32.0

77.1

8.0

28.0

2070

5.2

6.0

2070

31.0

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Poland

0.8

1.7

EU

0.9

1.6

Change 2016-2070, in %

Poland

-18.4

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.22. PORTUGAL 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

In  2015,  Portugal’s  GDP  was  around  €180  bn  or 
21,400 PPS per capita, below the EU average GDP 
per  capita  of  €29,600. The  population  of  Portugal 
is estimated to be around 10 million inhabitants in 
2016.  Over  the  coming  decades  it  is  projected  to 
fall gradually to 8.0 by 2070. This decrease of 23% 
contrasts with the expected increase of 2% for the 
EU as a whole. 

Total and public expenditure on health as % of 
GDP 

Total expenditure (311) on health as a percentage of 
GDP  (9.1%  in  2015,  latest  available  data)  has 
fallen since its peak of 10.8 in 2008 and is below 
the EU average (312) of 10.2% in 2015. Throughout 
the  last  decade,  public  expenditure  has  decreased 
as % of GDP: from 7.1% in 2009 to 6.1% of GDP 
in 2015 (EU: 7.8% in 2015), although it has been 
relatively stable from 2013. Looking at health care 
without  long-term  care(313)  reveals  a  smaller  gap 
between  public  spending  in  Portugal  and  the  EU 
average (5.9% vs 6.8% in 2015). 

When  expressed  in  per  capita  terms,  also  total 
spending  on  health  at  1,942  PPS  in  Portugal  in 
2015  was  far  below  the  EU  average  of  3,305.  So 
was public spending on health care: 1,297 PPS vs. 
an average of 2,609 PPS in 2015.  

Expenditure projections and fiscal sustainability  

As a consequence of population ageing, health care 
expenditure  is  projected  to  increase  by  2.4  pps  of 
GDP,  above  the  average  growth  expected  for  the 
EU  of  0.9  pps  of  GDP,  according  to  the  "AWG 

(311) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(312) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(313) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

reference scenario". When taking into account the 
impact  of  non-demographic  drivers  on  future 
spending growth (AWG risk scenario), health care 
expenditure  is  expected  to  increase  by  3.3  pps  of 
GDP from now until 2070 (EU: 1.6) (314).  

Portugal faces low fiscal sustainability risks in the 
short run.  

Risks  appear,  on  the  contrary,  to  be  high  in  the 
medium  term  from  a  debt  sustainability  analysis 
perspective due to the still high stock of debt at the 
end of projections (2028).  

In the long term, Portugal appears to face medium 
fiscal sustainability risks ( 315).  

Health status 

In  the  last  decades,  the  health  status  of  the 
Portuguese population has improved considerably. 
This  evolution  seems 
to  be  correlated  with 
increases  in  financial  resources  devoted  to  health 
care  and  to  improvements  in  socio-economic 
conditions. Life expectancy (84.3 years for women 
and  78.1  for  men  in  2015)  is  just  above  the  EU 
average  (83.3  for  women  and  77.9  for  men). 
However,  healthy  life  years  (55  years  for  women 
and  58.2  for  men  in  2015)  are  below  the  EU 
average  (63.3  and  62.6  respectively).  Infant 
mortality  is  below  the  EU  average  (2.9‰  vs. 
3.6‰).  The 
and 
tuberculosis  has  been  defined  as  a  public  health 
priority.  

incidence  of  HIV/AIDS 

System characteristics  

Coverage 

A  National  Health  Service  (NHS)  provides  100% 
population coverage (to all the resident population 
and  Portuguese  citizens).  The  NHS  is  mainly 
funded  by  general  taxation.  There  are  also  a 
number  of  complementary  public  and  private 
health 
"health 
schemes 
subsystems")  covering  certain  professions.  These 
include the banking sector private schemes and the 
three  public  subsystems  for  civil  servants,  police 

insurance 

(called 

(314) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(315) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

215 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

and military (ADSE, SAD and ADM). ADSE and 
SAD  are  funded  on  a  voluntary  basis  by 
employees' contributions collected centrally, while 
ADM  is  also  funded  by  state  budget.  These 
schemes cover about 14% of the population. 

Administrative  organisation  and 
collection mechanism  

revenue 

The  budget  for  the  health  sector  is  defined 
annually in parliament when the general budget is 
recent  years,  authorities  have 
approved. 
the  budget 
tightened 
execution.  The 
information  system  has  been 
strengthened  and  financial  flows  are  regularly 
followed up on both an accrual and cash basis. 

In 
the  monitoring  over 

In 2015, 66.8% of total health expenditure funding 
came from government sources (direct and indirect 
taxes  collected  centrally).  The  remaining  part  is 
private  expenditure  on  health  including  private 
voluntary  health 
insurance  and  out-of-pocket 
payments.  A  large  part  of  private  expenditure  is 
out-of-pocket  which  represents  27.7%  of  total 
expenditure  on  health  (EU  average  of  15.9%  in 
2015), showing an increase since 2005 (23.3) but a 
decrease  since  2010  (28.2).  The  rest  comes  from 
private insurance.  

The  Ministry  of  Health  sets  the  national  health 
policy  strategy,  defining  public  health  and  policy 
priorities,  specifying  the  regulatory  framework, 
defining the system organogram and providing the 
overall management of the health care system.  

is 

responsible 

The "Administração Central do Sistema de Saúde" 
(ACSS)  implements  the  decisions  of  the  Ministry 
of  Health  under  its  supervision.  It  coordinates, 
monitors and controls NHS resource allocation and 
use, human resources policies and health facilities 
management.  The  ACSS 
for 
defining  the  budget  allocation  across  regions  and 
areas  of  provision  (e.g.  contractos-programa  for 
hospitals),  for  defining  hospital  capacity  and  the 
service  network  (e.g.  definition  of  health  centres 
and hospital catchment areas and services provided 
by  different  hospitals)  and  for  developing  the 
contracting procedures  within the sector.  ACSS is 
also responsible for defining financial and activity 
targets  and  for  monitoring  the  financial  and 
activity  flows 
the  system.  Together  with 
"Servicos  Partilhados  do  Ministerio  da  Saúde" 
for  developing 
responsible 
(SPMS), 

in 

is 

it 

information  systems 
that  support  monitoring, 
assessment  and  policy  implementation  in  the 
system.  

The "Servicos Partilhados do Ministerio da Saúde"  
is  the  centralised  purchasing  agency  for  the 
Ministry  of  Health  and  tenders  for  and  purchases 
centrally  a  variety  of  medical  goods  and  services 
from  medicines  and  medical  devices  to  ICT 
Agency 
services. 
for 
"National 
The 
in  charge  of 
Pharmaceuticals"  (Infarmed) 
developing 
and 
and 
reimbursement  policies,  clinical  and  economic 
evaluation  and  monitoring  prescription  and 
dispensing practices together with SPMS.   

is 
implementing  pricing 

There  are  also  five  regional  health  authorities 
which  are  responsible  for  implementing  public 
health  objectives  and  for  purchasing  primary, 
specialist  and  hospital  care  for  their  respective 
catchment population under the framework defined 
by 
the  ACSS.  Nevertheless,  decision-making 
remains  highly  centralised  (which  may  actually 
have  helped  with  the  implementation  of  cost-
containment policies in recent times).  

Role  of  private  insurance  and  out  of  pocket 
co-payments  

Co-payments  (fixed  fees)  apply  to  primary  care 
and  specialist  consultations,  hospital  care,  home 
care  and  emergency  care.  Fees  are  lower  for 
primary  care  than  for  specialist  consultations  and 
these are lower than emergency care to encourage 
a  more  cost-effective  path  of  care.  Cost-sharing 
also  applies  to  pharmaceuticals  (a  share  of  the 
price)  and  public  coverage  of  eye  care  and  dental 
care  is  limited.  There  are  exemptions  based  on 
income, 
(e.g. 
fireman)  and  certain  medical  conditions.  As  a 
result,  more  than  55%  of  the  population  is 
in  publicly 
exempted  from  any  cost-sharing 
provided/ publicly funded services and goods.  

for  certain  population  groups 

The  take  up  of  private  voluntary  health  insurance 
has  been  growing  over  the  years,  mainly  through 
employers  as  benefits  package.  20.2%  of  the 
population 
takes  up  private  voluntary  health 
insurance,  but  it  only  accounts  for  5.5% of  health 
expenditure in 2015.  

216 

 
Coverage  of  services,  types  of  providers, 
referral systems and patient choice 

The  NHS  provides  coverage  for  a  wide  range  of 
health  care  services  and  goods.  NHS  supplies 
primary  health  care  (including  family  medicine, 
pre-natal and post-natal follow up, prevention and 
promotion), outpatient specialist consultations and 
hospital  care  (day-case  and  inpatient)  directly 
through  a  network  of  publicly  owned  facilities. 
The  NHS  also  provides  a  wide  range  of  related 
services 
services, 
physiotherapy  and  dialysis  care  either  directly  or 
through contracts with private providers. 

diagnostic 

including 

Primary  care  functions  as  the  central  pillar  of  the 
system.  NHS  primary  health  care  is  provided 
through  a  network  of  group  practices  which 
include  health  centres,  the  more  recent  Family 
Health  Units  (Unidades  de  Saude  Familiares  - 
USFs) and mobile units to outreach the more rural/ 
isolated  parts  of  the  country.  There  is  a  24-hour 
primary  care  and  paediatric  counselling  phone 
helpline.  Primary  care  provision 
is  mostly 
performed by the public sector.  

in  place 

Residents  have  to  register  with  a  family  doctor  (a 
general  practitioner  –  GP).  As  about  7,7  of  the 
population is not currently registered with a family 
doctor  (October  2018  data),  a  national  patient 
registry  has  been  put 
to  eliminate 
duplicate registration, identify vacancies in family 
doctors lists and allocate patients to family doctors. 
NHS  family  doctors  refer  patients  for  specialist 
care,  operating  as  gatekeepers.  In  other  words,  a 
compulsory  referral  system  is  in  place  from 
primary  care  and 
the 
outpatient specialist. NHS outpatient consultations 
typically 
in  hospital  outpatient 
departments.  There  is  an  integrated  nationwide 
electronic system to manage primary care referrals 
to  specialty  consultations  across  the  country.  This 
aims 
to  specialist 
consultations.  

the  family  doctor 

timely  access 

take  place 

to  ensure 

to 

The  NHS,  through  a  network  of  general  and 
specialised  hospitals  (including  3  oncological 
centres), provides most of the outpatient specialist 
care  and  hospital  day-case  and  inpatient  care.  In 
order  to  improve  access  and  reduce  the  waiting 
time for hospital surgery, authorities have in place 
an  integrated  central  and  nationwide  electronic 
system  to  manage  patients  on  waiting  list.  In 

Health care systems 

2.22. Portugal 

times  for  visits 

addition,  they  have  introduced  clinically  defined 
maximum  waiting 
to  GPs, 
outpatient  specialist  consultations  and  hospital 
surgery.  The  NHS  also  contracts  hospital  services 
from several private and social entities. When 75% 
of  the  maximum  waiting  time  for  surgery  has 
elapsed,  the  patient  can  choose  a  private  provider 
to  have  access  to  care.  This  mechanism  has 
allowed  reducing  waiting  times  for  surgery  by 
more  than  50%  since  2006.  The  vast  majority  of 
hospitals  are  public  (85.7%  of  total  acute  care 
beds,  with  6.6%  owned  by  private  not-for-profit 
hospitals  and  7.7%  owned  by  private  for-profit 
hospitals). 

Ambulatory diagnostic services, physiotherapy and 
dialysis  care  are  often  provided  by  the  private 
sector (private for-profit and not-for-profit entities) 
contracted  by  the  NHS  to  provide  care  for  NHS 
users. The contracting rules have been harmonised 
with  NHS  conditions  (e.g.  fees  have  been  aligned 
with NHS costs) in recent years. Since 2013, NHS 
developed  the  legal  framework  to  implement 
tender  processes  to  select  providers  thought  the 
lowest bid increasing providers’ competition. 

In addition, those who have enrolled in one of the 
public  sub-systems  have  directly  access 
to 
specialist or hospital care allowed by their scheme 
(which  contracts  only  private  specialists  or 
hospitals)  or  provided  by  their  own  facilities.  For 
these  patients  service  coverage  overlaps  to  a 
certain  extent  with  that  of  the  NHS,  notably  in 
terms  of  mainstream  ambulatory  specialties.  The 
government  also  has  a  system  of  vouchers  for 
dental care for certain population groups (pregnant 
women,  elderly  beneficiaries  of  the  solidarity 
supplement  and  young  people  under  16  years) 
based  on  an  indication  of  a  family  doctor  and 
based  on  clinical  criteria.  The  goal  is  to  improve 
access  to  these  services  as  NHS  coverage  is 
limited. For low income populations, there are also 
additional  benefits,  e.g. 
increased  medicines 
reimbursement, prescription glasses. 

Finally,  specialist  outpatient  care  can  also  take 
place  in  specialists'  private  individual  or  group 
practices  and  hospital  care  in  private  clinics  and 
hospitals  for  private  users  at  the  cost  of  patient. 
Often,  private  provision,  especially  outpatient 
consultations, is conducted by the same specialists 
that  work  for  the  NHS  although  the  public  wage 
and working time is adjusted accordingly.  

217 

 
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In  mainland  Portugal  (public  sector,  august  2018) 
there  are   29,481  practicing  physicians  (2.93  per 
1,000  inhabitants)  and  they  are  disaggregated  by 
specialists  (19,304)  and  interns  (10,177).  The 
specialty  of  family  medicine  started  in  the  early 
eighties  and  is  recognised  worldwide  as  it  can  be 
verified  by  The  "World  Health  Report  2008"  - 
primary health care ("Now More Than Ever") and 
"World  Organisation  of  Family  Doctors"  reports. 
Within the total number for public sector, there are 
(0.56  per  1,000 
5,598 
family  physicians 
inhabitants,  year  2018)  working 
family 
in 
practices. 

Portugal  suffered  from  staff  shortages  and  an 
unequal  distribution  of  resources  with  a  high 
concentration  of  physicians  including  GPs  in  big 
urban  areas  and  a  higher  concentration  in  the 
region  Centro.  To  address  these,  two  medical 
degrees were created – with a focus on improving 
the  skill  mix  towards  primary  care  and  needed 
specific specialties – and mobility rules have been 
changed slightly.  Also, a small  monetary bonus is 
given  to  doctors  who  moved  to  disadvantaged 
areas  and  further  measures  have  been  taken  to 
encourage the mobility of doctors and other health 
workers.  Acute  hospital  beds  stand  at  326  per 
100,000 inhabitants in 2015 below the EU average 
of  4026  per  100,000  inhabitants,  showing  a 
reduction over the decade with the increase of one 
day surgery and long term care network.  

regulation 

Staff  supply  is  regulated:  there  are  quotas  for 
medical students and by specialty and there is now 
some 
the  opening  of 
regarding 
vacancies to improve staff distribution. In addition, 
the  definition  and  adoption  of 
the  recently 
developed  3-year  hospital  strategic  plans  has 
implications  for  staff  distribution  and  vacancies. 
Authorities are also developing a human resources 
planning  instrument  to  help  identify  in  which 
geographic  areas  or  medical  specialties  there  may 
be  staff  shortages  developing  and  adjust  training 
accordingly.  

Purchasing  and  contracting  of  healthcare 
services and remuneration mechanisms 

Remuneration is defined by the government. USFs 
primary  care  doctors  receive  capitation  wages 
which  are  based  on  the  characteristics  of  the 
population  served  and  pay  for  performance.  In 
addition, as USFs are part of an ongoing reform to 

218 

create  more  autonomous  and  multidisciplinary 
teams  in  primary  care  and  incentives  for  better 
performance  (e.g.  better  follow  up  of  patients, 
notably  chronic  patients,  better  pre  and  post-natal 
care, more cost-effective use of medicines). In this 
context a small performance-related team bonus is 
paid to the practice on the basis of achieving pre-
negotiated targets. Health centres' doctors receive a 
salary.  

NHS  specialists  working  in  hospitals  are  paid  a 
salary.  Hospitals  are  paid  on  prospective  global 
budgets  based  on  DRGs,  with  the  possibility  to 
reallocate  resources  across  cost-categories.  In 
addition  to  the  transfers  from  the  government, 
hospitals generate their own revenue, through flat-
rate  user  charges  for  outpatient  and  diagnostic 
services,  special  services  (e.g.  individual  private 
rooms) and from privately insured patients. 

Doctors  in  outpatient  private  practices  are  paid  a 
fee for service and are paid a wage when providing 
hospital services. 

than 

lower 

Doctors'  consultations  per  capita  were  below  the 
EU average in 2012 (4.1 vs. 6.2). When looking at 
hospital  activity,  inpatient  discharges  per  100 
inhabitants  are 
the  EU  average 
(respectively  7.8  vs.  16.5)  while  day-cases  per 
100,000 inhabitants are higher at 8,243 vs. 7,635 in 
2015.  The  proportion  of  surgical  procedures 
conducted as day cases (51.2%) is therefore much 
higher  than  the  EU  average  of  32.3%  in  2015. 
Hospital average length of stay for curative care is 
above  the  EU  average  (8.8  days  vs.  7.6  days  in 
2015),  though  this  may  be  a  result  of  having  a 
greater proportion of complex cases as inpatient. 

Measures  of  input,  process,  output  and  outcome 
are used on a regular basis to compare the relative 
performance  of  hospitals  (available  at  a  website). 
This  process  has  been  extended  to  primary  care 
providers since 2014. 

There  have  been  however  increasing  concerns 
about  hospital  arrears,  which  have  continued  to 
increase  over  the  last  few  years  and  required 
several  injections  of  money  from  the  Ministry  of 
Finance.  

Although 
increasing  demand  and  personnel 
expenses  have  been  cited  as  factors,  the  recurrent 
in  certain  hospitals 
accumulation  of  arrears 

 
highlights  possible 
issues  of  under-budgeting, 
monitoring and budget-enforcement practices. The 
periodic  injections  of  funds  for  clearing  arrears 
alleviates  the  impact  on  suppliers,  but  so  far  does 
not  appear  to  tackle  the  underlying  hospital 
management 
their 
accumulation.  

issues  which 

lead 

to 

in 

The  matter  of  arrears  is  a  top  priority  for  the 
Health  and  Finance  Ministries.  For  that  purpose 
the  ‘Estrutura  de  Missão  para  a  Sustentabilidade 
do  Programa  Orçamental  da  Saúde’  was  created. 
This  Structure  was  designed  to  follow  up  on  the 
financial  performance  of  the  entities  that  are 
integrated  in  the  national  health  budget  program, 
and  intends  to  identify  and  evaluate  any  budget 
imbalances as well as promote measures that favor 
stability and sustainability. 

The  market  for  pharmaceutical  products,  the 
use  of  Health  Technology  Assessment  and 
cost-benefit analysis 

on 

clinical 

performance, 

The  authorities  have  in  place  a  large  number  of 
policies to control expenditure on pharmaceuticals. 
The  initial  price  of  all  reimbursable  medicines  is 
based 
economic 
evaluation,  the  cost  of  existing  medicines  and 
the  minimum 
international  prices  (based  on 
manufacturing price in ES, FR and Italy for 2018). 
Overall  payback  agreements  and  specific  payback 
and  price-volume  agreements  control  expenditure 
directly.  The  authorities  apply  internal  reference 
pricing,  whereby  the  maximum  reimbursement 
level of a product is based on the average of the 5 
cheapest  products  of  same  active  ingredient,  form 
and  dosage.  There  is  a  positive  list  of  reimbursed 
products  which  is  based  on  health  technology 
assessment information.  

promote 

authorities 

In  addition  to  compulsory  e-prescription  and  INN 
rational 
prescription, 
prescribing  of  physicians  through  compulsory 
treatment  guidelines  or  practice  protocols  and 
prescription  targets  in  primary  care.  Pharmacies 
have to dispense one of the five cheapest products 
of 
is 
complemented with monitoring of prescribing and 
dispensing 
and 
information campaigns on the prescription and use 
of  medicines.  Direct  advertisement  of  reimbursed 
pharmaceuticals is not allowed.  

ingredient.  This 

behaviour 

education 

active 

same 

and 

the 

Health care systems 

2.22. Portugal 

Portugal has made a very strong effort to promote 
the  use  of  generics  and  there  is  an  explicit  policy 
target  on  generics  equal  to  60%  for  the  NHS 
market.  The  price  of  generics  must  be  50%  less 
than the branded product when it enters the market 
and  subsequent  price  reductions  apply.  Generics 
application  for  pricing  and  reimbursement 
is 
evaluated faster than other medicines and legal and 
administrative  rules  have  been  simplified.  These 
new regulations, in the medicines department, have 
led  to  an  increase  in  the  use  of  generics.  The 
Infarmed 
controls 
regulates 
pharmaceuticals)  publishes  an  annual  statistical 
report on sales growth of pharmaceuticals and the 
impact on the NHS and on patients direct cost. 

(that 

and 

E-health  (e-prescription,  e-medical  records) 
and information and reporting mechanisms; 

The  authorities  have  introduced  a  number  of  e-
health  actions  including  the  individual  electronic 
NHS  card,  e-prescribing,  e-appointments  and 
electronic  patient  records.  These  e-actions  help 
improving  monitoring  and  control  of  prescription 
and consumption of services and goods and render 
the  referral  system  and  care  coordination  more 
effective, 
the  use  of  unnecessary 
pharmaceutical,  specialist  and  hospital  emergency 
care. 

reducing 

Health  promotion  and  disease  prevention 
policies 

Despite  the  large  health  improvement  since  the 
1970s, the authorities point to the need to improve 
health  status  further 
through  promotion  and 
prevention  activities.  Moreover,  the  authorities 
propose  to  continue  the  ongoing  primary  care 
reform  to  reinforce  promotion  and  prevention  for 
all  including  to  those  who  are  more  vulnerable  or 
at  greater  risk.  The  National  Health  Plan  2012-
2016 defined strategies, priorities and targets to the 
development of health prevention policies. 

Transparency and corruption 

Since  2011,  different  measures  have  been 
implemented  to  address  corruption  and  increase 
transparency.  In  terms  of  addressing  corruption, 
the  Ministry  of  Health  developed  a  structured 
partnership with the judicial and police authorities, 
and  created  an  anti-corruption  intra-ministerial 
coordination  group.  With  the  aim  of  preventing 

219 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

of 

reinforcing 

automation 

competition 

corruption,  several  legal  frameworks  have  been 
improved, 
and 
transparency  (e.g.  medical  prescription,  public 
invoice 
contracting).  The 
verification  (e.g.  medicines,  ancillary  exams,  long 
term care) increased the ability to detect fraud and 
increased  dramatically  the  number  of  criminal 
prosecutions.  In  parallel,  since  September  2011, 
financial, economic (P&L), activity, efficiency and 
quality  data  is  publicised  monthly  for  each  NHS 
institution,  contributing  to  the  transparency  of  the 
all health system. 

Recently 
reforms  

legislated  and/or  planned  policy 

the  hospitals.  This 

As  previously  mentioned,  the  creation  of  the 
‘Estrutura  de  Missão  para  a  Sustentabilidade  do 
Programa Orçamental da Saúde’ proposes that the 
Health and Finance Ministries are given tools that 
allow  them  to  identify  budget  imbalances,  and  so 
promote  approaches  that  favor  the  stability  and 
sustainability  of 
includes 
measures  that  contribute  to  the  reduction  of 
payment deadlines towards suppliers of the health 
sector. In addition, the Structure has the objective 
of  presenting  medium  term  strategic  options  that 
will  contribute  to  the  sustainability  of  the  NHS. 
For this, there  will be the need to produce studies 
in  the  financial,  investment  and  global  resource 
management  areas  as  well  as  in  the  organisation 
model. 

Recent policy response 

Fiscal consolidation to bring government revenues 
and  spending  into  line  had  implications  for  the 
health sector through the adoption of a wide range 
of  reforms  in  this  area.  Reforms  aimed  at  further 
improving  its  efficiency  and  controlling  spending 
in this area. Recent policies included:  

−  Review  and  increase  overall  NHS  moderating 

mainly emergency services; 

−  Enacted 

legislation  which 

automatically 
reduces  the  prices  of  medicines  when  their 
patent  expires  to  50  per  cent  of  their  previous 
price; 

220 

−  Annual  revision  of  prices  of  medicines  and  of 
countries  of  reference  in  order  to  achieve  cost 
savings;  

−  Improvement  of  the  monitoring  system  of 

prescription of medicines and diagnostic; 

−  Enacted  compulsory  prescriptions  by  INN  for 
physicians  at  all  levels  of  the  system,  both 
public  and  private,  to  increase  the  use  of 
generics and biosimilar  medicines and the  less 
costly available products; 

−  Enacted  legislation  aimed  at  removing  all 
effective  entry  barriers 
for  generic  and 
biosimilar medicines, in particular by reducing 
administrative/legal hurdles and timeframes for 
its  health  technology  assessment  in  order  to 
speed  up 
the  use  and  reimbursement  of 
generics;  

and 

−  Enacted  prescription  guidelines  with  reference 
to  medicines 
of 
complementary  diagnostic  exams  on  the  basis 
of  international  prescription  guidelines  and 
integrated  them  in  the  electronic  prescription 
system; 

realisation 

the 

−  Reinforcement of the centralised acquisition of 
vehicles,  utilities,  external  services  and  other 
cross functional goods and services; 

−  Enacted  measures 

increase  competition 
to 
among private providers and reduction of fees;  

−  As part of the reorganisation of health services 
provision  and  notably  the  concentration  and 
specialisation  of  hospital  services  and  the 
further development of a cost-effective primary 
care  service,  reinforcement  measures  aimed  at 
further  reduce  unnecessary  visits  to  specialists 
improve  care 
and  emergencies  and 
coordination; 

to 

−  On  the  basis  of  a  comprehensive  set  of 
indicators,  publication  of  regular  trimestral 
reports 
performance 
(benchmarking); 

comparing 

hospital 

−  Ensured  full  interoperability  of  IT  systems  in 
time 

to  gather 

in  order 

hospital, 

real 

 
Health care systems 

2.22. Portugal 

information  on  hospital  activities  and 
produce monthly reports; 

to 

−  Set-up of a system of patient electronic medical 
records and ensure access to all relevant health 
care facilities; 

−  Increased freedom of choice of providers in the 
NHS to ensure competition and more access to 
care provision; 

−  Implementation  of  health  education,  literacy 

and self-care program. 

−  Reorganisation  and 

network 

rationalisation  of 
through 

the 
hospital 
specialisation, 
concentration  and  downsizing  of  hospital 
services, joint management and joint operation 
of hospitals; 

−  Updated  the  legal  framework  applying  to  the 
organisation  of  working  time  of  healthcare 
staff;  

−  Reduction of patient transportation costs. 

Policy changes under preparation/adoption 

Possible future policy changes 

Some possible future policy changes include: 

−  Integrating  primary  care,  hospital  services  and 

continuous care; 

−  Increasing  access  at  the  primary  care  level  by 
enabling  the  possibility  to  contract  services 
with private primary care units; 

−  Taking  measures  to  organise  and  prepare  the 
health sector to face an ageing population; 

There 
preparation/adoption: 

are 

several 

policies 

under 

−  Increase  price  competition  for  generics  and 

biosimilar; 

−  Strengthening  the  model  of  integrated  care,  in 
permanent  coordination  between  the  Ministry 
of  Health  and 
the  Ministry  of  Labour, 
Solidarity  and  Social  Security,  to  consolidate 
the  co-responsibility  between  both  sectors, 
which guaranteeing access to care that meet the 
health  and  social  needs  of  patients’  chronic 
conditions  and  of  people 
in  situation  of 
dependence; 

−  Implementation  of  the  figure  of  the  family 

nurse (in line with family doctor); 

−  Implementation  of  an  integrated  management 

program for chronic disease;  

−  Dissemination 

health 
information 
professionals about new medicines (innovation, 
biosimilar, generics) and other relevant aspects; 

to 

−  Create  incentives  to  hospitals  for  the  use  of 

generics and some specific biosimilar; 

−  Give  benchmark  information  and  monitor  the 
consumption  of  medicines  and  its  expenditure 
in hospitals; 

−  Improve  health  technology  assessment  and 
economic  evaluation  of  specific  groups  of 
medical devices; 

−  Develop  a 
resources; 

forecast  mapping 

for  human 

consumption of medical devices. 

−  Implement  a  system  for  monitoring  hospital 

−  Implementation  of  measures  for 

territorial 
distribution  of  services  to  ensure  equity  in 
access and rationality in care provision; 

−  Development  of  services  according  to  the 

European Network of Reference Centres; 

Challenges 

The  analysis  above  shows  that  a  wide  range  of 
reforms have been implemented over the years, to 
a  large  extent  successfully  (e.g.  the  policies  to 
control 
to 
strengthen  primary  care  or  to  reduce  hospital  use 
or to improve data collection and monitoring), and 
which  Portugal  should  continue  to  pursue  and 

pharmaceutical 

expenditure 

or 

221 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

consolidate.  The  main  challenges 
for 
Portuguese health care system are as follows:  

the 

pharmaceuticals  and  before  buying  new 
equipment.  

•  To  further  enhance  health  promotion  and 
disease  prevention  activities  i.e.  promoting 
healthy  life  styles  and  disease  screening  given 
the recent pattern of risk factors (diet, smoking, 
alcohol, obesity) in various settings (at work, in 
school).  The  authorities  could  also  consider 
what  other  complimentary  measures  such  as 
higher  excise  taxes  on  tobacco,  alcohol,  soft-
drinks  or  tighter  road  safety  measures  could 
complement  existing  measures  including  the 
smoking ban recently introduced.  

increasing 

the  numbers  and 

•  To continue to enhance primary care provision 
by 
spatial 
distribution  of  GPs  and  nurses  and  increasing 
opening  hours  in  health  centres.  This  could 
reducing 
improve  access 
unnecessary  use  of  hospital  care  and  therefore 
overall  costs.  This  can  be  helped  through 
implementing 
the  comprehensive  e-agenda 
planned by the authorities.  

to  care  while 

•  To  investigate  if  there  is  room  to  include  an 
element  of  activity 
in 
outpatient  care  (e.g.  through  the  use  of  mixed 
payment  schemes)  to  induce  a  higher  number 
of outpatient consultations.  

related  payment 

•  To  increase  hospital  output  per  bed  while 
reducing  the  use  of  unnecessary  hospital  care 
and  to  strengthen  the  management  and  the 
budget  control  of  hospitals.  In  addition  to 
consolidate/  finalise  the  measures  pursued  in 
recent years to reduce duplication and improve 
efficiency  and  quality  in  the  hospital  sector 
(e.g.  concentration  and 
specialisation  of 
hospitals  within  regions),  authorities  could 
perhaps  also  consider  including  an  element 
in  hospital 
related  payment 
performance 
budgeting 
using 
procedures 
information  on  output  and  outcomes.  They 
could  also  consider  increasing  the  supply  of 
follow-up care for long-term care patients so as 
to  reduce  the  unnecessary  use  of  acute  care 
settings for long-term care patients.  

notably 

•  To  continue 

to 

improve  decision-making 
coherence  across  levels  of  government  and 
between  the  NHS  central  authority  and  its 
regional branches.  

•  To  improve  data  collection  in  some  crucial 
areas  such  as  resources  and  care  utilisation. 
Better monitoring of activity in the sector could 
be  used  for  planning  and  budgeting  purposes. 
This  should  include  efforts  to  assess  and 
publish evaluations of  the quantity and quality 
of  care  provided  by  the  various  providers  for 
the  use  of  health 
increase 
example.  To 
technology  assessment 
in  decision-making, 
including  for  assessing  new  equipment  or 

222 

 
Table 2.22.1:  Statistical Annex - Portugal 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

159

21.3

0.6

:

2005

10.4

9.4

0.9

2006

166

21.8

1.4

-1.7

2006

10.0

9.1

0.9

2007

175

21.9

2.3

1.9

2007

10.0

9.1

0.9

2008

179

21.4

0.1

2.4

2008

10.2

9.4

0.9

2009

175

20.3

-3.1

2.5

2009

10.8

9.9

0.9

2010

180

20.9

1.9

1.8

2010

10.8

9.8

1.0

2011

176

20.3

-1.7

-6.9

2011

10.2

9.5

0.7

2012

168

20.1

-3.6

-8.2

2013

170

20.2

-0.6

-2.5

2014

173

20.7

1.4

0.9

2015

180

21.4

2.2

-1.8

2012

2013

2014

2015

9.7

9.4

0.4

9.6

9.1

0.5

9.5

9.0

0.5

9.1

9.0

0.2

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

1,921

1,948

2,044

2,127

2,205

2,257

2,093

1,911

1,904

1,936

1,942

2,745

2,895

2,975

3,305

6.9

6.7

6.5

6.3

6.4

6.2

6.6

6.4

7.1

6.9

7.1

6.9

6.7

6.5

6.3

6.1

6.2

6.1

6.1

6.0

6.1

5.9

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

1,278

1,263

1,315

1,374

1,449

1,492

1,367

1,232

1,233

1,235

1,297

2,153

2,263

2,324

2,609

0.16

66.5

15.6

100.0

23.3

0.18

64.8

16.3

100.0

25.1

0.20

64.4

16.3

100.0

25.7

0.20

64.6

16.9

100.0

25.8

0.19

65.7

14.8

100.0

24.6

0.29

66.1

12.7

100.0

24.6

0.23

65.3

12.3

100.0

26.3

0.15

64.5

13.2

100.0

28.2

0.10

64.7

12.4

100.0

27.0

0.10

63.8

11.8

100.0

27.7

0.15

66.8

12.6

100.0

27.7

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

10.5

81.5

74.9

57.1

58.6

111

3.5

10.5

82.5

75.5

57.9

60.0

97

3.3

10.5

82.5

75.9

57.9

58.5

98

3.4

10.6

82.7

76.2

57.6

59.2

94

3.3

10.6

82.8

76.5

56.4

58.3

90

3.6

10.6

83.2

76.8

56.7

59.3

85

2.5

10.6

83.8

77.3

58.6

60.7

123

3.1

10.5

83.6

77.3

62.6

64.5

119

3.4

10.5

84.0

77.6

62.2

63.9

114

2.9

10.4

84.4

78.0

55.4

58.3

115

2.9

10.4

84.3

78.1

55.0

58.2

111

2.9

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

Composition of total current expenditure as % of GDP

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2.1

0.4

3.2

2.1

0.3

0.2

0.2

2.0

0.4

2.2

1.2

0.1

0.1

0.1

2.0

0.4

3.2

2.0

0.3

0.2

0.2

1.8

0.4

2.1

1.1

0.1

0.1

0.1

1.8

0.5

3.2

2.0

0.3

0.2

0.2

1.7

0.4

2.1

1.1

0.1

0.1

0.1

1.8

0.5

3.4

2.0

0.4

0.2

0.2

1.6

0.5

2.2

1.1

0.1

0.1

0.1

1.8

0.6

3.7

2.0

0.4

0.2

0.2

1.6

0.6

2.5

1.2

0.1

0.1

0.1

1.7

0.6

3.9

1.9

0.4

0.2

0.2

1.5

0.6

2.5

1.2

0.1

0.1

0.1

1.7

0.6

3.8

1.8

0.4

0.2

0.2

1.5

0.6

2.4

1.0

0.1

0.1

0.1

1.7

0.7

3.6

1.6

0.4

0.2

0.2

1.5

0.7

2.2

0.8

0.1

0.1

0.1

1.7

0.7

3.6

1.4

0.4

0.2

0.2

1.5

0.7

2.3

0.8

0.1

0.1

0.1

1.7

0.7

3.6

1.4

0.4

0.2

0.2

1.4

0.7

2.2

0.8

0.1

0.1

0.1

1.6

0.8

3.5

1.4

0.4

0.2

0.2

1.3

0.7

2.2

0.8

0.1

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

2
.
2
2
.

P
o

r
t
u
g
a

l

2
2
3

H
e
a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

 
 
 
 
 
 
 
  
 
 
 
2
2
4

Table 2.22.2:  Statistical Annex - continued – Portugal 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

2005

22.3%

4.2%

33.8%

22.1%

3.6%

2.3%

1.6%

29.0%

5.7%

32.7%

17.6%

1.5%

1.9%

1.5%

2005

:

:

2.6

:

:

:

13.3

2005

273

456

46

690

2006

21.7%

4.0%

34.6%

22.3%

3.7%

2.1%

1.8%

28.6%

5.5%

32.9%

17.7%

1.7%

1.6%

1.6%

2006

0.58

:

2.6

:

15.4

18.6

13.1

2006

279

481

47

617

2007

20.2%

5.1%

34.8%

22.2%

3.7%

2.1%

1.8%

26.8%

7.1%

33.7%

17.7%

1.6%

1.6%

1.6%

2007

0.89

:

2.6

:

:

:

12.6

2007

279

509

47

608

2008

19.6%

5.2%

35.8%

21.2%

3.9%

2.2%

1.8%

25.6%

7.3%

34.1%

17.5%

1.7%

1.7%

1.6%

2008

0.92

0.5

2.7

0.1

:

:

12.4

2008

282

534

48

559

EU- latest national data

2009

18.1%

6.2%

37.7%

20.1%

3.8%

2.1%

1.6%

23.3%

8.4%

35.9%

17.2%

1.7%

1.6%

1.4%

2010

17.4%

6.1%

39.2%

19.2%

3.9%

2.1%

1.9%

22.5%

8.3%

36.9%

17.4%

1.8%

1.5%

1.6%

2011

17.3%

6.4%

39.5%

18.4%

4.0%

2.1%

2.0%

22.6%

9.0%

37.7%

15.0%

1.9%

1.6%

1.7%

2012

18.2%

7.6%

38.9%

16.7%

4.1%

2.0%

2.0%

23.7%

10.9%

36.4%

13.5%

1.8%

1.3%

1.6%

2013

18.4%

7.9%

39.4%

15.6%

4.1%

1.8%

2.0%

23.8%

11.3%

37.2%

12.8%

1.6%

1.2%

1.6%

2014

18.4%

8.0%

39.5%

15.4%

4.1%

1.8%

2.0%

24.0%

11.6%

37.1%

12.8%

1.7%

1.2%

1.3%

2015

17.6%

8.5%

39.4%

15.5%

4.1%

1.8%

1.9%

22.6%

12.3%

37.0%

12.8%

1.7%

1.0%

1.3%

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

EU- latest national data

:

:

:

:

:

:

12.0

2009

288

560

49

553

:

:

:

:

:

:

12.3

2010

295

587

50

546

:

:

:

:

:

:

11.9

2011

304

634

51

535

:

:

:

:

:

:

12.0

2012

321

580

54

528

:

:

:

:

:

:

10.0

2013

337

610

57

523

:

:

:

:

16.1

16.8

9.9

2014

350

:

59

524

:

:

:

:

:

:

:

2015

365

:

62

518

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

330

835

78

408

338

825

78

407

2013

6.2

16

344

833

78

402

2015

6.3

16

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

3.9

8

4.1

8

4.5

8

4.0

8

4.1

8

4.2

8

4.1

8

:

8

:

8

:

8

6.2

17

6.2

16

1,450

7,520

8,451

9,327

9,692

9,905

10,152

7,530

7,918

8,243

6,362

6,584

7,143

7,635

75.0

7.1

:

62.9

8.5

:

63.0

8.4

:

63.6

8.6

53.7

64.3

8.7

54.9

63.6

8.7

55.7

66.2

9.0

56.2

64.2

8.9

48.7

64.8

8.9

50.3

64.0

8.8

51.2

77.1

8.0

28.0

76.4

7.8

29.1

76.5

7.7

30.9

76.8

7.6

32.3

3.9

8

1,012

74.0

7.0

9.5

Projected public expenditure on healthcare as % of GDP*

2016

2020

2025

2030

2035

2040

2045

2050

2055

2060

2065

2070

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

5.9

5.9

6.2

6.3

6.5

6.7

6.9

7.2

7.2

7.7

7.5

8.1

7.8

8.5

8.0

8.8

8.2

9.0

8.3

9.2

8.3

9.3

8.3

9.2

Population projections

Population projections until 2070 (millions)

2016

10.3

2020

10.2

2025

10.0

2030

9.9

2035

9.7

2040

9.6

2045

9.4

2050

9.1

2055

8.8

2060

8.6

2065

8.3

2070

8.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

Change 2016-2070, in pps.

Portugal

2.4

3.3

EU

0.9

1.6

Change 2016-2070, in %

Portugal

-22.6

EU

2.0

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
2.23. ROMANIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

In  2015,  GDP  per  capita  in  Romania  with  13,900 
PPS was one of the lowest in the EU (29,600 PPS). 
Romania’s economy has grown significantly since 
accession  to  the  European  Union,  but  the  country 
is still facing important development challenges. In 
light  of  a  continuously  difficult  economic  and 
three 
situation,  Romania  was  under 
fiscal 
precautionary  Balance-of-Payments 
assistance 
programmes provided by the European Union and 
the  International  Monetary  Fund.  Health  care 
reforms  were  part  of  the  conditionality  agreed 
under  the  programmes.  Current  population  is 
estimated at 19.9 million. Romania's population is 
characterised by a declining growth with an ageing 
population and a rising share of older age cohorts. 
The  population  is  projected  to  decrease  to  15.0 
million until 2070.  

Total and public expenditure on health as % of 
GDP 

Romania  has  historically  committed  a  relatively 
low  share  of  its  GDP  to  health  care.  Total 
expenditure  on  health  was  at  5.3%  of  GDP  in 
2015,  i.e.  nearly  half  the  EU  expenditure  level 
(EU:  10.2%  in  2015).  Total  public  spending  on 
health  was  at  4.2%  of  GDP  (EU:  8.0%).  Looking 
at health care without long-term care (316) reveals a 
similar picture with public spending below the EU 
average  (3.9%  vs.  6.8%  in  2015).  Spending 
relative to GDP has been relatively constant since 
2005.  In  2015,  only  11.7%  of  total  government 
expenditure  was  channelled 
towards  health 
spending  (EU:  15.0%).  In  per  capita  terms,  total 
(889 PPS) and public spending (706 PPS) are well 
below the respective EU averages (3,305 PPS and 
2,609 PPS) (317).  However,  per  capita  expenditure 
has tripled in the past ten years.  

(316) To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(317) Note  that  these  PPS  figures  reflect  current  plus  capital 
health expenditure in contrast to Eurostat data series, which 
reflect current expenditure only. 

Expenditure projections and fiscal sustainability  

("AWG 

Public  expenditure  on  health  care  is  projected  to 
increase  by  0.9  pps  of  GDP  ("AWG  reference 
scenario"),  at  the  average  increase  of  0.9  pps  for 
the  EU.  When  taking  into  account  the  impact  of 
non-demographic  drivers  on 
future  spending 
growth 
risk  scenario"),  health  care 
expenditure  is  expected  to  increase  by  2.1  pps  of 
GDP  from  now  until  2070  compared  to  the  EU 
average  of  1.6  pps.  Overall,  projected  health  care 
expenditure  poses  a  risk  to  the  medium  and  long-
(318). 
term  sustainability  of  public 
Medium  fiscal  sustainability  risks  appear  for 
Romania  over  the  long  run.  These  risks  derive 
primarily  from  the  unfavourable  initial  budgetary 
position,  compounded  by  age-related  public 
spending (319). 

finances 

Health status  

Health  outcomes  in  Romania  are  lagging  behind 
EU  standards.  Life  expectancy  at  birth  is  71.5 
years for men and 78.7 years for women, far below 
the  EU  averages  (EU:  77.9  for  men  and  83.3  for 
women). Also healthy life years are below the EU 
averages for women (59.4 vs. 63.3 years), and for 
men (59 vs. 62.6 years). Amenable mortality rates, 
i.e.  deaths  that  should  not  occur  with  timely  and 
effective  care,  are  well  above  EU  average  (318 
deaths in Romania versus 127 deaths in the EU per 
100,0000 inhabitants). Infant mortality is at a high 
level of 7.6‰ in 2015 (EU: 3.6‰), although it has 
fallen consistently since 2005 (15‰). 

System characteristics  

Administrative  organisation,  system  financing, 
revenue collection mechanism  

Law  95/2006  on  Health  Care  Reform  is  the  basic 
health  care  law  in  Romania,  defining  the  role  of 
social  health  insurance,  private  health  insurance, 
hospitals  organisation,  community  care,  primary 
health  care,  pharmaceuticals,  emergency  services, 
public  health,  and  national  health  programmes. 
The  system  is  organised  on  two  main  levels: 

(318) The 

2018 

Ageing 

Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(319) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

225 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

national/central  and  district.  The  national  level  is 
responsible  for  defining  general  objectives  and 
ensuring the fundamental principles of government 
health  policy;  the  main  central  institutions  in 
charge  are  the  Ministry  of  Public  Health  (MPH) 
and the National Health Insurance House (NHIH). 
The  ministry  defines  the  health  policies,  while 
the  social 
NHIF  autonomously  administrates 
health  insurance  system.  The  NHIF  is  the  main 
financial 
receiving 
contributions  collected  by  National  Agency  for 
Fiscal Administration (NAFA). Through an annual 
framework  contract,  the  health  care  services  are 
contracted  between  the  NHIH  and  providers  as 
well as the MPH. 

source  of 

system 

the 

Financing  is  based  on  income  related  health 
insurance  contributions.  The  rate  is  10.7%  of 
payroll, of which the employer pays 5.2% and the 
employee 5.5%. The self-employed categories pay 
5.5%  of  their  earnings.  Theoretical  coverage  is 
100%  of  the  population.  Many  groups  including 
children,  dependants,  disabled,  unemployed, 
military personnel and  war veterans, and those on 
sickness  or  maternity  leave  have  free  access  to 
health insurance. Due to these exceptions there are 
around  5  million  contributors  and  20  million 
beneficiaries.  Overall,  the  revenue  base  is  very 
narrow. 

A  total  of  42  District  Health  Insurance  Funds 
(DHIFs)  purchase  and  reimburse  care  for  their 
respective  population  by  establishing  contracts 
with  care  providers,  while  the  NHIH,  which 
regulates  and  administers  the  mandatory  health 
insurance, establishes contracts with the College of 
Physicians,  defining  remuneration  systems.  The 
State  budget  (through  taxation  revenues)  covers 
public  health  services  funding  (health  promotion 
and  disease  prevention  activities)  and  capital 
investment.  The  basic  benefits  package  is  defined 
yearly  in  agreement  between  the  NHIF  and  the 
Ministry  of  Health,  and  approved  by 
the 
Government.  

Since  2009,  with  the  support  of  the  European 
Commission  (EC),  the  World  Bank,  and  the 
International  Monetary 
the 
Government  of  Romania  has  been  working  on  a 
structural  reform  of  its  health  care  system.  The 
reform  programme  seeks  to  put  emphasis  on 
primary 
reduce 
inpatient  admission  services,  and 
unnecessary 

secondary  prevention, 

(IMF), 

Fund 

and 

to  essential 

develop  sustainable  access 
to  higher-quality 
secondary  ambulatory  services.  Recently,  a  new 
basic  benefits  package  was  approved  for  this 
purpose.  A  hospital  rationalisation  plan  was 
developed  and  some  small  hospitals  were  closed. 
A  simple  Health  Technology  Assessment  (HTA) 
tool  has  been  implemented  for  evidence-based 
technologies,  and  some 
access 
medicines  without  proof  of  health  benefits  were 
excluded  from  the  list  of  compensated  drugs, 
resulting  in  budgetary  savings.  The  basic  package 
should  be  fully  functional  in  two  to  three  years, 
and  during  this  period  it  is  necessary  to  perform 
continuous  monitoring,  timely  evaluation,  and 
economic/budget impact analysis in order to adjust 
the  package  to  the  population  health  needs,  in 
accordance to health system performance targets. 

The  pace  of  health  sector  reform  implementation 
has  been  slow  due  to  the  lack  of  resources  to 
finance some critical steps necessary to support the 
new  policies,  as  well  as  lack  of  administrative 
capacity. It is a challenge to consolidate the current 
hospital  structure 
if  an  alternative  modern 
ambulatory  service  is  not  fully  functional  before 
closing  down  and  eliminating  unnecessary  beds. 
Merging  fragmented  services  from  multi-building 
hospitals  cannot  be  easily  completed  without  the 
rehabilitation of an appropriate building to host the 
new comprehensive and articulated hospital.  

Coverage  and  role  of  private  insurance  and 
out of pocket co-payments 

Social  health  insurance  is  compulsory  for  all 
citizens and for foreigners residing in the country.  

The  share  of  private  total  health  expenditure 
(20.6% in 2015) is at the EU average of 21.6%, as 
a  result  of  a  large  reduction  in  out-of-pocket 
expenditure  (21.3%  of  total  health  expenditure  in 
2011 vs. 34% in 2001) and the efforts by national 
authorities  to  improve  access  to  care  for  certain 
groups  of  the  population.  However,  there  remains 
about  23%  of  the  population  that  is  not  correctly 
insured and cannot access services because they do 
not pay contributions, lack the appropriate official 
papers  and  residency  requirements  or  have  not 
registered with a family doctor/GP. There are plans 
to  give  the  uninsured  access  to  certain  preventive 
health programmes on top of emergency care.  

226 

 
Health care systems 

2.23. Romania 

Access  to  healthcare  remains  a  major  concern. 
Despite a mandatory health insurance system, only 
77  %  of  the  population  was  insured  in  2016. 
Compared with an EU average of 2.5 %, 6.5 % of 
the Romanians report having had unmet healthcare 
needs  due  to  cost,  distance  or  waiting  times  in 
2016.  Widespread  informal  payments  add  to  the 
costs  and  are  among  the  main  reasons  for  poor 
access  to  healthcare,  especially  for  patients  with 
low  income.  Access  to  healthcare  is  further 
hindered  by 
the  unavailability  of  health 
professionals.  The  number  of  physicians  and 
nurses  per  inhabitant  is  very  low  compared  with 
the  EU  average,  mainly  due  to  the  emigration  of 
qualified  physicians  to  other  EU  countries,  poor 
working  conditions  and  low  salaries.  Despite  this 
situation, there is no formal strategy on healthcare 
human resources in place.  

Current  cost-sharing  rules  do  not  necessarily 
encourage  a  greater  use  of  primary  care  services 
vis-à-vis  specialist  and  inpatient  care,  or  a  greater 
use  of  more  cost-effective  services,  although  they 
encourage  the  use  of  generics.  In  April  2013,  co-
payments  for  certain  medical  services  were 
introduced. Contributions are between RON 5 and 
10 per patient. Emergency care, family doctors and 
medical  laboratories  do  not  charge  a  co-payment. 
Children up to 18 years, youth aged 18-26 without 
income,  pregnant  women,  war  veterans,  persons 
with  chronic  diseases,  and  pensioners  receiving  a 
pension  benefits  inferior  to  RON  740  per  month 
are exempted from these co-payments.  

There  are  reports  of  significant  informal  (non-
official)  payments.  While  they  may  increase  the 
income  of  physicians,  informal  payments  do  not 
bring  additional  revenues  to  the  insurance  funds, 
do not encourage a  more effective  use of services 
and  constitute  an  additional  barrier  to  access  as 
there  are  no  exemptions  for  low  income  or  high 
risk  groups.  Some  studies  estimate  that  they 
increase  out-of-pocket  expenditure  to  more  than 
30%. Hence, it would be worth investigating if the 
current  cost-sharing  could  be  adjusted 
to 
encourage  greater  use  of  more  effective  and  cost-
effective  services:  e.g.  more  use  of  primary  care 
than  specialist  care,  more  health  promotion  and 
disease  prevention  activities  (e.g.  vaccination), 
pharmaceuticals,  while 
more 
tackling informal payments. 

cost-effective 

can 

and/or 

insurance 

companies 

offer 
Private 
complementary  health 
supplementary 
insurance.  Packages  cover 
the  services  not 
included  in  the  basic  benefit  package,  higher-
comfort hospital accommodation and co-payments 
charged  by  providers  for  the  services  included  in 
the  basic  benefit  package.  Eligibility  for  private 
the 
co-insurance 
mandatory  contribution  for  the  basic  package  of 
services. 

is  conditioned  on  paying 

Types of providers, referral systems and patient 
choice   

specialist  care 
centres 

Public and private provision coexists. Primary care 
is  provided  by  independent  general  practitioners 
in  private  practices. 
and  nurses  operating 
Ambulatory 
in 
is  provided 
specialised 
and  hospital  outpatient 
departments. Inpatient hospital care is provided in 
is 
hospitals,  mostly  publicly  owned, 
increasingly  under  the  responsibility  of  local 
authorities.  All  these  providers  establish  contracts 
with the NHIF.  

and 

the  difficulties 

The  total  number  of  practising  physicians  per 
100,000  inhabitants  (277  in  2015)  is  well  below 
the EU average (344 in 2015), but has been rising 
continuously throughout the last decade. This may 
explain 
in  availability  and 
distribution of physicians across the country. Data 
on  the  physician  skill-mix  indicates  that  the 
number  of  GPs  per  100,000  inhabitants  (62  in 
2015) 
the  EU  average  (EU:  78). 
Moreover,  GPs  seem  to  have  a  limited  medical 
role in health care delivery. The number of nurses 
(641 in 2015) per 100,000 inhabitants is below the 
EU average of 833. Romania has suffered heavily 
from staff  migration to other EU countries,  where 
qualified health staff is needed and wage levels are 
higher.  

is  below 

National  authorities  have  made  limited  efforts  to 
enhance primary care financing and provision and 
strengthen the referral system from primary care to 
specialist doctors as well as the gatekeeping role of 
GPs  (to  reduce  the  unnecessary  use  of  specialist 
and hospital care). All inhabitants have to register 
with a GP, who acts like a family doctor and as a 
gatekeeper  referring  patients  to  specialist  and 
hospital 
it  being 
care.  However,  despite 
mandatory,  many  have  not  yet  registered  with  a 
GP  and  the  referral  system  is  often  bypassed  by 

227 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

some groups of the population. In addition, urgent 
/after-hours access to primary care services is very 
limited resulting in an unnecessary use of hospital 
emergency  wards.  Patients  can  choose  their  GP 
and choose the specialist and hospital after referral. 
This referral and coordination role is to be further 
enhanced  through  the  use  of  ICT  systems  and  the 
implementation  of  electronic  patient  records,  as 
started  in  2015,  and  electronic  monitoring  of 
prescriptions,  which  can  help  control  expenditure. 
In  2014,  the  budget  for  primary  care  physicians 
was increased to roughly 8% of expenditure by the 
NHIH. However, compared to the EU, the budget 
for primary care lags significantly behind. 

Romania  has  seen  an  increase  in  the  number  of 
acute care beds per 100,000 inhabitants in the last 
decade  (456  in  2003  vs.  503  in  2015)  and  its 
number  is  higher  than  the  EU  average  (EU:  402). 
Many  hospital  beds  in  Romania  are  however  not 
necessarily  used  for  acute  care  but  for  other 
purposes  such  as  long-term  hospitalisation  of 
patients  with  chronic  diseases.  Further  reductions 
in  hospital  capacity  is  an  area  where  further 
improvements  can  still  be  made,  but  the  total 
number of beds and its use will, in the medium and 
long-run  strongly  depend  on  the  changes  in  the 
provision  of  long-term  care  services  implemented 
in  Romania  (which  can  reduce  bed  blocking  in 
acute  care  settings)  as  well  as  changes  in  surgical 
practices. 

Public  expenditure  on  inpatient  care  as  a  share  of 
GDP  is  below  the  EU  average  (1.2%  vs.  2.5%  in 
the  EU).  However,  inpatient  care  accounts  for 
roughly  32%  of  public  expenditure  on  health  in 
Romania, which is at the EU average. The number 
of hospital inpatient discharges was at a very high 
level,  with  21  discharges  per  100  inhabitants,  in 
2015 (EU: 16 in 2015). 

Total and public expenditure on outpatient care as 
a share of GDP were below the EU average (0.6% 
and 0.4% vs. 2.4% and 1.8% in the EU). Total and 
public expenditure on outpatient care as a share of 
current health expenditure were also below the EU 
average  (12%  and  10%  vs.  24%  and  23%  in  the 
EU in 2015). Low expenditure may be a sign of a 
health  system  which 
is  oriented  away  from 
ambulatory  and  towards  hospital  care,  providing 
potential 
cost-
effectiveness  of  care,  by  shifting  away  from 
hospital-centric health care provision. 

relatively 

increase 

the 

to 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

activities 

prevention 

Payment  systems  have  evolved  over  the  years 
involving a mixture of remuneration schemes. GPs 
receive  a  mix  of  capitation  and  fees  for  defined 
activities  (health  promotion,  disease  prevention 
and  disease  management  activities).  This  mixed 
system  intends  to  render  primary  care  more 
attractive  and  provide  incentives  for  primary  care 
including  some  health  promotion, 
provision, 
disease 
disease 
are 
management. 
remunerated  on  a  fee-for-service  basis  while 
hospital staff is paid on a salary basis. Acute care 
hospitals  remuneration  is  based  on  prospective 
activity-based  payment  using  DRGs  and  fee-for-
services  or 
rate  per  case.  Although 
significantly  improved  and  based  on  complex 
criteria, 
for  establishing  contracts 
between the NHIH and the various providers could 
be  further 
to  favour  cost-effective 
interventions in the long-run. 

and 
specialists 

Ambulatory 

the  basis 

improved 

flat 

The introduction of a new benefits package would 
require  a  revision  in  health  provider  payment 
mechanisms.  The  hospital  payment  system  is 
based  on  production  of  services  (a  Diagnosis 
Related  Group  (DRG)  system,  which  was  piloted 
in 2003 and implemented in 2005), but the system 
needs to be transformed to better estimate the costs 
and  eliminate  perverse  incentives.  For  example, 
some  mild  cases 
in 
ambulatory  services  are  being  admitted  because 
the DRG system overestimates the cost of treating 
those  cases.  On  the  other  hand,  some  more 
complex cases are being referred because the DRG 
value is below the real cost. In parallel, in primary 
care,  NHIF  allocates  6%  of  the  total  insurance 
fund,  while  introducing  a  cap  in  the  annual 
contract,  that  eliminates  the  incentives  to  increase 
primary health care services.  

that  could  be 

treated 

The market for pharmaceutical products 

Total  spending  on  outpatient  pharmaceuticals  has 
reached a respectable level 1.9% of GDP in 2015, 
rising  by  from  1.6%  of  GDP  in  2005.  Overall, 
spending  in  the  pharmaceutical  sector  grew  faster 
the  health  sector.  As  a 
than  spending 
outpatient 
of 
consequence, 
pharmaceuticals  within  total  health  expenditure 
has  reached  a  high  38%  in  2015  (from  28%  in 

in 
the 

share 

228 

 
2005). This is one of the highest shares in the EU. 
Much of the growth in expenditure has been borne 
by  the  private  sector  financing  of  outpatient 
pharmaceuticals. 

the  manufacturers 

In order to control the spending bill for the public 
payer,  pharmaceutical  spending  is  limited  by  a 
defined threshold, and overspending is recuperated 
from 
(payback,  claw-back 
system).  The  system  has  been  criticised,  because 
of the high overspending that has to be financed by 
manufacturers,  but  has  proved  to  provide  an 
effective  budget  ceiling.  The  pharmaceutical 
budget  is  still  structurally  overspent  increasing 
future 
is 
recovered via the claw-back tax and is thus budget 
neutral, it has led to withdrawals of cheap generic 
medicines from the market. The planned revisions 
of 
the  public 
reimbursement  for  distributors  of  pharmaceutical 
products  to  incentivise  the  provision  of  low  cost 
medicines to patients are yet to be implemented. 

risks.  While  overspending 

the  claw-back 

tax  and  of 

fiscal 

the 

Recommendations 
listing  of 
regarding 
medicines  on  the  national  formulary  are  the 
responsibility  of 
the  National  Transparency 
Committee  (NTC).  However  the  NTC  processes 
appear  to  be  opaque  and  ad  hoc.  Recently,  an 
interim  Health  Technology  Assessment  (HTA) 
process  was  elaborated  for  the  approval  of  new 
drugs,  and  since  2015,  the  Ministry  of  Health 
applies  a  rapid  systematic  HTA  process  to  delist 
and enlist  molecules  from  the list of reimbursable 
medicines. 

pricing 

With respect to pricing, there is extensive reliance 
on  the  use  of  external  reference  pricing  for 
medicines  manufactured  outside  Romania  (with 
cost-plus 
those  manufactured 
domestically).  External  reference  pricing  is  based 
on the lowest price from within a basket of 12 EU 
countries  according  to  an  algorithm  published  by 
the  Ministry  of  Public  Health.  However,  prices 
have not been updated in the past years. 

for 

Prescription  medicines 
accordance with four reimbursement lists:  

subsidised 

are 

in 

−  List  A: 

includes  most  commonly  used 
medicines  (largely  generics),  reimbursed  at 
90% (10% co-insurance)  

Health care systems 

2.23. Romania 

−  List  B:  includes  mostly  originator  medicines; 

reimbursed at 50% (50% co-insurance)  

included 

−  List  C:  comprises  medicines  for  chronic 
diseases 
the  National  Health 
in 
Programs and/or for specific population groups 
(pregnant  women,  children,  teenagers,  etc.). 
List  C  medicines  are  fully  reimbursed  for 
eligible beneficiaries.  

−  List  D:  medicines  without 
effectiveness, reimbursed at 20%. 

proven 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

to 

implement  evidence-based  access 

An interim Health Technology Assessment (HTA) 
tool 
to 
essential  technologies  has  being  implemented  in 
2015, and reimbursement rates of some medicines 
without  proof  of  health  benefits  were  reduced  to 
20% from the list of compensated drugs, resulting 
in significant savings.  

Corruption 

for  corruption 

Corruption  is  present  in  many  economic  sectors 
and  involves  appointed  and  elected  officials  at  all 
levels of government as  well  as civil servants and 
employees of public institutions. This is borne out 
by  the  record  of  criminal  investigations  and 
(320).  Preventing 
convictions 
corruption in public administration was one of the 
key  priorities  of  the  2012-2015  national  anti-
corruption strategy. The evaluation of the strategy 
shows some progress in putting in place corruption 
prevention  measures  at  the  level  of  national 
administration.  It  concludes,  however,  that  local 
administration  structures  are  severely 
lagging 
behind  in  terms  of  building  up  the  necessary 
capacity  to  prevent  corruption  effectively.  The 
government  included  additional  measures  in  the 
renewed  anticorruption  strategy  2016-2020 
to 
remedy 
the 
evaluation. 

the  weaknesses 

identified 

in 

Corruption  remains  a  challenge  in  the  health 
sector,  despite  some  recent  action  to  combat  the 
problem.  Oversight  of  public  procurement 
contracts  in  the  health  sector  is  insufficient  (see 
section  3.1).  The  centralised  procurement  unit  in 

(320) COM (2016) 41 final; SWD (2016) 16 final. 

229 

 
                                                           
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

the Ministry of Health is heavily understaffed and 
its  mandate  covers  only  25 %  of  hospitals.  The 
lack  of  transparency  in  medical  reimbursements 
constitutes  a  severe  challenge  in  putting  in  place 
measures  to  prevent  fraud  and  corruption  over 
reimbursement claims. This has a direct impact on 
the  health  budget.  Although  services  provided  in 
private health units are partially covered by public 
funds  under  the  single  national  health  insurance 
scheme,  they  are  not  included  in  the  monitoring 
exercise  for  the  use  of  public  funds.  While 
healthcare was one of the key sectors addressed by 
the  2012-2015  national  anti-corruption  strategy, 
the  sectorial  strategy  did  not  produce  tangible 
results. The challenge facing the renewed sectorial 
strategy  is  to  integrate  the  findings  of  existing 
policy assessments into a comprehensive approach 
that extends to all relevant players and processes. 

Recently 
reforms 

legislated  and/or  planned  policy 

Romania  has  embarked  on  a  set  of  reforms  in 
recent  years.  A  National  Health  Strategy  2014-
2020  was  approved  by  the  end  of  2014.  The 
strategy  covers  the  following  areas:  public  health 
and  health  care  (with  a  focus  on  improving  the 
health  of  women  and  children,  reduce  morbidity 
and  mortality  of  non-communicable  diseases 
ensuring  equitable  access  –  especially 
for 
vulnerable  groups  –  to  healthcare  quality  and 
efficient in terms of cost, health research, eHealth 
technologies  and  health  infrastructure  (national, 
regional and local). 

Several  pilot  projects  were  implemented,  such  as 
to  improve  access  to  health  care  for  vulnerable 
persons,  programmes  for  prevention  and  curative 
health  of  women  and  children,  to  increase  access 
to  health  care  of  persons  living  in  remote  and 
isolated communities.  

In addition, in 2014 a new package of basic health 
services was approved, introducing chronic disease 
management  provided  by  family  doctors.  At  the 
primary health care level, preventive consultations 
were  introduced  for  people  over  the  age  of  18  to 
check for certain major diseases and conditions. 

Starting from July 2017, a total of 465,230 retired 
people  with  monthly  income  of  less  than  Lei  700 
(€150)  and,  retirees  with  income  from  pensions, 
social  allowances  and  earned  monthly  income  of 

230 

less than Lei 900 (€193) (whether or not they have 
other  earnings)  benefit 
in 
outpatient  care  with  90%  compensation  from  the 
reference  price  (corresponding  to  the  common 
international nomenclature from the sub-list B). 

from  medicines 

In  addition,  the  implementation  of  several  health 
programmes has continued in order to increase the 
access of vulnerable people to health services, such 
as vaccination, prevention, supervision and control 
of  HIV/AIDS 
tuberculosis, 
infection 
surveillance  and  limitation  of  microbial  resistance 
and  healthcare-associated  infections,  monitoring 
use of antibiotics, transplantation of organs, tissues 
and  cells  of  human  origin,  women  and  children 
health, etc. 

or 

Also day  hospitalisations  were regulated and their 
financing  improved  to  reduce  excessive  use  and 
duration  of  hospitalisations.  The  basic  package 
aimed to decrease admissions to hospitals, increase 
the number of cases resolved in day-care facilities 
and to establish the conditions for the development 
of  primary  health  care  and  ambulatory  services. 
Under the package, certain diagnoses (104 medical 
conditions),  surgical  procedures  (96)  and  medical 
services  (36)  will  be  dealt  with  in  day-care 
facilities.  Admission 
is  allowed, 
to  hospital 
however, in cases of medical need.  

to  generate  savings,  a  centralised 
In  order 
procurement  system  was  developed  and 
the 
capacity of centralised procurement unit enhanced, 
focusing  on 
the  procurement  of  medicines, 
vaccines  and  of  other  medical  supplies.  In  2014, 
there  were  15  centralised  procurements  for  drugs, 
vaccines  and  other  medical  supplies,  with  savings 
of more than RON 47 million.  

the 

the 

to  modernisation  of 
following 

IT 
As 
regards 
infrastructure, 
introduction  of 
electronic  prescriptions  in  2012  a  system  of 
eHealth  cards  was  implemented  in  2015.  Cards 
serve  as  a  mandatory  tool  for  reimbursement  for 
most  medical  services  delivered  by  registered 
providers. NHIH distributed more than 15  million 
health  insurance  cards,  and  health  insurance  card 
usage  commenced  in  February  2014  and  became 
mandatory  on  1  May  2015.  In  2014,  NHIH  also 
implemented  the  electronic  patient  file  system, 
replacing  the  prior  hard-copy  patient  file  system. 
The  electronic  file  system  is  currently  functional 
and  accessible.  The  National  Health  Insurance 

 
Health care systems 

2.23. Romania 

in 

the  Health  System  aimed 

To  reduce  informal  payments,  the  project  Good 
Governance 
to 
develop  a  coherent  policy  to  prevent  and  combat 
corruption  in  health,  some  components  of  which 
are covered in the National Action Plan to increase 
the  quality  of  care  and  reduce  vulnerabilities,  the 
regulation  regarding  ethics  council 
in  public 
hospitals,  regulating  the  organisation  of  a  system 
for  monitoring  and  control  of  notifications  and 
complaints  regarding  patients'  rights  and  their 
abuse to healthcare professionals, was approved. 

the  healthcare 

In  line  with  strategic  directions  of  the  health 
strategy,  an  analysis  on  the  resources  needed  to 
modernise 
infrastructure  was 
developed  and  set  out  in  a    project  funded  with  a 
loan  by  the  World  Bank  that  started  in  2015. The 
main  objectives  of  the  project  on  health  sector 
reform for improving the quality and efficiency of 
the health system are: 

−  rationalising the hospital network by providing 
goods, services other than consulting, advisory 
services  and  training  in  emergency  regional 
regional 
hospitals,  district  hospitals  and 
hospitals selected; 

−  strengthening 

secondary 

outpatient 
specialist  by  providing  goods,  works,  services 
other than consulting, consultancy and training; 

care 

− 

and 

other 

relevant 

improving  the  capacity  of  the  Ministry  of 
government 
Health 
institutions for governance and management of 
the  sector,  to  reduce  the  gap  between  policy 
and  practice  and  to  reinforce  the  capacity  and 
improve  quality  of  care  by  providing  goods, 
works, 
advisory, 
other 
services 
consultancy and training; and 

than 

House  (CNAS)  obtained  European  funding  (of 
about €1 million) for an "Open Source Healthcare 
Insurance  Gateway  for  Electronic  Exchange  of 
Social  Security  Information"  IT  project  to  set  up 
an  electronic  exchange  of 
information  with 
counterpart institutions from other EU countries.  

The  IT  platform  Monitorizarecheltuieli (321)  has 
been  used  to  increase  transparency  in  public 
procurement  and  hospital  management.  In  2017, 
data regarding 3,310 award procedures defined by 
the  Law  No  98/2016  on  public  procurement  and 
4,014  direct  purchase  procedures  were  published 
on  this  IT  platform.  Furthermore,  the  financial 
reports  of  378  public  hospitals  were  published  in 
2017. 

to 

in 

reduce 

treating  patients 

In  order 
the  excessive  use  of 
hospitalisation,  the  funds  allocated  for  outpatient 
care  and  primary  health  care  were  increased  to 
ambulatory 
encourage 
specialist  and  the  family  physician.  Additional 
funds  have  been  allocated  for  primary  care  from 
RON  1424.9  million  in  2014  (6.7%)  to  RON 
1513.7  million  in  2015  (7%  from  total  health 
expenditure of NHIH). In the period 2016-2018 the 
aim  is  to  continue  with  an  annual  increase  of  5% 
(compared to the allocation for 2015) of funds for 
primary  health  care.  In  2016  the  budget  for 
primary  care  amounted  to  RON  1515.5  million 
(including  permanent  centres),  approximately  at 
the  level  of  2015,  and  it  represented  7%  of  total 
health  care  expenditure  of  NHIH,  excluding 
amounts  for  cost-volume  contracts  and  cost  for 
salary  increases  related  to  personnel  paid  from 
public  funds  provided  by  GEO  35/2015.  In  order 
to  stop  the  brain  drain  in  the  outpatient  health 
funds  have 
sector,  salaries  paid  by  public 
significantly 
in  2018  with  Law 
153/2017.  

increased 

In  2018,  funds  allocated  to  primary  health  care 
have increased with approximately 17% compared 
to 2017. The outpatient services were extended by 
introducing  a  basic  package  of  medical  services 
in  outpatient  clinics. 
that  can  be  provided 
Furthermore, 
the  day  hospitalisation  services 
package  has  been  expanded  to  cover  for  diseases 
that  have  been  previously  provided  by  continuous 
care within hospitals. 

(321) The  IT  platform  Monitorizarecheltuieli  can  be  accessed 

under www.monitorizarecheltuieli.ms.ro. 

in 
implementation  of 

−  supporting  the  Ministry  of  Health  and  the 
the 
Project  Management  Unit  (PMU) 
management  and 
the 
project, including  fiduciary duties,  monitoring, 
evaluation  and  reporting  by  providing  goods, 
consulting, 
other 
works, 
consulting 
and 
audit 
operational costs.    

than 
training, 

services, 

services 

231 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  To  make  more  use  of  cost-effectiveness 
information,  as  planned,  in  determining  the 
basket  of  goods  and  the  extent  of  cost-sharing 
and  define  the  latter  to  induce  cost-effective 
behaviour.  To  explore  if  current  cost-sharing 
could  be  adjusted  to  encourage  greater  use  of 
more effective and cost-effective  services: e.g. 
more  use  of  primary  care  than  specialist  care, 
more  health  promotion  and  disease  prevention 
activities (e.g. vaccination), more cost-effective 
pharmaceuticals. 

•  To reduce the causes of structural overspending 
of  the  pharmaceutical  budget,  increasing  the 
cost-effectiveness  of  prescribed  and  used 
medicines,  which  could  make  more  room  for 
financing of new cost-effective innovations. 

•  To tackle corruption in the health system.  

•  To  continue  to  improve  accountability  and 
governance of the system and identify possible 
cost-savings in the health sector administration, 
as  it  currently  involves  many  national  and 
district  institutions.  To  ensure  that  resource 
allocation between regions is not detrimental to 
poorer regions. 

•  To  continue  to  improve  data  collection  and 
monitoring  of  inputs,  processes,  outputs  and 
outcomes 
performance 
assessment  can  be  conducted  and  use  to 
improve  access,  quality  and 
continuously 
sustainability of care. 

regular 

that 

so 

•  To clearly establish public health priorities and 
and  disease 
enhance  health  promotion 
prevention activities, i.e. promoting healthy life 
styles  and  disease  screening  given  the  recent 
pattern  of  risk  factors  (smoking,  alcohol)  and 
the  pattern  of  both 
infectious  and  non-
infectious diseases. 

Challenges 

The  analysis  above  shows  that  a  number  of 
reforms  have  been  implemented  over  the  years 
aiming  to  improve  the  efficiency  of  care  delivery 
and  which  Romania  should  continue  to  pursue. 
Reforms have met with a number of obstacles and 
there is still room for improvement in core areas of 
care. The main challenges for the Romanian health 
system are as follows: 

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
the increasing health care expenditure over the 
coming  decades,  which  can  pose  a  risk  to  the 
long-term sustainability of public finances.   

•  To improve the basis for more sustainable and 
larger  financing  of  health  care  in  the  future  to 
improve  access  as  well  as  quality  of  care  and 
its  distribution  between  population  groups  and 
regional areas. 

•  To  increase  equity  in  financing  of  care  and 

tackle informal payments. 

•  To  define  a  comprehensive  human  resources 
strategy  to  ensure  a  balanced  skill-mix,  avoid 
staff shortages and motivate and retain staff to 
the sector. 

•  To  continue  to  enhance  and  better  distribute 
primary  health  care 
services  and  basic 
specialist  services  to  improve  equity  of  access 
and  the  effectiveness  and  efficiency  of  health 
care  delivery;  to  ensure  an  effective  referral 
systems from primary to specialist and hospital 
care  and  improving  care  coordination  between 
types  of  care,  notably  by  ensuring  that  users 
register  with 
the 
their  GP  and 
development of electronic patient records in the 
future. 

through 

•  To  continue  the  efforts  to  decrease  over  and 
unnecessary  use  of  hospital  inpatients  care  by 
the  number  of  hospital  beds, 
decreasing 
through 
and 
hospital 
rationalisation: to increase day case surgery, to 
improve  the  provision  of  after-hours  primary 
care  services,  and  to  reduce  the  number  of 
uninsured who tend to use emergency services 
rather than primary care services (which are not 
covered to large extent). 

restructuring 

232 

 
Table 2.23.1:  Statistical Annex – Romania 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

80

13.2

4.8

:

2006

98

14.0

8.7

0.6

2007

125

14.2

8.5

11.7

2008

142

14.2

10.1

14.3

2009

120

13.0

-5.1

-1.3

2010

127

13.0

-2.2

2.8

2011

133

13.1

2.5

-3.5

2012

134

13.2

1.7

1.0

2013

144

13.0

3.9

4.6

2014

150

13.3

3.5

2.9

2015

160

13.9

4.5

-1.4

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

5.5

5.5

0.0

433

4.5

4.4

353

0.08

81.6

9.9

:

18.5

5.1

5.1

0.0

494

4.2

4.0

404

0.15

81.7

13.4

:

20.0

5.2

5.2

0.0

652

4.5

4.2

559

0.30

85.8

11.2

:

17.6

5.4

5.3

0.1

787

4.5

4.3

657

0.25

83.5

9.1

:

18.2

5.7

5.6

0.1

699

4.6

4.4

569

0.21

81.5

10.6

:

20.8

6.0

5.8

0.1

779

4.9

4.7

636

0.21

81.7

10.9

:

19.6

5.6

5.5

0.1

775

4.6

4.3

636

0.26

82.1

9.8

5.6

5.5

0.1

774

4.6

4.4

640

0.24

82.7

11.7

100.0

20.7

100.0

19.5

5.6

5.2

0.4

846

4.3

4.1

647

0.17

76.5

11.8

:

20.2

5.6

5.0

0.5

880

4.2

4.0

658

0.18

74.8

11.5

86.0

20.3

5.3

5.0

0.3

889

4.2

3.9

706

0.31

79.4

11.7

86.0

21.3

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

2005

21.4

75.4

68.4

:

:

225

15.0

2006

21.3

76.1

69.0

:

:

216

13.9

2007

2008

2009

2010

2011

2012

2013

2014

2015

21.1

76.8

69.5

62.5

60.5

198

12.0

20.6

77.5

69.7

62.9

60.0

185

11.0

20.4

77.7

69.8

61.7

59.8

182

10.1

20.3

77.7

70.0

57.5

57.3

179

9.8

20.2

78.2

70.8

57.0

57.4

344

9.4

20.1

78.1

70.9

57.7

57.6

339

9.0

20.0

78.7

71.6

57.9

58.6

325

8.9

19.9

78.7

71.4

59.0

59.0

319

8.4

19.9

78.7

71.5

59.4

59.0

318

7.6

EU- latest national data

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,745

2,895

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

2,153

2,263

2,324

2,609

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.0

0.0

0.5

1.6

:

0.4

0.2

2.0

0.0

0.4

0.7

0.0

:

0.2

1.9

0.0

0.4

1.4

:

0.3

0.3

1.8

0.0

0.3

0.6

0.0

:

0.3

1.8

0.0

0.5

1.4

:

0.3

0.3

1.8

0.0

0.4

0.6

0.0

:

0.3

1.9

0.0

0.6

1.4

:

0.3

0.1

1.9

0.0

0.4

0.6

0.0

:

0.2

2.1

0.0

0.5

1.4

:

0.5

0.1

2.0

0.0

0.4

0.5

0.0

:

0.1

2.4

0.0

0.5

1.4

:

0.4

0.1

2.3

0.0

0.3

0.6

0.0

:

0.1

1.9

0.0

0.5

1.7

:

0.4

0.1

1.9

0.0

0.3

0.8

0.0

:

0.1

1.3

0.3

0.6

1.6

:

0.4

0.1

2.0

:

0.4

0.8

0.0

:

0.1

1.5

0.3

0.6

2.1

0.0

0.1

0.2

1.4

0.3

0.4

1.3

0.0

0.1

0.2

1.4

0.3

0.6

1.9

0.1

0.1

0.2

1.4

0.3

0.4

1.1

0.0

0.1

0.2

1.3

0.3

0.6

1.9

0.1

0.1

0.1

1.2

0.3

0.4

1.2

0.0

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
e
a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

2
.
2
3
.

R
o
m
a
n
a

i

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2
3
3

 
 
 
 
 
 
 
 
 
 
 
2
3
4

Table 2.23.2:  Statistical Annex - continued – Romania 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

36.9%

0.0%

9.1%

2006

37.0%

0.0%

8.3%

2007

35.3%

0.0%

9.0%

28.3%

27.9%

26.1%

:

6.8%

4.0%

:

5.3%

6.3%

:

6.5%

5.6%

44.9%

45.4%

42.9%

0.0%

8.4%

16.8%

0.5%

:

4.3%

0.0%

7.7%

14.5%

0.5%

:

8.0%

0.0%

8.6%

15.0%

0.5%

:

7.9%

2005

2006

:

:

:

:

:

:

:

:

:

:

:

:

7.7

8.5

2005

2006

217

548

67

690

2005

4.8

:

:

:

:

:

2016

4.3

4.3

2016

19.7

216

563

82

617

2006

5.0

:

:

:

:

:

2020

4.4

4.6

2020

19.3

2007

0.11

0.1

0.3

0.0

:

:

10.6

2007

212

566

123

608

2007

4.9

21

:

:

7.7

:

2025

4.6

5.1

2025

18.6

2008

36.2%

0.0%

10.9%

25.5%

:

5.8%

1.7%

44.1%

0.0%

10.3%

14.2%

0.2%

:

3.5%

2008

0.13

0.2

0.4

0.0

7.9

20.5

11.9

2008

221

555

66

559

2008

5.1

23

:

:

7.7

:

2030

4.8

5.4

2030

18.0

0.0%

8.4%

10.7%

0.2%

:

2.3%

2009

0.19

0.2

0.5

0.0

:

:

10.4

2009

226

569

59

553

2009

5.2

24

2009

37.6%

0.0%

9.4%

2010

40.3%

0.0%

9.1%

2011

34.2%

0.0%

9.2%

25.0%

24.7%

30.4%

:

8.3%

1.4%

:

6.2%

1.9%

:

6.9%

2.0%

2012

24.3%

5.3%

10.0%

29.4%

:

6.8%

1.6%

2013

28.0%

4.8%

10.6%

40.9%

0.8%

1.5%

2.9%

46.4%

49.7%

43.1%

44.7%

34.8%

0.0%

7.3%

12.5%

0.2%

:

2.6%

2010

0.24

0.2

0.6

0.0

:

:

9.0

0.0%

7.6%

18.2%

0.2%

:

2.5%

2011

0.31

0.2

0.7

0.0

:

:

9.1

:

8.0%

18.1%

0.2%

:

2.1%

2012

0.38

0.3

0.9

0.0

:

:

9.6

6.1%

9.0%

32.4%

0.5%

1.9%

3.6%

2013

0.44

0.3

1.0

0.0

:

:

9.6

2014

28.6%

5.0%

11.5%

37.4%

1.0%

1.8%

3.0%

35.7%

6.3%

10.1%

28.1%

0.8%

2.3%

3.8%

2014

0.47

0.3

1.1

0.0

9.1

19.8

:

2015

25.5%

5.1%

12.1%

38.4%

1.2%

2.0%

2.4%

32.0%

6.5%

9.8%

30.0%

0.8%

2.6%

3.1%

2015

0.54

0.4

1.2

0.0

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

237

526

68

546

2010

5.0

23

239

534

68

535

2011

4.8

21

261

580

69

528

2012

4.9

22

264

601

64

523

2013

4.8

22

270

616

64

524

2014

5.3

21

277

641

62

518

2015

5.4

21

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

4,333

5,205

5,569

6,819

8,399

9,895

13,022

6,362

6,584

:

7.5

15.0

2035

5.0

5.8

2035

17.5

:

7.4

18.3

2040

5.1

6.0

2040

17.1

:

7.5

20.6

2045

5.2

6.2

2045

16.7

:

7.5

23.8

2050

5.3

6.4

2050

16.3

:

7.4

27.6

2055

5.3

6.5

2055

16.0

:

7.5

32.0

2060

5.3

6.5

2060

15.7

:

7.5

38.2

2065

5.3

6.5

2065

15.3

77.1

8.0

28.0

2070

5.2

6.4

2070

15.0

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Romania

0.9

2.1

EU

0.9

1.6

Change 2016-2070, in %

Romania

-23.9

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.24. SLOVAKIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

derive primarily from the projected impact of age-
related  public  spending  (notably  healthcare  and 
pensions) (325). 

General  country  statistics:  GDP,  GDP  per 
capita; population 

Health status 

GDP per capita in PPS in Slovakia is at 21,600 and 
below  EU  average  of  29,600  in  2015.  Slovakia's 
current  population  stands  at  5.4  million  people  in 
2015  and  has  been  fairly  stable  throughout  the 
decade. The projections reveal a decrease from 5.4 
million people in 2016 to 4.9 million in 2070. 

Total and public expenditure on health as % of 
GDP 

Total  expenditure  on  health  as  a  percentage  of 
GDP  (7.0%  in  2015)  is  below  the  EU  average 
(10.2%). It has increased from 5.4% in 2003, but is 
lower  than  that  registered  peak  in  2009  (8.5%  of 
GDP)  and  decreased  by  1.1  pps  only  in  a  year. 
Total public expenditure on health as a percentage 
of  GDP  is  below  the  EU  average  (in  2015  it  was 
5.6%  compared  to  8.0%  in  the  EU).  Looking  at 
health  care  without  long-term  care (322)  reveals  a 
similar picture with public spending below the EU 
average (5.6% vs. 6.8% in 2015). Total (1,556 PPS 
in 2015) and public (1,246 PPS in 2015) per capita 
expenditure  are  lower  than  the  EU  average  (3305 
PPS and 2,609 PPS) (323). 

Expenditure projections and fiscal sustainability  

Public  expenditure  on  health  care  is  projected  to 
increase  by  1.2  pps  of  GDP  ("AWG  reference 
scenario"), much above the average increase of 0.9 
pps  for  the  EU.  When  taking  into  account  the 
impact  of  non-demographic  drivers  on  future 
spending  growth  ("AWG  risk  scenario"),  health 
care expenditure is expected to increase by 2.6 pps 
of  GDP  from  now  till  2070  compared  to  the  EU 
average of 1.6 pps (324). 

Over  the  long  run,  medium  fiscal  sustainability 
risks  appear  for  the  Slovak  Republic.  These  risks 

(322) To  derive  this  figure,  the  SHA  aggregate  HC.3  for  LTC 

(health) is subtracted from total health spending. 

(323) Note  that  these  PPS  figures  reflect  current  plus  capital 
health  expenditure  in  contrast  to  EUROSTAT  data  series, 
which reflect current expenditure only. 
2018 

(324) The 

Report, 

Ageing 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

Despite showing an improvement, the health status 
of  the  Slovak  population  lags  slightly  behind  the 
EU average. While showing  a consistent increase, 
life  expectancy  (80.2  years  for  women  and  73.1 
years  for  men  in  2015)  is  still  below  the  EU 
average (83.3 for women and 77.9 for men). So are 
healthy life years (55.1 years for women and 54.8 
years for men in 2015 vs. EU average of 63.3 and 
62.6  respectively),  which  have  been  interestingly 
showing a decreasing trend after 2007, only to start 
picking  up  again  over  the  recent  years.  Amenable 
mortality rates show a consistent decrease over the 
decade but are still fairly high notably compared to 
other countries of similar GDP per capita (e.g. 250 
per  100,000  inhabitants  in  Slovakia  for  2015  and 
127  in  the  EU).  Infant  mortality  is  also  above  the 
EU average (5.1‰ vs. 3.6‰ in 2015). 

System characteristics  

financing, 

System 
population  coverage  and 
insurance and out-of-pocket payments  

collection, 
role  of  private 

revenue 

The  Slovak  health  care  system  is  a  compulsory 
insurance  scheme  covering  all 
social  health 
the 
residents.  In  practice,  a  small  share  of 
population  (about  4%  in  2011)  (326)  does  not  pay 
the  required  contributions  ( 327) and  is  not  covered 
if  they  are  not  entitled  to  automatic  membership 
(328). Insured persons are allowed to choose health 
insurance  fund  among  three  health  insurance 
companies.  The  State  pays  the  contributions  of 
some  population  groups  (dependent  children, 

(325) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(326) Source: 

http://www.udzs-
sk.sk/documents/14214/21128/Sprava_o+stave+vykonavan
ia+VZP_2014_final.pdf/d1948cc6-023c-4529-be7d-
15022d29f5ea. 

(327) For  all 

the  economically 

inactive  people  health 
contributions are paid by the state. The aforementioned 4% 
comprises  of  the  self-payers,  self-employed  persons  and 
employers  who  do  not  pay  the  required  insurance  even 
though they should. 

(328) Old-age  pensioners,  persons  on  early  retirement  or  those 
receiving a disability pension whose degree of incapacity is 
70% or more. 

235 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

pensioners, persons taking care of children aged up 
to  3  years,  all  students  up  to  the  age  of  26,  full-
time  postgraduate  students  up  to  the  age  of  30, 
PhD  students  and  other  groups)  to  ensure  their 
coverage. 

Public  health  insurance  is  assured  by  three  health 
insurance companies (HICs), one of which is state-
owned and two of which, have the form of private 
joint stock companies. The market is dominated by 
the state-owned company, whose share amounts to 
63% of the total insurers in 2016 (329).  

Mandatory insurance contributions vary according 
to  groups:  14%  of  the  gross  monthly  earning  for 
employees  (employers  pay  10%  and  employees 
4%,  7  %  for  disabled  persons  (the  self-employed 
pay  7%,  and  for  the  employed  the  employer  pays 
5%  and  employee  pays  2%)  and  self-employed. 
The  minimum  assessment  base  for  the  groups 
equal  the  average  wage  divided  by  two.    The 
contributions  paid  by  the  State  on  behalf  of  some 
population groups (dependent children, pensioners, 
persons taking care of children aged up to 3 years) 
amounted to 4.4% of the average wage in 2016. 

In 2015, the Government approved a reform of the 
social  protection  contributions  to  incentivise  low-
wage  labour  supply  and  demand.  It  includes  a 
health  contribution  allowance  (HCA),  for  an 
income  up  to  €380,  which  was  equal  to  the 
minimum  wage  in  2015,  though  the  allowance  is 
fixed  to  this  amount  and  is  not  supposed  to  be 
automatically adjusted to the increase in minimum 
wage.  For  an  income  above  the  €380  up  to  €570 
per  month,  the  health  contribution  allowance 
gradually  decreases.  Deductible  allowances  are 
only  applicable  for  income  from  employment, 
while  when  determining  the  entitlement  other 
revenues are also considered. The cash shortfall of 
revenue of HICs (amounting to 0.21 % of the GDP 
in 2015) was compensated from the state budget.   

Moreover,  a  risk  equalisation  scheme  has  been 
introduced  by  the  State  which  can  redistribute 
to  compensate 
companies'  revenues 
between  insurance  companies  for  the  existing 
demographic  and  socio-economic  differences  of 
the  insured.  Redistribution  criteria  include  sex, 

in  order 

(329) Source: 

http://www.udzs-
sk.sk/documents/14214/92018/VE_11_2018_sprava_stav+
VZP_2017.pdf/c5568cdb-9177-4db6-be25-86fd82bc9425. 

236 

age,  costly  chronic  diseases  (so  called  Pharmacy 
Cost  Groups)  and  the  number  of  policyholders 
whose contribution is paid by the State ( 330). New 
schemes will be introduced in 2019. Especially the 
Multiple-Year  High  Cost  (MYHC)  groups,  which 
additionally  redistribute  the  risk  among  cost-
similar policyholders. 

In  2015,  68%  of  total  health  expenditure  funding 
came  from  mandatory  health  contributions  plus 
6.7% government sources (direct and indirect taxes 
collected  centrally).  The  remaining  part  is  private 
expenditure  on  health  including  private  health 
insurance  and  out-of-pocket  payments.  A  large 
part  of  private  expenditure 
is  out-of-pockets 
(though  not  necessarily  cost-sharing  for  publicly 
goods  and  services  as  explained  below)  which 
represent 18.4% of total expenditure on health (EU 
average  of  15.9%  in  2015).  This  is  nevertheless 
lower than in previous years.  

lowered 

(prescriptions 

Small  lump-sum  fees  (co-payments)  for  many 
medical  services  and  goods  were  introduced  in 
2003 with the aim of controlling consumption but 
in 2006 most of them were abolished (primary and 
specialist  outpatient  care,  hospital  stays)  or 
considerably 
for 
medicines).    Following  the  changes  in  2006, 
various  payments  were  introduced  by  individual 
healthcare  providers.  In  2015,  the  government 
passed legislation to regulate payments by banning 
e.g.  payments  for  appointments  at  a  scheduled 
time. However, the media have since reported that 
new payments have been introduced to bypass the 
legislation  ( 331).  In  addition  to  cost-sharing  for 
medicines,  fees  apply  to  emergency  services, 
ambulance  transportation  and  spa  treatment.  A 
small  number  of  services  (e.g.  in  dental  care  (332) 
and cosmetic surgery) are not covered. The aim of 
introducing  fees  was  to  limit  excess  demand  and 
ensure  a  coherent  path  of  care.  However,  there 
the  already  high  private 
were  concerns  for 
expenditure and they  were abolished. Note that in 
addition 
there  are 
formal  out-of-pockets 
persistent,  considerable  and  unmeasured  informal 
payments.  These  are  not  adjusted  to  individual 

to 

(330) http://www.zakonypreludi.sk/zz/2004-580. 
(331) http://www.health.gov.sk/?poplatky-v-zdravotnictve. 
(332) Standard dental care is covered, but the use of non-standard 
materials  is  not:  https://www.vszp.sk/poistenci/zdravotna-
starostlivost/kedy-platit-za-zdravotnu-starostlivost.html  or 
http://www.dovera.sk/najcastejsie-otazky/a295/co-mi-
preplatite-u-zubara. 

 
                                                           
                                                           
socio-economic characteristics, so they can have a 
negative  impact  on  access  and  discourage  a  more 
effective  use  of  services.  The  design  of  cost-
sharing  is  an  area  that  may  require  further  policy 
analysis. 

The share of voluntary private health insurance of 
total  current  health  expenditure  in  2015  was  only 
1.8%.  Private  health  insurance  in  Slovakia  has 
mostly  a  supplementary  function  covering  non-
essential services not provided under social health 
insurance.  

for 

health 

services 

different 

The State defines annually health care expenditure 
targets 
but 
overshooting  is  possible.  The  State  can  influence 
the  HIC. 
the  volume  of  funds  available 
Furthermore,  it  can  influence  spending  through 
regulation in particular areas (e.g. price-setting for 
medical  rescue  services).  However,  on  the  whole, 
it  is  up  to  the  HIC  to  decide  on  healthcare 
spending. 

to 

organisation: 

Administrative 
of 
government, levels and types of social security 
settings 
involved,  other 
institutions  

involved,  Ministries 

levels 

The  Ministry  of  Health  develops  the  national 
health  policy  strategy,  defines  public  health  and 
policy  priorities  and  provides 
the  overall 
management of the health care system as a whole. 
The  Ministry  of  Health  and  the  Office  for  the 
Supervision of Health Care regulate and supervise 
the activity of the health insurance companies. 

The  contracts  between  HIC  and  inpatient  and 
outpatient  providers  regulate  only  the  mandatory 
list of services covered by public health insurance, 
whereas  prices  and  detailed  conditions  are 
negotiable  without  regulation.  The  network  of 
strategic  public  healthcare  providers  and  general 
practitioners are privileged (333) as HIC are obliged 
to  sign  contracts  with  all  these  hospitals  and  their 
departments.  Other  providers  or  certain  types  of 

(333) These  healthcare  providers  (HCPs)  were  selected  by  the 
government  as  “strategic  providers”.  The  majority  is 
public,  however  a  growing  proportion  is  privately  owned. 
HICs are obligated to conclude contracts with these HCPs, 
no  matter  what  the  quality  of  their  service  provision  is. 
This makes strategic providers privileged compared to non-
strategic  HCPs.  Only  hospitals  have  been  designated 
strategic, not GPs. 

Health care systems 

2.24. Slovakia 

their  services  may  be  omitted  from  contracting. 
Reimbursement of pharmaceuticals is regulated via 
a specified list of  medicines with fixed prices and 
reimbursement levels.  

There  are  constrains  on  the  health  insurance 
companies’  use  of  profits  made  from  public 
insurance  and  payments  for  health  care  provision. 
In 2007, the government banned the use of profits 
to pay dividends. In 2011, the Constitutional court 
found this was not in line with the Constitution. As 
of  2011,  HICs  may  again  use  profits  to  pay 
dividends.  However,  conditions  apply,  that  is 
before  paying  out  dividends,  HIC  must  create 
1.reserves  for  the  provision  of  planned  healthcare 
(i.e.  healthcare  to  be  provided  to  patients  on 
waiting lists) and 2. a separate reserve fund at least 
to the value of 20 % of common capital stock. 

Coverage  of  services,  types  of  providers, 
referral systems and patient choice 

by 

facilities 

contracted 

inpatient),  emergency  and 

A wide range of health care services and goods is 
provided through a network of private and publicly 
insurance 
owned 
companies:  primary  health  care,  outpatient 
specialist consultations and hospital care (day-case 
and 
transporting 
medical  services,  and  a  range  of  related  services 
including imaging diagnostic services, laboratories 
(334),  physiotherapy,  dialysis  care,  home  nursing 
insurance 
agencies 
general 
companies 
practitioners  and  pharmacies  and  a  specified 
minimum number of specialists and hospitals. 

hospices.  Health 

contract 

have 

and 

all 

to 

The  provision  of  health  care  is  decentralised  and 
based  on  a  public-private  mix.  Public  and  private 
health care providers sign contracts with the health 
insurance  companies  in  order  to  be  eligible  for 
reimbursement.  General  practitioners  (GPs)  and 
outpatient  specialists  can  be  independent  private 
providers  or  public  providers.  Most  private 

(334) A comparison of spending data among EU countries (based 
on available Eurostat data) shows that per capita spending 
on  laboratories  and  diagnostic  imaging  in  Slovakia  is 
higher  than  the  EU  average  level,  70  and  40  PPS  per 
inhabitant  respectively  in  2015.  The  average  spending  of 
Hungary,  Poland  and  the  Czech  Republic  is  significantly 
lower and well below the EU average. Similarly, spending 
on transportation and medical rescue services in Slovakia is 
with 40 PPS per capita above the EU average (30 PPS per 
capita),  though  comparable  with  the  spending  in  Poland 
and the Czech Republic in 2015. 

237 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

primary  care  providers  have  contracts  with  health 
insurance  companies.  Only  some  private  primary 
care providers such as dentists are working on the 
basis of direct payments from patients and without 
a contract with health insurance companies. There 
is  some  current  policy  discussion  on  encouraging 
group practices rather than individual practices.  

Patients have to register with a GP whom they can 
choose  freely.  A  so-called  "exchange  card", 
introduced in 2008, works as a referral tool from a 
GP  to  a  specialist  or  hospital.  The  aim  is  to  have 
GPs referring patients for specialist care, operating 
as  gate-keepers.  Since  1  April  2013,  the  GP 
referral  system  is  in  operation  again,  after  it  was 
abolished  in  2010.  However,  the  system  does  not 
(e.g.  accident  and 
work 
emergency,  chronic  care,  outpatient  psychiatric 
care,  dentists,  ophthalmologists,  dermatologists 
and  gynaecologists  are  exempted)  and  it  does  not 
appear to be very effective due to shortages of GPs 
especially  in certain areas (335). This is something 
the authorities see as a policy priority. 

for  all  specialties 

reform 

level.  The  2007 

Secondary  and  tertiary  care  are  provided  in  a 
number  of  general  and  specialised  hospitals, 
polyclinics,  hospices  and  nursing  homes.  The 
ownership  and  management  of  most  public 
institutions  has  been  decentralised  from  central  to 
introduced 
regional 
healthcare 
all  GPs, 
districts,  whereby 
gynaecologists and dentists are obliged to provide 
care  to  each  patient  resident  in  their  respective 
territorial  districts,  who  in  turn  has  the  right  to 
choose  freely  his/her  physician.  Moreover,  a 
minimum  network  of  public  health  care  providers 
was  established  (including  37  hospitals,  a  part  of 
which is now privately owned) (336), which have to 
be contracted by the health care companies. While 
choosing the providers beyond the list of minimum 
public  network  each  fund  could  establish  its  own 
evaluation  criteria.  The  government  adopted  an 
official  list  of  indicators  to  assess  the  quality  of 
providers. 

(335) In  2014,  the  government  introduced  a  residential  program 
to facilitate the training of GPs and paediatricians for rural 
areas  (http://www.health.gov.sk/?rezidenti).  The  aim  is  to 
train 
year 
(http://www.health.gov.sk/?faq-rezidenti). 
(336) https://www.vszp.sk/poistenci/zdravotna-

100-150 

doctors 

a 

starostlivost/pevna-siet-poskytovatelov-k-1-1-2016.html. 

238 

to 
the  health 

In  case  of  out-patient  medical  treatment,  there  is 
the  primary  care  physician 
direct  access 
contracted  by 
insurance  company 
(information  about  the  contracted  physicians  shall 
be  provided  by  each  of  the  health  insurance 
companies).  If  the  specialist  outpatient  care  is 
needed,  the  referral  of  primary  care  physician  is 
requested.  Patients  do  not  pay  for  the  specialist 
(337).  When 
outpatient 
hospitalisation  is  needed,  the  referral  of  GPs  is 
requested 
immediate 
hospitalisation.  In  this  case  the  patient  does  not 
have to pay a fee for the health care provided.  

provided 

except 

case 

care 

of 

in 

There  is  direct  access  to  the  contracted  dentist 
(information  on  the  contracted  dentists  shall  be 
provided  by  each  health  insurance  company). 
There  is  a  "standard"  dental  treatment  which  is 
reimbursed  by  the  public  health  insurance.  The 
price difference for additional treatment or above-
standard  is  paid  by  the  patient.  The  price  of  non-
standard  treatment  is  determined  by  each  dental 
practice  and  varies  between  clinics.  The  dentist  is 
obliged to inform the patient in advance about the 
expenses for services with private co-payment and 
about the expenses of direct  payment and in  what 
amount. 

fees  are  applied 

to  emergency  care, 
User 
differentiating  between  outpatient  and  hospital 
emergency care. In the case of hospital emergency 
care  (Medical  First  Aid  or  Hospital  Emergency 
Service) a fee of €10 applies to all patients, except 
to  those  who  had  an  immediate  accident  or  had 
been hospitalised on the grounds of the emergency 
health condition. Conversely, the fee for outpatient 
emergency care is €2 and is meant to serve patients 
with non-acute health problems. 

Some  primary  and  specialist  outpatient  care  also 
take  place  in  specialists'  private  individual  or 
group  practices  and  some  hospital  care  takes  in 
private clinics and hospitals at the cost of patient.  

The  number  of  practicing  physicians  per  100,000 
inhabitants (345 in 2015) is at the EU average (344 
in  2015).  The  number  of  GPs  per  100,000 
inhabitants  (42  in  2007,  latest  available  data)  is 
also  below  EU  average  (78.3  in  2015).  The 
numbers  suggest  that  the  skill  mix  may  need  to 

(337) In  practice,  fees  may  apply.  Fees  are  mostly  related  to 

accompanying services and administrative steps. 

 
                                                           
                                                           
improve  to  ensure  a  good  distribution  of  GPs, 
currently  deemed  unequal  by  the  authorities,  and 
the  effectiveness  of  the  referral  system  and  the 
GPs'  gatekeeping  role  which  the  authorities  want 
to  reinforce.  Indeed,  this  is  one  of  the  policy 
priorities  of 
the 
introduction of the residential programme for GPs. 
Acute  hospital  beds  stand  at  488  per  100  000 
inhabitants and are higher than the EU average of 
402  per  100  000  inhabitants  in  2015,  though 
showing a reduction over the last decade.  

the  Slovak  authorities  with 

A next consideration to be made is the existence of 
staff  supply  regulations.  As  it  turns  out,  there  are 
no  quotas  for  medical  students  as  the  pool  of 
graduated  medical  students  through  the  entire 
hierarchy  is  sufficient.  The  location  of  physicians 
is  partially  managed  by  HICs  since  each  HIC 
manages  its  own  minimal  network  of  physicians 
depending  on  the  geographical  density  of  their 
clients. Specialists in locations with fewer patients 
have more convenient contracts. 

Purchasing  and  contracting  of  healthcare 
services and remuneration mechanisms 

Primary  care  physicians  are  paid  mainly  on  a 
capitation  basis.  Specialists  are  paid  on  a  fee-for-
service  basis.  The  current  system  of  financing 
health  care  is  based  on  a  combination  of  a  point 
and  fixed  price  system.  For  outpatient  care,  each 
medical  service  has  a  point  value  listed  by  the 
Slovak  Ministry  of  Health.  As  the  list  of  medical 
services  with  assigned  point  values  is  not  being 
updated regularly and new services/ procedures are 
being  introduced,  HICs  now  set  fixed  prices  for 
these, rather than setting a point value.  

Assessing  and  adjusting  hospital  remuneration  is 
something  the  authorities  have  indicated  as  a 
policy  priority.  Until  2017,  for  inpatient  care, 
hospitals  were  typically  paid  fixed-rates  for  long-
terms  stays  of  chronic  patients.  For  most  hospital 
stays  hospitals  got  payments  per  discharge.  These 
depended  on  the  department  and  were  negotiated 
by  HICs  and  HCPs (338).  From  2017  on,  a 
diagnostic-related 
payment 
mechanism 
to  be  gradually 
implemented.  In  2017,  individual  hospitals  had 

(DRG)  started 

group-linked 

(338) Source: 

http://hpi.sk/cdata/Publications/hpi_zakladne_ramce_2014.
pdf. 

Health care systems 

2.24. Slovakia 

individual  rates  in  order  to  avoid  significant 
financial  fluctuations  and  destabilisation  of  the 
inpatient sector. Every HIC has its own safety net 
system,  allowing  for  additional  payments  should 
the DRG-based payment substantially deviate from 
the  original  payment  mechanism  (payment  for 
hospitalisation/discharge)  of  the  hospitals.  The 
to 
safety  nets  ensure  stability 
individual  providers.  A  five-year  convergence 
process of individual rates to a single nation-wide 
basic  rate  will  be  initiated  in  2018  and  should  be 
completed by 2022. 

in  payments 

Health  insurance  companies  are  responsible  for 
contracting  hospitals.  They  sign  contracts  with 
health  care  providers  for  different  quantity  of 
health  care  services  on  the  basis  of  selected 
regional  needs.  They  have  the  possibility  to 
differentiate  the  quantity  of  health  care  services 
purchased according to the quality of providers. As 
of 2018, HICs have introduced payment via global 
budgets  (equal  monthly  payments  based  on  6 
months average of previous term), which has to be 
based  on  DRG  reporting.  It  serves  as  another 
safety net to avoid under-financing.  

The number of physicians' consultations per capita 
is  well  above  the  EU  average  (11.4  vs.  6.3  in 
2015). When looking at hospital activity, inpatient 
discharges  are  higher 
the  EU  average 
(respectively  19.3  vs.  16.2  per  100  inhabitants)  in 
2015.  Hospital  average  length  of  stay  for  curative 
care is slightly below the EU average (7.2 days vs. 
7.6 days in 2015).  

than 

The  market  for  pharmaceutical  products,  the 
use  of  Health  Technology  Assessment  and 
cost-benefit analysis 

to 

Medicines are divided into three categories by law 
according 
their  clinical  performance  and 
economic  evaluation:  medicines  fully  paid  by  the 
health  insurance;  medicines  partially  paid  by  the 
health insurance company and with co-payment by 
patients; and medicines fully paid by patients. The 
physician who prescribes the medicines is obliged 
to inform patients on the reimbursement category, 
in  which  a  medicine  is  placed.  The  pharmacy  is 
obliged  to  issue  the  receipt  of  the  amount  of 
overall payment and the private co-payment.  

A  number  of  measures  have  been  adopted  to 
control pharmaceutical expenditure. In addition to 

239 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

initial  model  was  based  on 

price  reductions,  external  reference  pricing  and  a 
regressive  mark-up  were  introduced  in  recent 
years.  The 
the 
referencing  of  prices  against  the  average  of  six 
lowest prices in  the EU. In 2011, referencing  was 
tightened, so that drug prices could not exceed the 
level  of  the  second  lowest  price  in  the  EU.  As  of 
2013,  prices  are  referenced  at  the  level  of  the 
average of the three lowest prices for a given drug 
in the EU. Slovakia has established a greater use of 
generics as a policy priority.  

In  June  2016,  the  international  reference  pricing 
has  been  extended 
to  medical  devices  and 
specialised  medical  material.  At  first  535  medical 
devices  representing  11%  of  all  medical  devices  
immediate  price 
were  referenced 
reduction  of  about  21%  on  average  compared  to 
prices  in  the  previous  year.  Selected  medical 
materials 
(such  as  pacemakers,  stents,  and 
defibrillators)  were  included  as  well.  Next,  in 
October 2016, the reference pricing was expanded 
to include all medical materials.  

leading 

to 

Some  groups  of  medicines  that  are  used  in 
outpatient care are procured centrally by insurance 
companies  (for  example,  vaccines,  oncological 
medicines, 
purchase 
pharmaceuticals on their own from their budgets. 

Hospitals 

etc.). 

E-Health, Electronic Health Record 

During  2017,  all  doctors  were  connected  to  an 
eHealth  environment.  Selected  eHealth  elements, 
such  as  a  National  health  portal,  ePrescription,  
eMedication,  electronic  health  documentation  and 
eAllocations,  have  become  functional  at 
the 
there  are  no 
beginning  of  2018.  However, 
intentions  to  fully  replace  paper-based  health 
documentation with eHealth forms.  

Health  promotion  and  disease  prevention 
policies 

The need to improve  health status further through 
promotion  and  prevention  activities  is  a  policy 
priority.  Slovakia  spends  less  on  prevention  and 
public  health  services  than  the  EU  average  (2.2% 
of  public  current  health  expenditure  relative  to 
3.1% in the EU in 2015). 

240 

Transparency and corruption 

The  contracts  between  HICs  and  healthcare 
providers  are  published  online  mandatorily.  All 
contracts  of  state-owned  healthcare  providers  are 
also  mandatorily  published  online  (including 
public  procurement  contracts).  Online  publishing 
is also used as a tool to put into transparency any 
interactions among physicians and pharmaceutical 
companies. The companies have to publish a list of 
doctors  who  took  part  on  the  organised  by  them 
medical  congresses  and  conferences.  Since  July 
2016,  companies  publish  all  transfers  of  value  to 
health  care  providers  (e.g.  doctors  and  nurses), 
including the name of the health care provider, the 
value  and  purpose  of  the  transfer  of  value  (both 
financial and non-financial) ( 339). 

Recently 
reforms  

legislated  and/or  planned  policy 

Health insurance 

The  system  of  risk  compensation  in  public  health 
insurance  was  extended  by  adding  the  morbidity 
parameter  through  classification  of  policy  holders 
in  pharmaceutical  cost  groups  (PCG).  Since  the 
second  half  of  2012,  the  revenues  of  insurance 
companies  have  thus  been  following  real  costs  of 
treatment of their policy holders.  

Reform of primary care 

The  average  number  of  patient  visits  per  year  in 
Slovakia  is  almost  twice  as  much  compared  with 
the EU average (11.4 vs. 6.3 in 2015). One reason 
for  this  is  a  poor  integration  of  health  care 
providers which is demonstrated by a high degree 
of fragmentation of primary health care providers; 
where  2,933  territorial  units  (340)  (municipalities) 
exist with a total of 2,863 primary care physicians 
(341).  The  other  problem  is  the  high  rate  of 
referrals; a  high  number of patient  visits  indicates 
inadequate  patient  management  by  primary 
physicians, where more than 80% of patients with 
chronic  disease  are  transferred  from  the  first 
contact  with  a  GP  physician  directly  to  a  hospital 

(339) http://www.health.gov.sk/Clanok?mz-zavadza-

transparentnejsie-pravidla-pri-zverejnovani-vydavkov-
farmaceutickych-firiem-na-propagaciu-a-marketing. 

(340) http://www.vlada.gov.sk/slovensko. 
(341) Source : 

http://www.nczisk.sk/Documents/publikacie/analyticke/zdr
avotnictvo_slovenskej_republiky_v_cislach_2014.pdf. 

 
                                                           
specialist. The Ministry of Health has taken actions 
to  proportionally  change  the  redistribution  of 
patients  visits  from  nowadays  80%  managed  by 
specialists and only 20% fully managed by GPs to 
around 60% and 40% in the next few years. Efforts 
to  make  the  profession  of  a  general  practitioner 
more  attractive  are  continuing,  in  order  to  attract 
young  doctors.  The  Ministry  of  Health  has 
legislatively defined a new  form of preparation of 
general 
their 
university  studies,  and  as  from  July  2014,  GP's 
have  the  possibility  to  perform  pre-operation 
examinations of patients with common diseases. In 
2015 legislation was passed allowing GPs broader 
rights  in  treating  chronic  patients,  previously 
treated by specialists (e.g. patients with diabetes).   

practitioners 

already 

during 

Improving  the  financial  management  and 
economy of providers 

The  Slovak  Government  undertakes  measures  to 
ensure  that,  on  average,  health  care  facilities 
established by the Ministry of Health of the Slovak 
Republic  will  operate  on  a  balanced  budget 
without  needing  additional  financial  assistance 
from  the  state  budget  and  that  their  indebtedness 
will be considerably reduced. The indebtedness of 
state  hospitals  has  not  slowed  down  since  2012 
(342).  Thus,  a  newly  established  unit  for  the 
management of hospitals operated by the Ministry 
of  Health  together  with  supervisory  bodies  in 
hospitals  should  reinforce  surveillance  and  help 
improve  financial  management  of  state-owned 
hospitals.  

prior 

The financial management of hospitals needs to be 
set  in  a  manner  that  rewards  performance  and 
introducing 
to 
efficiency.  However, 
performance-based 
remuneration  of  executive 
managers,  it  is  necessary  to  ensure  systematic 
collection,  monitoring  and  evaluation  of 
the 
financial 
indicators.  Correctly 
relevant 
management  of  hospitals  may  considerably  help 
prevent 
thus 
increase  the  efficiency  of  spending.  Hospital 
managements  should  also  focus  on  operational 

the  accumulation  of  debts  and 

set 

(342) According  to  data provided  to  the  Ministry  of  Finance  by 
the  Ministry  of  Health,  in  2012  the  indebtedness  of 
hospitals affiliated with the Ministry of Health grew by €93 
million,  in  2013  by  €95  million.  In  2014  the  rate  slowed 
down  to  €71  million,  but  in  2015  it  again  rose  to  €108 
million.  At  the  end  of  2017  total  indebtedness  reached 
€791 million. 

Health care systems 

2.24. Slovakia 

savings  by  curtailing  duplication  of  processes  and 
personnel. 

Savings  in  the  procurement  of  energy,  materials, 
services and other inputs used by hospitals can be 
achieved  by  centralising  purchases  at  the  level  of 
hospitals’  managements.  Furthermore,  with  the 
introduction of central procurement, hospitals  will 
be  able  to  spend  their  funds  more  effectively 
without compromising on the treatment of patients. 
Centralised procurement by the Ministry of Health 
continues  and  is  already  implemented  in  state-
owned  hospitals.  A  framework  agreement  set  up 
first for the procurement of CT technology, will be 
now also used for procurement of MRI technology 
and hospital beds. 

Better integration of healthcare provision 

One  of  the  planned  steps,  conducive  to  stabilise 
expenditure,  is  the  introduction  of  an  integrated 
model  of  health  care  provision.  The  position  of 
general  practitioners  is  supposed  to  be  further 
reinforced  in  order  to  reduce  more  expensive 
treatment in hospitals and by specialist physicians. 
The  residency  programme  will  bring  a  new 
generation  of  general  practitioners  and  help 
improve 
treatment  management  process. 
Medical  students  will  be  required  to  undergo  a 
period  of  training  in  outpatient  facilities  already 
during  their  university  studies.  Following  the 
completion  of  their  study  programmes,  graduates 
will  be  required  to  work  for  a  certain  number  of 
years  in  outpatient  facilities  in  Slovakia.  One  of 
the  key  components  of  the  integrated  model  of 
health  care  provision  will  include  the  application 
of e-Health in practice. 

the 

An insufficient coordination of the current types of 
establishments in the treatment process often leads 
to  cases  where  more  specialised  and  costly 
healthcare  provider  than  medically  necessary  is 
dealing  with  relatively  simple  medical  cases.  A 
clear  definition  of  the  types  of  hospitals  and  the 
extent  of  care  provided  by  them  and  a  better 
coordination  of  involvement  of  outpatient  and 
inpatient facilities in individual stages of treatment 
could  help  increase  the  efficiency  in  the  use  of 
capacities.  Hospitals  types  should  be  defined 
according  to  the  extent  of  healthcare  provision. 
The portfolio of healthcare provision should reflect 
the variability of cases and the levels of difficulty 
so that adequate capacity is achieved for the needs 

241 

 
                                                           
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

of  the  catchment  area.  At  the  same  time,  the 
coordination  between  outpatient  and 
inpatient 
establishments should improve. The aim will be to 
set the system in a way that will allow providers at 
each  level  to  be  used  in  individual  cases  so  that 
staff  and  physical  resources  would  not  be  wasted. 
Particular  setting  and  detailed  definitions  will  be 
gradually  profiled  in  the  Strategic  Healthcare 
Framework  for  2014  –  2030  which  is  an  ex  ante 
conditionality for using EU financial resources. In 
2018,  the  Ministry  of  Health  has  introduced  in 
cooperation  with  HICs  the  stratification  plan  of 
hospitals  which  should  reform  the  current  system 
and  implement  new  set  of  rules  for  selective 
contracting  based  on  evidence-based  hospital 
referral (EBHR – minimal quantitative standard for 
achieving sufficient quality of care). New hospital 
typology is crucial in this endeavour and therefore 
it  is  important  to  achieve  great  consensus  on 
political and also on health care providers level.  

Introduction  of  diagnosis-related  group  (DRG) 
payments  

of 

other 

diseases 

presence 

With  the  introduction  of  diagnosis-related  group 
payments  by  2022,  it  will  be  possible  to  identify 
internal  reserves  of  resources  in  the  public  health 
insurance  system,  increase  transparency  in  the 
insurance  companies  and 
relations  between 
hospitals  and  manage  them  in  a  meaningful  and 
effective  manner.  For  every  hospital  case,  the 
DRG  system  will  assign  a  portion  of  funds  set  in 
advance  –  based  on  diagnosis,  procedure,  age, 
gender, 
or 
complications  and  other  measurable  criteria.  If  an 
identical  procedure 
the 
treatment  of  an  identical  diagnosis,  every  hospital 
will  receive  the  same  amount  from  an  insurance 
company.  DRG  payments  will  provide  a 
transparent  healthcare  funding  system  for  in-
patient  healthcare  facilities,  thus  bringing  more 
fairness to the funding of healthcare providers. The 
creation  of  a  uniform  platform  for  the  funding  of 
the  provided  hospital  services  in  the  form  of  the 
DRG  system  will  contribute  to  the  possibility  to 
compare  healthcare  provided  in  the  individual 
healthcare  facilities,  and  a  broader  scope  of 
information  will  be  collected  for  decision-making 
and control.  

is  performed  during 

In 2018, hospitals are  being reimbursed via global 
budgets,  which 
represent  an  equal  monthly 
payment. The budget has to be “filled” from DRGs 

242 

and if there is a 20% difference between reporting 
and payments, the HIC or the provider are obliged 
to start new negotiations. At the same time, a five-
initiated, 
year  convergence  process  has  been 
insuring  the  transition  from  individual  hospital 
rates to single nation-wide basic rates in 2022.  

Construction of a modern hospital in Bratislava 

Along  with  the  adoption  of  measures  aimed  at 
stopping  the  growing  indebtedness  of  hospitals, 
investments will be made in acute hospitals which 
will  replace  some  of  the  most  obsolete  and  least 
efficient  facilities.  The  intention  to  build  a  new 
hospital  in  Bratislava  was  included  in  the  2016 
government  manifesto  and  will  be  financed  from 
public funds. 

Challenges 

The analysis above shows, that a range of reforms 
have  been  started/implemented  in  recent  years. 
However, when it comes to the efficiency of health 
care  provision,  Slovakia’s  performance 
is 
relatively  low  (343).  The  main  challenges  for  the 
Slovak health care system are as follows: 

•  To continue increasing the efficiency of health 
care spending in order to adequately respond to 
perceived  current  inefficiencies,  such  as  high 
spending  on  ancillary  services  (diagnostic 
imaging, 
and 
medical  rescue  services),  pharmaceuticals  and 
medical goods, as well as the increasing health 
care expenditure over the coming decades. This 
is  a  risk  to  the  long-term  sustainability  of 
public finances.   

transportation 

laboratories, 

•  To introduce an integrated care  model, e.g. by 
establishing  health  centres  and  devising  and 
implementing  the  master  plan  for  an  effective 
care 
geographic 
resources,  by  safeguarding  accessibility  and 
delivering efficiency gains.  

distribution 

health 

of 

•  To  further  promote  the  supply  of  general 
practitioners  by  removing  the  restrictions  on 
the  volume  and  range  of  primary  health 
services,  introducing  the  performance  element 
the 
to  payment  schemes,  and 
attractiveness of being a general practitioner. 

improving 

(343) http://www.finance.gov.sk/Default.aspx?CatID=8789. 

 
                                                           
•  To  ensure  balanced  hospital  budgets  by 
improving the efficient utilisation of resources, 
improving 
hardening  budgetary  constraints, 
in  procurement 
guidance  and  supervision 
processes  and  enhancing  payment  systems,  by 
introducing a diagnosis-related groups payment 
system as planned currently. To continue recent 
efforts  to  optimise  the  utilisation  of  acute  care 
beds (low bed occupancy rates imply an excess 
of hospital beds which may lead to inefficiency 
the  operating  costs  of  hospitals),  by 
in 
introducing  effective 
referral  system  and 
implement 
admissions.  To 
of 
control 
stratification of hospitals to increase quality of 
care and achieve better allocation of resources.  

•  To  implement  measures  for  a  comprehensive 
streamlining  of  public  hospital  care,  including 
transforming  acute  care  beds  into  long-term 
care beds. A new hospital typologisation can be 
is 
instrumental 
therefore  important  to  achieve  consensus  on 
political and health care providers level. 

this  endeavour  and 

in 

it 

•  To  promote  the  rational  use  of  medicines  by 
combining different policies, such as electronic 
prescription,  monitoring  and  guidelines  linked 
with electronic systems and providing feedback 
to  physicians  appears  an  effective  way  of 
improving  prescription  behaviour.  This  may 
reduce the risk of over-prescription and  wrong 
co-medication.  To 
a  national 
procurement  system  for  pharmaceuticals  in 
order  to  enhance  the  bargaining  power  of 
hospitals against pharmaceuticals companies.  

introduce 

•  To fully implement and extend the pilot project 
including  
information 
tools, 
on  ‘e-health’ 
records  and  e-referrals, 
electronic  health 
aiming 
improve  coordination  between 
to 
inpatient  and  outpatient  care  and  to  limit 
overuse of services and pharmaceuticals.  

•  To  continue  to  improve  data  collection  and 
monitoring  of  inputs,  processes,  outputs  and 
performance 
outcomes 
assessment  can  be  conducted  and  used  to 
continuously 
improve  access,  quality  and 
sustainability of care. 

regular 

that 

so 

Health care systems 

2.24. Slovakia 

243 

 
2
4
4

Table 2.24.1:  Statistical Annex – Slovakia 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

EU- latest national data

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

6.9

5.5

1.4

769

5.2

5.1

583

0.14

75.8

18.8

97.6

23.6

7.2

5.5

1.7

928

5.0

4.9

652

0.13

70.2

19.3

96.3

26.6

5.2

5.1

833

0.11

69.1

21.7

95.5

27.4

2005

39

15.0

6.7

:

2006

46

16.1

8.4

13.0

2007

56

17.7

10.7

16.5

2008

66

18.5

5.4

2.4

2009

64

17.5

-5.6

9.1

2010

68

19.0

4.8

2.5

2011

71

19.2

3.4

-3.2

2012

73

19.6

1.5

4.0

2013

74

19.8

1.4

1.8

2014

76

20.6

2.6

3.2

2015

79

21.6

3.8

-9.5

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

7.6

6.5

1.1

7.3

6.6

0.7

8.5

6.9

1.6

8.3

7.2

1.1

7.8

7.0

0.8

8.0

7.6

0.3

8.0

7.5

0.5

8.1

6.9

1.1

7.0

6.9

0.1

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

1,206

1,374

1,538

1,585

1,551

1,633

1,671

1,724

1,556

2,745

2,895

5.5

5.4

6.1

6.0

5.9

5.8

5.7

5.6

5.6

5.5

5.7

5.6

5.7

5.6

5.6

5.5

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

1,028

1,102

1,120

1,141

1,150

1,191

1,216

1,246

2,153

2,263

2,324

2,609

0.12

74.8

18.9

95.4

26.1

0.12

71.7

17.3

95.4

26.9

0.11

70.6

16.9

95.4

27.2

0.12

73.6

17.1

95.2

23.6

0.10

70.5

17.2

95.0

23.2

0.11

71.2

17.4

94.6

23.3

0.13

70.6

16.7

94.2

18.0

0.13

80.0

15.7

93.8

18.4

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

5.4

78.1

70.2

56.6

55.2

92

7.2

5.4

78.4

70.4

54.6

54.5

86

6.6

5.4

78.4

70.6

56.1

55.6

102

6.1

5.4

79.0

70.9

52.5

52.1

116

5.9

5.4

79.1

71.4

52.6

52.4

110

5.7

5.4

79.3

71.8

52.0

52.4

105

5.7

5.4

79.8

72.3

52.3

52.1

262

4.9

5.4

79.9

72.5

53.1

53.4

261

5.8

5.4

80.1

72.9

54.3

54.5

262

5.5

5.4

80.5

73.3

54.6

55.5

243

5.8

5.4

80.2

73.1

55.1

54.8

250

5.1

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

1.9

0.0

1.2

2.2

0.5

0.2

0.3

1.9

0.0

0.8

1.7

0.1

0.1

0.3

1.5

:

1.6

2.2

0.6

0.3

0.3

1.2

0.0

1.1

1.6

0.2

0.1

0.3

1.7

0.0

1.7

2.2

0.6

0.4

0.3

1.4

0.0

1.2

1.5

0.2

0.2

0.3

1.7

0.0

1.6

2.2

0.6

0.4

0.3

1.4

0.0

1.3

1.6

0.2

0.2

0.3

1.8

0.0

1.9

2.4

0.8

0.4

0.3

1.5

0.0

1.5

1.7

0.2

0.2

0.3

1.8

0.0

1.8

2.4

0.8

0.5

0.3

1.5

0.0

1.3

1.7

0.2

0.2

0.3

1.7

0.0

1.8

2.2

0.7

0.2

0.3

1.6

0.0

1.4

1.5

0.2

0.1

0.3

1.7

:

1.9

2.0

0.7

0.3

0.3

1.6

:

1.3

1.4

0.2

0.1

0.3

1.8

:

1.9

2.0

0.7

0.2

0.3

1.7

:

1.4

1.3

0.2

0.1

0.3

1.9

0.0

1.5

1.9

0.5

0.1

0.3

1.7

:

1.4

1.3

0.2

0.1

0.3

2.0

0.0

1.5

1.9

0.6

0.2

0.2

1.8

:

1.3

1.3

0.2

0.1

0.2

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

r

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r

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Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2.24.2:  Statistical Annex - continued – Slovakia 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

34.3%

0.0%

21.4%

40.6%

9.8%

2.9%

5.1%

36.8%

0.0%

15.2%

32.5%

2.8%

1.8%

5.5%

2005

0.43

0.8

1.1

0.1

:

:

10.8

2005

304

632

:

690

2005

11.3

18

:

67.0

7.3

:

2016

5.6

5.6

2016

5.4

2006

27.5%

:

29.0%

40.1%

10.3%

5.9%

5.3%

25.3%

0.0%

22.8%

32.4%

3.3%

2.6%

5.9%

2006

0.45

0.7

1.2

0.1

:

:

10.3

2006

317

633

:

617

2006

10.4

18

:

68.0

7.2

:

2020

5.8

5.9

2020

5.5

2007

25.6%

0.0%

25.9%

33.5%

9.4%

5.7%

4.2%

26.6%

0.0%

24.3%

29.4%

3.1%

2.9%

5.5%

2007

0.57

0.8

1.4

0.1

:

:

10.6

2007

300

662

42

608

2007

11.2

17

:

67.9

8.6

:

2025

6.0

6.4

2025

5.5

2008

25.2%

0.0%

24.6%

33.6%

9.1%

5.6%

4.7%

26.0%

0.0%

24.5%

29.4%

3.2%

2.8%

5.8%

2008

0.61

0.8

1.4

0.1

15.1

19.3

11.4

2009

26.4%

0.0%

28.1%

35.4%

10.9%

6.1%

4.2%

25.8%

0.0%

25.5%

28.5%

3.4%

3.0%

4.9%

2009

0.61

0.9

1.3

0.1

15.1

19.5

10.6

2008

2009

337

658

:

559

2008

12.1

18

:

67.5

8.5

:

2030

6.2

6.9

2030

5.5

330

637

:

553

2009

11.6

18

:

67.3

8.3

:

2035

6.5

7.3

2035

5.4

2010

25.2%

0.0%

24.8%

33.1%

10.4%

6.3%

4.0%

26.6%

0.0%

23.3%

28.7%

3.3%

3.0%

5.0%

2010

0.68

0.9

1.4

0.1

:

:

10.1

2010

336

640

:

546

2010

11.6

18

:

66.5

8.2

:

2040

6.6

7.6

2040

5.4

2011

24.0%

0.0%

25.5%

31.3%

10.0%

3.0%

3.7%

28.4%

0.0%

24.3%

27.1%

3.6%

1.6%

4.8%

2011

0.70

0.9

1.5

0.1

:

:

10.2

2011

331

628

:

535

2011

11.0

18

:

65.5

8.0

:

2045

6.8

7.9

2045

5.3

EU- latest national data

2012

21.6%

:

24.4%

26.6%

9.1%

4.2%

3.3%

2013

23.8%

:

24.9%

26.5%

9.2%

2.1%

3.4%

2014

27.3%

0.6%

22.0%

27.0%

7.5%

1.9%

4.2%

2015

28.3%

0.6%

22.4%

26.9%

8.4%

2.2%

3.2%

29.7%

30.4%

31.0%

32.1%

:

24.2%

24.7%

3.6%

1.5%

4.6%

:

24.9%

23.8%

3.7%

1.5%

4.5%

:

24.3%

24.1%

3.8%

1.8%

5.2%

:

24.4%

23.9%

4.0%

2.4%

4.0%

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

2012

0.63

0.9

1.6

0.1

:

:

10.1

2012

336

580

:

528

2012

11.2

:

:

67.3

7.5

:

2050

6.9

8.1

2050

5.3

2013

0.67

0.9

1.5

0.1

:

:

9.9

2013

339

580

:

523

2013

11.0

:

:

67.4

:

:

2055

6.9

8.2

2055

5.2

2014

0.83

0.9

1.7

0.1

15.9

22.9

10.6

2014

343

:

:

524

2014

11.3

19

0

68.9

7.3

0.0

2060

7.0

8.3

2060

5.1

2015

0.88

0.9

1.8

0.2

:

:

:

2015

345

:

:

518

2015

11.4

19

0

68.7

7.2

0.0

2065

6.9

8.3

2065

5.0

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

6.8

8.1

2070

4.9

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Slovakia

1.2

2.6

EU

0.9

1.6

Change 2016-2070, in %

Slovakia

-9.5

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

H
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5

 
 
 
 
 
 
 
  
 
 
 
2.25. SLOVENIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  country  statistics:  GDP,  GDP  per 
capita; population 

Slovenia  has  a  population  of  just  above  2  million 
inhabitants,  which  is  slightly  more  than  0.4%  of 
the  EU  population.  With  a  GDP  of  39  billion,  or 
22,600 PPS per capita in 2015 it scores lower than 
the  EU  weighted  average  (29,600). When  looking 
at the unweighted average and at the median level 
though,  respectively  25,200  and  22,100  PPS, 
Slovenia  faces  a  significantly  lower  gap,  standing 
at  89.7%  of  the  average,  and  closely  resembling 
the median. However measured, this gap is mainly 
due  to  the  economic  crisis  which  since  2008 
reduced  the  national  income,  whereas  in  2008 
Slovenia's  GDP  level  in  PPS  per  capita  was  91% 
that of the EU average.  

The  Slovenian  population  is  projected  to decrease 
from  2.1  million  in  2015  to  2  million  in  2070,  a 
decrease  of  5%  in  comparison  to  the  EU  average 
increase of 2%. 

Total  and  public  expenditure  on  health(344)  as 
% of GDP 

In 2015 total expenditure on health care amounted 
to 8.9% of GDP, having slightly increased, though 
not steadily, during the last decade (8.3% in 2005). 
This  is  below  the  EU  average  of  10.2%,  when 
looking  at  weighted  average.  Looking  at  the 
unweighted  average  and  at  median  EU  values 
however, respectively 8.7% and 8.9%, the level of 
total  health  expenditure  in  Slovenia  is  slightly 
higher than the former and at the same level of the 
latter  EU  values.  The  same  applies  to  public 
expenditure  on  health  care,  broadly  constant  over 
the  last  decade  (+0.4  pps)  and  accounting  for 
6.5% (345)  of  2015  GDP,  which  is  below  the  EU 
(346) average of 8%  when looking at the  weighted 
figure,  but  is  higher  both  than  the  unweighted 
(6.4%)  and  than  the  median  (6.2%)  values.  Also 
when measured in per capita terms, both total and 
public  health  care  expenditure  are  lower  than  the 
EU  weighted  average:  2,002  PPS  vs.  3,305  PPS 

(344) This aggregate includes capital investments. 
(345) Including  public  long-term  health  expenditure  (HC.3)  and 

capital investments. 

(346) This figure refers to the weighted average. 

246 

and 1,460 PPS vs. 2,609 PPS respectively (figures 
for  2015  in  €PPS).  Comparing  these  values  to 
unweighted  average  (2,526  PPS)  brings  Slovenia 
closer  though  not  above  average,  but  it  places 
Slovenia at the median (2,002) for the total figure. 
With an unweighted average value of 1,894 and a 
median  of  1,460,  a  similar  reasoning  applies  to 
public health expenditure PPS, with Slovenia at the 
median level. Looking at health care without long-
term  care (347)  reveals  a  similar  picture,  with 
spending below the EU average, but with a smaller 
gap (5.7% vs 6.8% in 2015). 

As  a  result  of  declining  revenues  of  compulsory 
health insurance contributions (and in  view of the 
target  that  compulsory  health  insurance  should  be 
financed without any further borrowing or increase 
in the contribution rate), public health expenditure, 
declined in real terms in 2012 and 2013 (348). Since 
2014  public  health  expenditure  has  been  rising  in 
real  terms,  underpinned  particularly  by  stronger 
growth  in  employment  and  wages  and  hence 
higher  inflows  into  the  health  insurance  fund.  In 
2015  public  current  public  health  expenditure 
reached 6.1% of GDP and total public expenditure, 
including investments reached 6.5 % of GDP. The 
share of public expenditure declined from 2010 to 
2014,  but  from  2014  to  2015  it  increased  up  to 
72.9%. 

In 

Slovenia  had  already  recorded  relatively  low 
health  expenditure  growth  before  the  crisis,  but 
also  during  the  crisis  called  for  strict  austerity 
measures. 
the  period  2000-2009  health 
expenditure per capita averaging 4.7% growth per 
year  in  real  terms  in  EU28  countries  and  in 
Slovenia  4.0%;  during  the  crisis  in  2009-2012  it 
declined  to  0.6%  in  EU28  countries  and  in 
Slovenia  it  fell  annually  by  0.5%  in  real  terms 
(349). 

Expenditure projections and fiscal sustainability 

Driven  by  the  change  in  demographic  structure, 
public  spending  on  health  care  is  projected  to 

(347) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

(348) OECD  Stat,  2018.  Calculations  by 
Development Report 2018, page 120). 

IMAD  (IMAD 

(349) OECD  Health  at  a  glance:  Europe  2014  and  Institute  of 
(2015) 
Indicators  of  Slovenia's 

Macroeconomic  Analysis  and  Development 
Development 
Development. Health expenditure. 

report  2015. 

 
                                                           
                                                           
Health care systems 

2.25. Slovenia 

in 

increase 

increase by 18% or 1.0 pp of GDP, more than the 
13%  average 
the  EU  (0.9  pps) 
according  to  the  "AWG  reference  scenario"  (350). 
When  taking  into  account  the  impact  of  non-
demographic  drivers  on  future  spending  growth 
("AWG risk  scenario"), health care expenditure is 
expected  to  increase  by  2  pps  of  GDP  from  now 
until 2070 (EU: 1.6).  

Medium  fiscal  sustainability  risks  appear  over  the 
medium  and  the  long  run  due,  especially  for  the 
long-term  risk  categorisation,  to  the  projected 
increase  in  age-related  public  spending,  notably 
deriving  from  pensions,  healthcare  and  long-term 
care (351). 

Health status  

The  indicators  of  health  status  of  the  Slovenian 
population  appear  similar  to  those  of  the  EU 
average.  Life  expectancy  at  birth  for  both  women 
and  men  was  respectively  83.9  years  and  77.8 
years in 2015, similar to the EU average (83.3 and 
77.9  years  for  men  and  women  respectively). 
Nevertheless, in 2015 the healthy life years at birth 
for both sexes were, 57.7 years (women) and 58.5 
years  (men),  substantially  lower  than  the  EU-
average  (63.3  and  62.6  respectively)  (352).  Infant 
mortality  of  1.6‰  (2015)  is  well  below  the  EU 
average of 3.6‰. 

rates (353) 

from  both  cancer  and 
Mortality 
cardiovascular diseases have dropped over the last 
20  years,  but  they  are  still  above  the  EU  average 
(and  for  men  they  are  the  highest  in  Europe). 
External  causes  of  death  are  particularly  high  for 
men  and  women  because  of  the  high  numbers  of 
falls  (particularly  in  old-age)  as  well  as  suicides 
(mortality  from  suicide  was  the  fourth  highest  in 
Slovenia in 2014).  

(350) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(351) European Commission (2018), Fiscal Sustainability Report 
https://ec.europa.eu/info/sites/info/files/economy-

(2018) 
finance/ip094_en_vol_2.pdf. 

(352) Data on life expectancy and healthy life years is taken from 
the Eurostat database. Data on life-styles is taken from the 
Eurostat database and the OECD health data. 

(353) State of Health in the EU Slovenia Country Health Profile 
and  European 

2017,  OECD,  Health  Observatory 
Commission. 
https://ec.europa.eu/health/sites/health/files/state/docs/chp_
sl_english.pdf. 

in 

than 

The lifestyle-related risk factors are in general less 
prevalent 
the  other  EU  countries. 
Percentage  of  regular  smokers  (18.9%  in  2014) 
was below the EU average in the recorded closest 
years (20.9% in 2015) and alcohol consumption in 
2014 (10.5% litres per capita) was close to the EU 
average number (10.2 litres per capita in 2015). 

System characteristics 

financing, 

System 
collection 
mechanism,  coverage  and  role  of  private 
insurance and out of pocket co-payments 

revenue 

The  Slovenian  health  system  is  a  Bismarckian 
system based on statutory health insurance, which 
is  fully  regulated  by  national  legislation  and 
insurer,  Health 
administered  by 
the  single 
Insurance 
(HIIS),  an 
Institute  of  Slovenia 
independent  public  institution.  HIIS  operates  in 
accordance  with  the  "Stability  Pact",  whereby 
HIIS  is  not  allowed  to  record  a  loss  at  the  end  of 
the year or go into debt and it cannot itself increase 
insurance  contribution  rates  (354).    The  health 
is  mandatory,  providing 
insurance 
universal  coverage.  The  extent  of  rights  deriving 
from  compulsory  health  insurance  is  specified  by 
the law on health care and health insurance and the 
regulations  on  compulsory  health  insurance,  i.e. 
the  act  adopted  by  the  assembly  of  the  Health 
Insurance Institute of Slovenia.  

system 

Compulsory  health  insurance  comprises  insurance 
in  the  case  of  illness  or  injury  outside  work,  and 
insurance  in  the  case  of  injury  at  work  and 
occupational  diseases.  The  extent  of  rights  to 
health  care  services  is  defined  in  percent  share  of 
the  total  service  costs.  This  means  that  the 
compulsory health insurance "covers" the majority 
of health related risks, however, not necessarily all 
of them and neither in full. The balance is either to 
be paid by the insured person, or, alternatively and 
most  common,  the  insured  person  takes  out  a 
complementary  insurance  policy  with  a  private 
health insurance company. More than 95 % of the 

(354) European  Observatory  on  Health  System  and  Policies, 
World Health Organization and Ministry for Health (2016). 
Analysis  of  Health  System  in  Slovenia.  Health  System 
Expenditure 
report. 
http://www.mz.gov.si/fileadmin/mz.gov.si/pageuploads/An
aliza/Report_Expenditure_review_Slovenia_FINAL_FOR
MATTED_without_cover.pdf. 

Review. 

Final 

247 

 
                                                           
                                                           
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

population  liable  for  co-payments  is  insured  by 
voluntary complementary health insurance (355).  

In the 2009–2013 period a series of measures were 
introduced  to  balance  Health  Insurance  Institute 
operations.  To  generate  additional 
revenues 
measures  included  increasing  contributions  for 
self-employed  and  requiring  contributions  from 
student  employers  (356).  However,  the  majority  of 
measures  focused  on  reducing  expenditure  by 
reducing the prices of health services, transferring 
expenditure 
a 
to 
portion  of 
schemes, 
health 
complementary 
lowering  expenditure  on  medicines,  medical 
devices, sickness allowances and obligations under 
international 
These  measures 
reduced  health  care  providers’ 
significantly 
revenue  from compulsory  health insurance,  which 
had  an  impact  on  increasing  the  losses  of  these 
providers, particularly hospitals (357). 

agreements. 

insurance 

health 

on 

Voluntary  health  insurance  (VHI)  has  two  main 
forms:  complementary  VHI  provides  insurance  to 
cover  co-payments  only,  and  supplementary  VHI 
provides  insurance  for  a  higher  standard  and  a 
wider  scope  of  benefits 
the  mandatory 
insurance.  Since  co-payments  for  some  health 
services  can  represent  high  financial  burden  for 
share  of  population  holding 
patients, 
complementary  health  insurance  is  very  high  and 
comprises  more  than  95  %  of  those  who  are 
eligible to pay co-payments (358).  

than 

the 

Overall  levels  of  enrolment  in  complementary 
health  insurance  have  not  changed  dramatically 
during  the  crisis  (359).  Total  enrolment  in  2014 
(1,433,484)  was  at  its  highest  level  since  2008 
(1,455,828).  Since  2009,  the  government  has 
started  to  cover  co-payments  for  economically 
disadvantaged  people  who  meet  predetermined 

(355) Health 

Insurance  Institute  of  Slovenia.  Web  page: 

http://www.zzzs.si/zzzs/internet/zzzseng.nsf/o/87C028D74
130DE0AC1256E89004A4C0C. 

(356) Health  Insurance  Institute  of  Slovenia. 

  Web  page: 

http://www.zzzs.si/zzzs/internet/zzzseng.nsf/o/87C028D74
130DE0AC1256E89004A4C0C. 

(357) Institute  of  Macroeconomic  Analysis  and  Development 
(2014)  Development  report  2014.  Indicators  of  Slovenia's 
Development. Health expenditure. 

(358) OECD Health Statistics 2015. 
(359) Overall,  the  largest  decrease  in  total  enrolment  was  in 
2010,  when  the  number  of  VHI  enrolees  fell  by  around 
12,000  people  (-0.8%);  there  were  smaller  decreases  in 
VHI enrolees of around 8,200 and 3,800 in 2009 and 2011, 
respectively. 

248 

criteria (360). To avoid cream-skimming by insurers 
and  to  equalise  the  variations  in  risk  structure,  a 
risk-equalisation  scheme  was  introduced  in  2005. 
Risk equalisation is retrospective, calculated on the 
basis  of  expenditures  for  health  care  services  and 
for  health  care  providers  (361).  Premiums  have 
been  community  rated  since  2005,  are  similar 
across the insurers (i.e. premiums currently do not 
differ across insurers by more than €1 per month). 
The  large  premium  increase  (by  more  than  16  %) 
in  2014  was  in  response  to  the  2012  "Fiscal 
Balance Act", which shifted some costs from HIIS 
to complementary VHI in an effort to keep public 
expenditure sustainable.  

groups 

vulnerable 

Out-of-pocket  payments  exist  as 
two  main 
mechanisms:  cost  sharing  and  direct  payments. 
Cost  sharing  takes  the  form  of  flat  rate  co-
payments and applies to most types of health care 
services  and  to  all  patients  with  the  exception  of 
(children, 
social 
some 
unemployed,  those  with  income  below  a  given 
threshold,  chronically  ill).  However,  since  a  large 
majority  of  patients  is  covered  by  voluntary 
insurance  covering  complementary  co-payments, 
this  form  hardly  exists  in  the  form  of  direct 
payments. The latter are used, however, in case of 
visits to the providers  who do not have a contract 
with  the  HIIS,  to  the  specialists  without  a  GP's 
referral  and  to  private  dentists.  The  out-of-pocket 
payments are also used to avoid waiting times and 
pay for extra services,  not included in the general 
benefit package of the social insurance system. 

health 

insurance 

Compulsory 
contributions 
constitute the major source of health care financing 
with  66.5%  of  current  health  expenditure  (2016) 
(362). General national and municipal-level taxation 
represents only 3.8% of current health expenditure, 
and  is  mostly  devoted  to  the  financing  of  capital 
investments 
specialised  health 
institutions at national and regional levels, national 
health  programmes,  medical  education  and 
research  (Ministry  of  Health)  and  public  health 
centres  and  public  pharmacies  (municipalities). 

in  hospitals, 

(360) Health  Insurance  Institute  of  Slovenia. 

  Web  page: 

http://www.zzzs.si/zzzs/internet/zzzseng.nsf/o/87C028D74
130DE0AC1256E89004A4C0C. 

(361) Health  Insurance  Institute  of  Slovenia. 

  Web  page: 

http://www.zzzs.si/zzzs/internet/zzzseng.nsf/o/87C028D74
130DE0AC1256E89004A4C0C. 

(362) Statistical Office of the Republic of Slovenia, 2018. Health 

Expenditure and Sources of Funding 2016.  

 
                                                           
                                                           
The share of government budget funding is one of 
the  lowest  in  the  EU  and  transitioning  towards  a 
system  that  is  less  reliant  on  contributions  could 
future  stability  of  health  care 
improve 
financing. 

the 

Contributions  to  fund  the  HIIS  are  mostly  related 
to  earnings  from  employment.  The  contribution 
rate  amounts  to  13.45%  of  gross  income,  out  of 
which  6.36%  is  paid  by  the  employee  and  7.09% 
by the employer. Both together represented 97% of 
compulsory insurance revenues in 2016 (including 
all types of categories of insured persons (363). The 
other  source  of  HIIS  revenues  is  general  taxation 
with only 3% (364).  

Public  health  expenditure  accounted  for  about 
14.9%  of  the  total  general  government  health 
expenditure in 2016 (365). 

organisation: 

Administrative 
of 
government, levels and types of social security 
settings 
involved,  other 
institutions 

involved,  Ministries 

levels 

The  coverage  by  compulsory  health  insurance 
(CHI)  is  universal.  It  covers  the  contributors 
(employees,  pensioners,  farmers,  self-employed), 
their  dependants  (subsidised  by  the  compulsory 
health 
insurance),  but  also  unemployed  and 
individuals  without  income  (whose  contributions 
are paid by the National Institute for Employment, 
central  government  and  municipalities).  The 
benefits  package  comprises  a  wide  coverage  of 
primary, 
services, 
pharmaceuticals,  medical  devices,  long  sick  leave 
and travel costs. Some services are 100% covered 
by  CHI,  while  others  are  only  covered  up  to  a 
certain share of the service’s  full value. However, 
the  difference  to  the  full  value  is  usually  covered 
by complementary health insurance.  

secondary 

tertiary 

and 

More than 95 % of insured CHI that are liable for 
co-payments 
in  voluntary 
complementary  health  insurance  to  cover  cost-
system. 
social 
sharing 

included  also 

security 

the 

in 

is 

(363) Self-employed,  pensioners,  farmers,  self-payers  and  other 

categories. 

(364) OECD  Health  at  a  glance  2017.  Sources  of  health  care 

financing. Page 139. 

(365) Eurostat Database 2018 (General Government Expenditure 

by COFOG).  

Health care systems 

2.25. Slovenia 

Complementary  health  insurance  guarantees  full 
co-payment  coverage  for  all  services  covered  by 
compulsory  health  insurance.  This  could  lead  to 
unnecessary care (366). Introducing a  fee for  some 
health  services,  which  could  not  be  covered  and 
reimbursed  by  complementary  insurance,  would 
represent a supplementary tool for cost control for 
the public  health care  fund. There is also room to 
continue to rationalise the public benefit basket by 
reducing 
the  reimbursement  rate  or  delisting 
certain  less  medically  necessary  services,  such  as 
spa 
ambulance 
transportation or less clinically-effective medicines 
(367). 

non-emergency 

treatments, 

Private  sources  account  for  27.1%  of  total  health 
expenditure  in  2015  and  exceed  the  EU  level 
(21.6%  weighted  average,  23.6%  unweighted 
average).  Private  sources  consist  of  two  main 
sources  of  financing:  out-of-pocket  payments, 
representing 12.5% and voluntary health insurance 
accounting  for  14.5%  in  2015.  Total  private 
expenditure  has  been  increasing  over  the  recent 
years:  its  average  real  yearly  growth  per  capita 
over  the  period  2005-2015  has  amounted  to  2.1% 
(OECD  average:  1.6  %)  (368).  Out-of-pocket 
expenditure  accounted  for  12.5%  of  total  current 
health expenditure in 2015, compared with 15.9% 
in  the  EU-28  (unweighted  average  21.8%)  (369). 
During  the  crisis,  a  significant  share  of  the 
shortfall in public funding was compensated for by 
complementary  health  insurance  schemes,  so  that 
only 
out-of-pocket 
marginally, however, voluntary health expenditure 
increased  considerably  more  than  out-of-pocket 
expenditure.    Had  this  not  been  the  case,  they 
would  have  been  significantly  affected  by  lower 
availability  and  higher  out-of-pocket  payments  as 
public funding declined (370). 

expenditure 

increased 

Slovenian households allocate the largest shares of 
out-of-pocket expenditure to medical goods (2015: 
40%;  of  which  36% 
for  over-the-counter 
medicines), therapeutic appliances (20%; of which 
16%  for  glasses),  various  other  health  services 
(physiotherapy)  and  alternative  medicine  (11%), 

(366) OECD (2013). 2013 Economic Survey – Slovenia.  
(367) OECD (2013). 2013 Economic Survey – Slovenia. 
(368) OECD Stat 2018. 
(369) Source Eurostat Database. 
(370) Institute  of  Macroeconomic  Analysis  and  Development 
(2014)  Development  report  2014.  Indicators  of  Slovenia's 
Development. Health expenditure.  

249 

 
                                                           
  
                                                           
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dental  care  (8%)  and  specialist  outpatient  care 
(8%).  In  2009–2013,  increases  in  out-of-pocket 
expenditure  were  recorded  by  medical  goods, 
long-term  institutional  care  and  patient  transport), 
while  significant  decreases 
in  out-of-pocket 
expenditure  were 
recorded  by  dental  care, 
specialist outpatient care, and various other health 
(physiotherapy,  alternative  medicine) 
services 
(371). 

Slovenian households allocate the largest shares of 
out-of-pocket expenditure to medical goods (2015: 
the  counter 
35%;  of  which  32%  for  over 
medicines,  therapeutic  appliances  (21%;  of  which 
the most for glasses), various other health services 
(physiotherapy)  and  alternative  medicine  (around 
10  %),  dental  care  (8%)  and  specialist  outpatient 
care (8%) (372). 

Types of providers, referral systems and patient 
choice 

Public primary health care is provided by a mix of 
public  and  private  providers  with  concessions. 
Public  providers  include  health  care  centres  and 
health  stations,  institutions  established  and  owned 
by 
local  communities.  Private  providers  are 
individual  health  care  professionals  working 
individually or in  group practices offering various 
combinations of services and specialties. 

The patients can choose the primary care provider 
among  those  who  have  a  contract  with  the  HIIS 
and have the right to change them after a year. The 
personal physician plays the role of the gatekeeper 
since  his  referral  is  necessary  to  proceed  to 
specialist  and  hospital  care.  The  referral  is  not 
required  only  in  case  of  chronic  diseases  or  long-
term  treatment  when  many  consecutive  contacts 
with a specialist are necessary. Moreover, patients 
can  select  a  private  physician  of  their  choice,  but 
must cover all costs out-of-pocket. 

Specialist  outpatient  care  is  provided  in  hospitals 
or  private  health  facilities,  while  ambulatory 
services  are  provided  in  the  polyclinics  affiliated 
with  hospitals,  in  community  health  centres  or  in 
private specialists' offices.  

(371) OECD Stat 2015. 
(33)  OECD  Stat  2018  (Based  on  data  by  the  System  of  Health 

Accounts).  

(372) OECD  Stat  2018  (Based  on  data by  the  System  of  Health 

Accounts). 

250 

Specialists  can  also  work  part  time  in  private  and 
public health centres, based on civil law contracts. 
There  exist  also  some  private  polyclinics,  which 
may  or  may  not  have  contracts  with  HIIS  and, 
based on whether or not they hold a contract, paid 
either 
insurance 
form  of 
reimbursement, or as out-of-pocket payments. 

social 

the 

in 

Although  the  number  of  physicians  has  been 
growing  more strongly in recent  years, Slovenia’s 
gap  with  the  EU  remains  significant.  In  the  last 
decade,  the  number  of  practising  physicians  per 
100,000 population has been slowly growing from 
225  in  2003  to  283  in  2015  (EU  average  in  2015 
was  344) (373).  In  the  2005–2016  period,  the 
number  of  practicing  physicians  in  Slovenia  grew 
on  average  annually  by  2.3%,  which  was  faster 
than in the EU28 average (1.5 %) (374).  

Slovenia  lags  the  most  regarding  the  number  of 
general  practitioners.  Following  the  adoption  of 
measures (375) to strengthen primary health care, in 
recent  years  the  number  of  general  practitioners 
has increased reaching 55 per 100 000 inhabitants 
in  2015,  still  significantly  lower  than  the  EU 
average  (2015:  78)  (376).  This  suggests  under 
provision and problems with access to the primary 
health  care,  especially  in  light  of  the  gatekeeper 
function  exercised  by  the  latter.  One  of  the 
indicators  showing  the  capacity  of  the  primary 
level  to  assume  a  greater  workload  is  the  ratio  of 
general  practitioners 
this 
indicator too Slovenia lags behind the EU average: 
the  proportion  of  general  practitioners  in  the  total 
number  of  physicians  stands  at  19%,  compared 
with  23%  in  the  EU.  In  Slovenia,  at  the  primary 
level,  besides  general  practitioners,  there  are  also 
paediatricians  and  gynaecologists  who  have  their 
own patients.  

to  specialists.  On 

per 

100,000 

(373) According  to  national  sources,  the  figure  for  2016  is  307 
population. 

physicians 
https://podatki.nijz.si/Selection.aspx?px_path=NIJZ%20po
datkovni%20portal__5%20Viri%20v%20zdravstvu__1%2
0Izvajalci%20zdravstvene%20dejavnosti&px_tableid=BPI
_kazalniki.px&px_language=sl&px_db=NIJZ%20podatko
vni%20portal&rxid=f346f106-811d-4b01-89dc-
800bcecede2e. 

(374) Eurostat  Database,  2018.  Own  calculation  for  EU28 

average (unweighted). 

(375) The  introduction  of  so-called  family  medicine  model 
registered  nurses  assume  greater 
practices  where 
responsibilities;  and  additional  funding  for  the  primary 
level of health care (Ministry of Health, 2012). 

(376) Eurostat. 

 
                                                           
                                                           
in 

to 

introduce  changes 

The number of nurses, however, is in line with the 
EU averages (827 per 100 000 in Slovenia vs. 837 
in  the  EU).  Therefore,  Slovenia  has  adequate 
the 
opportunities 
responsibilities  of  nurses  in  view  of  the  fact  that 
the number of qualified nurses has been growing in 
recent  years  (377)  as  well  as  in  view  of  the  high 
ratio  of  practicing  physicians  to  nurses.  The  large 
inflow of nurses to the labour market will have to 
be  regulated  by  additional  systemic  measures  in 
both health care (a further transfer of certain duties 
from  doctors  to  registered  nurses)  and  long-term 
care  (faster  development  of  community  nursing 
care) (378). 

Due  to  a  lack  of  providers  or  long  waiting  times 
for some specialised services and surgeries, access 
to  some  health  care  services  remains  limited. 
Specific incentives could be developed to promote 
and  encourage  staff  to  work  in  some  specialities 
currently in shortage. An increase in the supply of 
primary-care  doctors  would  allow  more  extensive 
gatekeeping  and  cost-effective  prevention  in  the 
medium  term,  though  this  strategy  could  boost 
spending in the short term. Nevertheless, and more 
generally,  the  human  resources  strategy  needs  to 
tackle staff and population ageing in the future. 

To tackle the shortage of doctors at primary level, 
particularly  in  demographic  areas  with  an  ageing 
population,  an  analytical  document  ( 379)  was 
prepared  in  2013,  with  the  objective  to  reach  a 
proportion  of  1.500  patients  to  one  doctor  at 
primary care level over the following 5 years. 

To  achieve  this  objective,  it  was  estimated  that 
1,364  GPs  would  be  required  at  national  level, 
which  required  additional  318  GPs  in  each  of  the 
following five years.  

Since  2013  the  number  of  places  available  for 
general  practitioners  specialisations  was  increased 
so  that  66%  of  available  specialisations  were 
allocated  to  general  practitioners.  The  number  of 
available  specialisation  for  general  practitioners 

(377) In 2008–2012, on average 445 nurses graduated every year, 

12% more than on average in the period 2003–2008. 

(378) Institute  of  Macroeconomic  Analysis  and  Development 
(2014)  Development  report  2014.  Indicators  of  Slovenia's 
Development. Health Care Resources. 

(379) "Public network  of  primary  health care  in  the Republic  of 
the  field  of  general  practitioners  and 

Slovenia 
paediatricians at the primary level", (2013). 

in 

Health care systems 

2.25. Slovenia 

also  increased  consistently  between  2014  and 
2018, but many posts were left unfilled due to the 
low attractiveness of this specialisation. 

By reducing the proportion of patients to GPs, this 
is  expected  to  improve  not  only  the  quality  and 
safety of patient care, but also to reduce the cost of 
patient  care,  due  to  the  gatekeeping  function  of 
primary care.  

It  is  also  acknowledged  that  the  existing  primary 
healthcare system needs to be upgraded in order to 
be  able  to  cope  with  future  challenges.  In  this 
view, almost all family practices (a few are left to 
join  in  2018)  have  evolved  into  “family  medicine 
model practices”. Family medicine model practice 
is  a  medical  practice,  where  a  family  medicine 
team, in addition to a junior nurse, is supported by 
a graduate nurse (registered nurse) with additional 
knowledge,  which  ensures 
transfer  of 
competencies  from  a  doctor  to  a  graduate  nurse 
who treats and manages chronic patients.  This is a 
strengthening  of  family  medicine  teams  and  an 
improvement in basic public health services, which 
is a priority policy area.  It is expected to result in 
the improved management of patients with chronic 
diseases,  since  part  of  their  care  should  be  taken 
over by a graduate nurse. A graduate nurse should 
also cope with some other tasks to be carried out in 
family  practice  outpatient  clinics,  in  particular  in 
the  area  of  preventive  care  and  health  care  in 
outpatient clinics of the registered population. 

the 

In 2018, there were 30 hospitals in Slovenia, and a 
large majority of them were state owned. Although 
legal  provisions  allow  for  establishment  of  new 
private  hospitals,  privatisation  remained  limited 
there  have  not  been  significant  private 
and 
investments in health infrastructure. 

The capacity of acute care hospitals beds (422 beds 
per  100  000  inhabitants  in  2015) (380),  average 
length  of  stay  (6.8  days)  and  the  number  of 
inpatient  discharges  (18  per  100  000  inhabitants) 
are  similar  to  the  average  figures  for  the  EU 
(respectively 402 beds, 7.6 days and 16 discharges 
per  10000  inhabitants)  and  suggest  an  efficient 
utilisation  of  hospital  care.  However,  the  number 
of  hospital  beds  in  acute  care  could  be  further 
lowered,  as  low  occupancy  and  turnover  rates 
point to excess capacity. In a number of countries 

(380) EUROSTAT and OECD. 

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the  decline  in  the  number  of  acute  care  hospital 
beds  accelerated  in  2010–2011  because  of  the 
economic  crisis  and  austerity  measures  in  public 
health  care;  at  first  there  was  no  such  response  to 
the crisis in Slovenia. Nevertheless, the number of 
acute  care  beds  declined  in  2012,  which  is 
probably related to the rationalisation of operations 
in  hospitals.  The  data  about  the  proportion  of 
surgical procedures conducted as day cases is low 
compared to EU average (9.7% vs. 32.3% in 2015) 
and, despite recent progress in increasing the share 
of  surgeries  carried  out  as  day  cases,  more  could 
be  done  to  further  develop  ambulatory  care  (381). 
This  suggests  that  a  strategy  to  increase  day  case 
interventions  should  be  then  encouraged  also  to 
reduce waiting times for surgery.  

With regard to the transfer of health care services 
from  hospital 
to  ambulatory 
inpatient  care 
outpatient  care  or  day  care,  data  have  been 
improving from year to year. According to data for 
2016,  the  proportion  of  cataract  surgeries  carried 
out  as  day  cases  was  97.8%%,  above  the  EU 
average of 84.2%. However, the share of inguinal 
hernia  repair  and  of  tonsillectomy  performed  as 
day  cases  are  still  largely  below  the  average (382). 
Slovenia  is  also  considering  the  introduction  of 
more systematic monitoring and making necessary 
changes  to  the  model  of  payment  of  providers  of 
specialist  services  at  the  secondary  and  tertiary 
levels. 

Pricing,  purchasing  and  contracting  of 
healthcare 
remuneration 
mechanisms 

services 

and 

Within each annual financial plan the HIIS defines 
a  maximum  overall  amount  to  be  spent  on  health 
services in the upcoming year. This annual budget 
is  defined  in  cooperation  with  the  Ministry  of 
Health  and  the  Ministry  of  Finance,  taking  into 
consideration  the  macroeconomic  situation  which 
affects  the  expected  revenues  of  the  system.  The 
national health budget is determined at the national 
level,  with  no  further  geographical  disaggregation 
(local  tax  revenue  is  managed  separately  by  local 
authorities according to their own criteria). 

The first stage consists of partnership negotiations 
with different  groups of  health care providers and 

other  stakeholders  over  the  volume  of  services  to 
be  provided  and  reimbursed  by  the  HIIS.  The 
second  stage  involves  the  individual  providers  in 
the  negotiations  with  the  HIIS  on  the  type  and 
volume of services that will be provided, the tariffs 
for  these  programmes  and  services,  methods  of 
payment,  quality  requirements,  the  supervision  of 
the 
the 
individual 
the 
contracting  parties.  The 
reimbursements  are 
capped, thus the services provided in excess of the 
contracted  amounts  –  however,  with  some 
exceptions  - are not paid for. The same applies to 
the  services  which  have  been  contracted  but 
actually not provided. 

implementation  of 
rights  and 

the  contract  and 
responsibilities  of 

is 
Voluntary  complementary  health 
provided  by  one  mutual 
insurance  company 
obliged  by  law  to  provide  VHI  for  co-payments 
and 
insurance 
two 
companies. 

profit-oriented 

insurance 

private 

Public  expenditure  on  health  administration  and 
health  insurance  as  a  percentage  of  GDP  (0.1%) 
and  as  a  percentage  of  current  health  expenditure 
(2.3%) was slightly below the EU average in 2015 
(respectively  0.3%  and  3.4%).  Over  the  last 
decade,  major  efforts  have  been  done  to  reduce 
administrative  costs  and  improve  the  general 
management  of  the  sector  and,  given  the  system's 
organisation  and  regulation,  it  is  important  that 
they  be  paired  with  measures  to  improve  quality 
monitoring.  

Payment  mechanisms  and  levels  are  regulated 
based on annual contractual arrangements between 
the  HIIS  and  health  care  providers  as  explained 
before.  Each  programme  has  an  annual  budget  at 
the  national  level,  which  is  then  translated  into 
caps in budgets for individual providers.  

through  a 
Primary  care  providers  are  paid 
combined system of capitation and fee-for service 
payments. The reimbursable volume of services is 
outlined 
in  prospectively  determined  annual 
contracts.  Half  of  the  value  of  these  services  is 
paid per capita for the patients registered  with the 
physician, while the other half is paid on the basis 
of  fee-for-service,  according  to  the  number  of 
services provided. 

(381) OECD (2013). 2013 Economic Survey – Slovenia. 
(382) EU26. Figures were taken from Health at a Glance (2018). 

Outpatient  specialist  care  is  remunerated  on  the 
basis  of  fee-for-service,  according  to  an  HIIS 

252 

 
                                                           
classification  of  services,  whereas  the  volume  of 
services  provided  is  outlined  in  the  contracts.  In 
order  to  promote  preventive  services  and  reduce 
specialists'  referrals,  one  of  the  eligibility  criteria 
for  HIIS  payments  is  the  implementation  by  the 
providers  of  prospectively  determined  volumes  of 
preventive services. 

Different  payment  mechanisms  are  valid  for 
certain  types  of  services:  for  non-acute  inpatient 
care  reimbursement  is  based  on  prospectively 
determined  number  of  bed  days,  for  psychiatric 
on 
care 
prospectively  determined  number  of  cases,  dental 
services on the fee-for service model. 

rehabilitation 

programme 

and 

in 

in  payments 

Since  2003  hospital  care  has  been  reimbursed 
according  to  a  Diagnosis-Related  Group  (DRG) 
model. This replaced the per-case payment system, 
which  consisted 
for  complete 
inpatient episodes and, as such, did not account for 
the  differences  in  severity  of  cases.  It  provided  a 
perverse incentive to increase the number of single 
inpatient admissions. The DRG model is based on 
a  classification  of  653  diagnosis-related  groups, 
which  are  defined  by  the  clinical  diagnosis, 
procedures  undertaken  and  length  of  treatment. 
Payment  is  based  on  the  volume  and  value  of 
the 
programmes  determined  prospectively 
contract.  The  annual  volume  of  a  health  care 
programme reimbursable by the HIIS is limited by 
the  budget,  and  defined  on  the  basis  of  the 
the 
respective  programme  executed  during 
previous  year,  adjusted  by  the  additional  annual 
programmes  aiming  at  improving  access  to  health 
services  and  the  efficiency  of  providers.  The  cost 
weight  used  to  calculate  the  value  of  case-mix  is 
calculated  as  the  relative  price  of  each  DRG  in 
comparison  to  the  average  DRG  price  at  national 
level.  Since  2005, 
two  procedures,  dialysis 
services and transplantation programme, have been 
excluded  from  the  prospective  DRG  model  and 
reimbursed  retrospectively  on  the  fee-for-service 
and  per-case  basis  respectively.  In  2013,  a  new 
version  of  the  Australian  DRG  model  (v6.0)  was 
imported,  but  only  used  for  the  classification  of 
patients. 

The  hospitals'  employees  are  salaried  under 
general  rules,  with  some  specialists  having  a 
special health care contract.  

Health care systems 

2.25. Slovenia 

The market for pharmaceutical products 

In  2015  pharmaceutical  spending  accounted  for 
0.8%  of  GDP  and  12.7%  of  public  health  care 
expenditure,  close  to  the  average  figures  for  the 
EU (1 % and 12.7% respectively). 

takes 

into  account 

Slovenia  introduced  an  external  price  referencing 
mechanism  for  setting  maximum  prices.  The 
mechanism 
the  prices  of 
medicinal  products 
in  Germany,  Austria  and 
France. If due to the size and other characteristics 
of  the  Slovenian  market,  the  maximum  allowed 
price  does  not  enable  the  marketing  authorisation 
holders  to  supply  the  market,  a  higher  maximum 
price can be set as an exception. Internal reference 
pricing uses the national system of reference prices 
for mutually interchangeable pharmaceuticals. The 
system is based on generic substitution of products 
officially  recognised  as  mutually  interchangeable 
(based on their therapeutic similarity) and listed in 
a  national  list  of  substitutable  pharmaceuticals. 
The  lowest  drug  price  in  the  same  group  will  be 
used  as  reference  price.  Medicinal  products 
financing from public revenues is regulated by the 
Health  Care  and  Health  Insurance  Act  and  falls 
within  the  competence  of  the  Health  Insurance 
Institute  of  Slovenia.  Slovenia  also  has  a  system 
defining 
i.e.  groups  of 
pharmaceuticals  that  have  the  same  therapeutic 
indication, for which health insurance covers those 
medicinal products that are comparable in efficacy, 
safety and cost–effectiveness. 

therapeutic  clusters, 

Members  of  a  special  committee,  formed  of 
experts from various health care fields, decide the 
levels  of  reimbursement  based  on  cost-benefit 
analyses  and  available  financial  resources.  A 
positive 
that  are 
list  details  pharmaceuticals 
reimbursable (70% reimbursed by the compulsory 
insurance  and  the  rest  either  by  complementary 
insurance either by out-of-pocket payments). 

the  volume  and 

Each  physician  has  a  prescribing  number  in  order 
to  control 
type  of 
pharmaceuticals  prescribed.  Appropriate  penalties 
can be issued by the HIIS to contracted physicians 
in case of irregularities. 

the 

Over  the  past  decade,  structural  measures  were 
on 
adopted 
pharmaceutical  products,  currently  standing  at 
18.4% as a share of total health expenditure, down 

expenditure 

rationalise 

to 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

facilitated 

from  21.8%  in  2005.  Lowering  costs  through  the 
aforementioned  measures  –  particularly 
for 
generics  and  innovative  medical  products  (with 
the 
expired  patent  protection)  – 
financing of new innovative medicinal products for 
which  there  is  no  alternative  on  the  market.  In 
order  to  ensure  the  entry  of  new  innovative 
medicinal  products  on  the  market,  additional 
systemic  measures  are  being  introduced,  such  as 
joint public contracts for the purchase of medicinal 
products in hospitals (383).  

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

Health technology assessment (HTA) is performed 
at  a  very  basic  level.  An  important  step  forward 
has  been  the  launch  of  a  programme  for  the 
standardisation  of  equipment  and  the  introduction 
of 
technical  guidelines.  In  2005,  a  standard 
procedure  for  assessing  and  implementing  new  or 
adapted  health  care  programmes  and  other  new 
methods  of  work  among  the  programs  of  health 
care  was  introduced.  It  was  revised  then  in  2009. 
In  2010  the  Ministry  of  Health  started  with 
activities  to  set  up  an  HTA  network  for  the 
organised and systematic assessment of health care 
technologies (old and new) for all submitted health 
technologies proposals. 

Health 
technology  assessment  (HTA),  would 
clearly  also  be  an  asset  in  terms  of  efficient 
allocation  of  resources  and  could  help  determine 
which  (new)  benefits  should  be  covered  by  the 
HIIS.  Certain  HTA  mechanisms  are  used  during 
regular  assessments  within 
for 
Medicinal  Products  and  Medical  Devices  of  the 
Republic of Slovenia, Health Insurance Institute of 
Slovenia  and  Health  Council,  but  the  NHP  does 
envisage their wider use and the draft government 
Act  on  Health  Care  Quality  and  Safety  envisages 
the creation of an HTA agency. 

the  Agency 

E-health  and  health-system  information  and 
reporting mechanisms 

The  national  eHealth  project  includes  different 
electronic  solutions  with  a  strategic  goal 
to 
increase  the  quality  and  efficiency  of  the  health 
system, including better planning and management 

(383) The Ministry of Health (2014). 

254 

of health care organisations and the health system 
as a whole.  

A  significant  progress  in  the  field  of  eHealth  was 
made  in  2015  and  national  implementation  is 
continuing 
last  years.  All  hospitals, 
healthcare centres and pharmacies are connected to 
the  healthcare  network  that  enables  secure  and 
reliable communication between them.  

the 

in 

The central register of patient data (a solution that 
enables  exchange  and  shared  use  of  medical 
documents)  currently  enables  access  to  over  11 
million  documents  for  over  1,69  million  patients 
and thus enables health professionals to save time 
and make medical decisions based on accurate data 
(form  discharge  letters,  ambulatory  results  and 
patient summaries).   

launched 

nationally 

ePrescription  was 
in 
November  2015.  More  than  92%  of  prescriptions 
are  already  prescribed  electronically.  The  main 
advantage of the system is a possibility for doctors 
and  pharmacists 
interactions  and 
to  check 
contraindications of the prescribed medicines. 

The  national 
implementation  of  a  central 
information  system  for  collecting  data  from  all 
waiting  lists  was  launched  at  the  end  of  2015,  all 
healthcare  providers  are  regularly  sending  data 
about  all  patients  waiting  for  the  medical  service. 
Enabling  eBooking  of  medical  services  is  already 
mandatory  for  all  healthcare  providers  on  a 
secondary  and  tertiary  level.  eReferral  became 
obligatory  in  beginning  of  2017  and  over  90%  of 
referrals are already written electronically. 

A patient portal that enables a patient to see his/her 
own  medical  data  in  eHealth  databases,  gives  or 
takes  consent 
to  medical  professionals  was 
published and put in use in 2017. 

A "telestroke solution" (i.e. a system that enables a 
remote consultation and examination of the patient 
with  a  suspected  brain  stroke  through  a  video 
conference system) is in full use.  

Some other, minor solutions that provide valuable 
data  are  also  in  full  use  (collecting  quality 
indicators  of  medical  care  from  all  family 
medicine  ‘model’  practices  is  in  place  from  the 
beginning  of  2015,  a  portal  for  safe  exchange  of 
radiology picture material is enabled and in use, an 

 
                                                           
Health care systems 

2.25. Slovenia 

application  for  doctors  for  terminologies  is  in 
place). 

quite high (72.1% of the target population in 2015 
(386). The same applies to breast cancer screening.  

Health  promotion  and  disease  prevention 
policies 

through  State's  and  HIIS's 

Health promotion and disease prevention is mainly 
large  scale 
done 
programmes.  Non-governmental  organisations 
play  a  prominent  role  in  the  area  of  health 
promotion  and  disease  prevention.  Since  2017 
there  has  been  a  significant  increase  of  NGO 
funding.     

incidence  of 

cancer.  Beyond 

The Slovenian government has launched a number 
of  policies  and  strategies  such  as  the  National 
Programme  on  Nutrition  and  Health  Enhancing 
Physical  Activity  2015–25  and 
the  National 
Cancer Control Programme 2017-2021 to curb the 
rise in overweight, obesity and hypertension and to 
the 
reduce 
implementation  of  several  EU  Directives,  new 
legislation  on  tobacco  control  adopted  in  2017 
includes a ban on all tobacco-and-related-products 
advertising,  promotion  and  sponsorship,  including 
a  display  ban  (mandatory  from  march  2018)  on 
tobacco and related products at the points of sale It 
also  includes  the  implementation  of  licencing  for 
retailers  of  tobacco  and  related  products  and  ban 
on  selling  to  minors  and  using  e-cigarettes  and 
other  tobacco  related  products  in  closed  public 
places  and  workplaces,  The  new  Act  also  made 
plain  packing  mandatory  as  of  2020  and  banned 
smoking in all vehicles in the presence of minors.  

The  most  recent  health  promotion  campaigns 
included (384): tackling regional health inequalities, 
HIV/AIDS  prevention,  anti-smoking  and  alcohol 
policy,  food  and  nutrition,  enhancing  physical 
activity, improving mental health and reducing all 
forms  of  addiction  or  dependency.  Vaccination 
rates  for  diphtheria,  tetanus  pertussis  are  high 
(95%) (385). 

in  place 

Slovenia  has 
three  national  based 
population cancer screening programmes (cervical 
cancer,  breast  and  colorectal  cancer).  The 
proportion of screening rates for cervical cancer is 

(384) National Institute of Public Health and Ministry of Health. 
(385) OECD. health at glance 2015. 

Slovenia has traditionally had a strong network of 
primary  health  providers,  with  health  promotion 
and disease prevention programs being an integral 
part  of  service  delivery  at  the  primary  level. 
Cardiovascular  disease  prevention  programmes 
with lifestyle interventions against key risk factors 
for  non-communicable  diseases  (tobacco  use, 
obesity,  high  blood  pressure,  diabetes)  have  been 
in place since 2002. From 2011 a system of family 
medicine  model  practices  has  been  introduced  to 
strengthen  prevention  work  and 
to  navigate 
chronic patients through health system.   

In  2015,  public  expenditure  on  prevention  and 
public  health  services  as  a  %  of  GDP  (0.2%)  and 
as a percentage of total current health expenditure 
(2%) was below the EU average for the same year 
(0.3% and 3.2% respectively).  

Recently 
reforms  

legislated  and/or  planned  policy 

is 

towards 

ongoing 

Improving  health  care  and  maintaining  its  fiscal 
and financial sustainability are high on the political 
agenda.  Work 
the 
implementation  of  a  reform  of  the  healthcare 
sector. The economic crisis, rising unemployment, 
insufficient 
ageing 
population  were  main  triggers  for  reforming  the 
health  care  system.  In  June  2013  the  Ministry  of 
Health  opened  a  public  debate  on  the  new 
legislation proposal on health care.  

resources 

financial 

and 

compulsory 

combination 

is  based  on 

The 
and 
of 
complementary  health  insurance,  which  are  the 
main financial sources for financing health care, is 
insufficient  and  not  in  line  with  guidelines  of 
social  welfare  policy.  Importantly,  the  current 
financing 
system 
(contributions) 
to  cyclical 
fluctuations,  and  do  not  guarantee  sustainable 
financing  in  the  future.  Work  was  put  into 
providing  financial  projections  and  scenarios  of 
abolishing  complementary  health  insurance  and 
introducing  other/alternative  ways  of  solidarity-
based financing schemes.  

sources  of 
subject 

that  are 

(386) Oi Ljubljana, 2015. 

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is 

One  envisaged  reform 
the  broadening  of 
contribution rates to certain new types of revenues 
with the aim of equalising the financial burden and 
diminishing  large  differences  in  contribution  rates 
among specific groups of insured persons or better 
balancing  the  burden  on  the  insured  based  on  the 
widest  possible  social  consensus.  Some  steps  in 
this direction were done in 2013 with the adoption 
of the amendments to the "Health Care and Health 
Insurance Act". Contribution rates of some groups 
of  the  population  (self-employed,  farmers  etc.) 
were 
that  partial  broadening  of 
contribution bases was introduced. 

raised,  so 

The  findings  from  the  analysis  of  the  health  care 
system  undertaken  in  cooperation  with  the  World 
Health Organisation and the European Observatory 
on Health Systems and Policies offered support in 
the  reform  process.  On  the  basis  of  the  analysis, 
the  "National  Health  Care  Resolution  Plan  2016-
2025"  was  approved  by  the  previous  government 
in December 2015 and was adopted by Parliament 
in March 2016. In this document (387), the Ministry 
of  Health  committed  to  ensuring  an  effective 
planning  of  human  resources  in  health  care, 
covering  the  current  needs  of  the  population  as 
well  as  accounting  for  the  changing  demographic 
structure.  As  a  first  step,  amendments  to  the 
Medical  Services  Act  were  adopted  in  July  2017, 
providing  a  legal  basis  for  to  the  Ministry  of 
Health  to  plan  and  forecast  future  needs  for 
different  specialisations  of  physicians  in  areas  of 
employment that are currently less attractive. 

A  public  discussion  on  a  proposal  of  the  new 
"Health  Care  and  Health  Insurance  Act”  was 
concluded in the first quarter of 2017, but the new 
Health  Care  and  Health  Insurance  Act  with 
measures  for  counter-cyclical  actions  and  a  more 
stable  financing  of  the  healthcare  system  was 
never  adopted.  In  addition,  amendments  to  the 
Medical  Practitioners  Act  were  adopted,  where 
financing of salaries and other costs for internship 
and  specialisation  is  transferred  from  HIIS  to  the 
general budget. 

In  September  2017  legislation (388)  was  adopted 
with the aim to gain additional budgetary funds for 

(387) The Resolution on National Health Care Plan 2016-2025": 

Together for a society of health". 

(388) The Act Determining Intervention Measures to Ensure the 
Institutions 

Financial  Stability  of  Public  Healthcare 
Established by the Republic of Slovenia. 

256 

public  hospitals.  Fifteen  public  hospitals  received 
€135.7  million  from  budgetary  funds  to  cover 
accumulated losses and to pay overdue obligations 
to suppliers. At the same time these are undergoing 
a  process  of  rationalisation  based  on  individual 
recovery plans that should be completed by 2021. 

In the area of waiting times changes were enforced 
legislation (389).  With 
the 
amending  existing 
implementation  of 
the  eBooking  of  medical 
services  a  uniform  base  has  been  established  to 
manage  waiting 
the 
amendments was to ensure transparency and better 
management  of  waiting  lists  and  to  regulate  a 
comprehensive  supervision  of  the  provision  of 
patients’ and obligations. 

lists.  The  purpose  of 

is 

in  2017 

in  progress, 

In  addition,  the  Ministry  of  Health  has  launched 
and/  or  designed  a  number  of  proposed  measures, 
also  in  line  with  the  "National  Health  Care  Plan" 
with  a  focus  on  health  promotion  and  disease 
prevention.  The  national  programme  on  nutrition 
and physical activity was adopted in July 2015 and 
implementation 
the 
comprehensive  Action  plan  has  been  adopted.  In 
the  same  direction 
the 
is 
"Dementia Strategy". The aim of the strategy is to 
ensure  preventive  measures,  early  diagnosis  and 
appropriate standard of health and social protection 
and  medical  care  for  people  with  dementia.  In 
2017  the  Government  adopted  two  important 
documents.  First,  comprehensive  Cancer  control 
plan  2017-2021  with  aim  to  tackle  increasing 
prevalence of cancer diseases and second, National 
HIV/AIDS strategy until 2025.  

the  adoption  of 

safety 

The  new  Pharmacy  Practice  Act  adopted  on  15 
December  2016  entered  into  force  on  27  January 
2017.  It  introduces  new  services  in  order  to 
increase  patient 
regarding  prescribed 
therapy, 
reduce  side  effects  and  additional 
hospitalisation  and  reduce  costs,  namely  clinical 
pharmacy  and  seamless  care  in  hospitals  and 
pharmaceutical  care  at  the  primary  level.  The  Act 
also restricts vertical integration in both directions: 
producer - wholesaler - pharmacy and vice versa to 
of 
assure 

independence 

professional 

the 

(389) The Act Amending the Patient Rights Act and Rules on the 
management  of  waiting  lists  and  waiting  times  the 
individual  health  services 
maximum  permissible  for 
http://www.pisrs.si/Pis.web/pregledPredpisa?id=ZAKO737
9. 

 
                                                           
                                                           
Health care systems 

2.25. Slovenia 

pharmacists. The guiding principle remains public 
health protection and care for health of individuals. 

the  system  in  terms  of  fiscal  sustainability  and 
stable  financing.  The  main  challenges  for  the 
health system appear as follows: 

Further  proposals  concern  pharmacies  and  their 
regulation.  The  proposed 
legislation  aims  at 
ensuring  better  regulation  of  pharmacies  and  the 
cost-effectiveness  of  the  system.  On  the  hospital 
level,  seamless  care  and  clinical  pharmacy  are 
envisaged 
the  prescription  of 
medicines  and  to  achieve  better  compliance  and 
safety for patients.  

to  optimise 

In July 2017, the Ministry of Health designated the 
coordination  and  working  group  for  preparing  the 
National  cost  analysis  of  the  activities,  performed 
by  the  hospitals.  The  purpose  of  the  national  cost 
analysis  was  to  eliminate  the  shortcomings  of  the 
Diagnosis-related  group  –  DRG)  system-financed 
acute  hospital  treatment  evaluations,  specialist 
ambulatory  service  activities  and  at  a  later  stage 
presumably  other  activities,  performed  by  the 
hospitals. 

concessions 

Amendments to Health Services Act were  adopted 
in  the  Parliament ( 390).  They  deal  with  criteria  for 
granting 
for  public  healthcare 
services,  aiming  at  improving  transparency  and 
accessibility  of  healthcare  services.  The  amended 
Act  defines  the  nature  of  the  public  healthcare 
service,  defines  legally  recognised  providers  (i.e. 
public  institutions  and  concessionaires)  and  states 
that  it  is  carried  out  under  a  non-profit  regime. 
Furthermore,  the  Act  includes  a  comprehensive 
regulation  of  the  conditions  under  which  health 
activities  can  be  carried  as  well  a  comprehensive 
regulation  of  various  forms  of  supervision  over 
providers of healthcare services.  

The  priorities  of  the  current  government  focus  on 
efficient  management  of  hospitals  and  waiting 
times.  

Challenges 

The  Slovenian  health  care  system  has  recently 
undergone  a  comprehensive  review  highlighting 
critical  areas  of  improvement  that  should  shape 
planned  reforms  in  the  sector.  Though  a  set  of 
efficiency-oriented  measures  was 
adopted, 
Slovenia has not yet solved the main challenges of 

(390) https://www.uradni-list.si/glasilo-uradni-list-

rs/vsebina?urlurid=20173026. 

quality 

spending, 

promoting 

•  To continue increasing the efficiency of health 
care 
and 
integrated care as well as focussing on costs in 
view of the increasing health care expenditure, 
which is a challenge to the fiscal sustainability 
over 
instance 
furthering  the  efforts  in  the  area  of  prevention 
and rationalising hospital care). To this end, to 
promote  public  procurement  as  a  means  to 
rationalise expenditure. 

the  coming  decades 

(for 

•  To improve the basis for more sustainable and 
efficient  financing  of  health  care  in  the  future 
(e.g.  considering  additional  sources  of  general 
budget  funds),  aiming  at  a  better  balance 
between resources and spending, as well as the 
number  of  contributors  and  the  number  of 
beneficiaries.  This  implies  tackling  the  lack  of 
sufficient 
stabilisers, 
especially  in  view  of  the  need  to  re-consider 
the role of complementary health insurance as a 
driver of excess demand and avoidable costs.  

automatic 

in-built 

and 

coordination 

•  To  tackle  the  excessive  use  of  specialist  and 
hospital  care  by  strengthening  the  role  of  the 
primary  care  sector  and  family  doctors  as  
gatekeepers 
and 
the 
integration of care among different health care 
levels,  while  ensuring  adequate  coverage  both 
in  urban  and  in  rural  areas.  To  this  end  to 
enhance  processes  and  procedures  along 
patients' care pathways. To promote the use of 
quality indicators and patient oriented measures 
for health care procedures. 

•  To  further  the  efforts  to  contain  long  waiting 
lists  for  some  health  care  services  by  a  more 
efficient  allocation  of  human  and  capital 
resources  between  sectors  and  specialisations 
through active purchasing of services by public 
health insurance institute and by promoting day 
cases  for  surgical  procedures.  To  this  end, 
promote  the  use  of  ICT  in  the  gathering, 
storage,  use 
exchange  of  health 
information.  

and 

•  To 

foster 
specialisation 

the  process  of  modernisation, 
among 
competition 

and 

257 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

To 

hospitals, for example by allowing for selective 
contracting  of  hospitals  by  health  insurance 
funds,  and  extending  legal  possibilities  for 
financing  of  hospital  care 
quality-based 
services. 
reimbursement 
improve 
mechanisms  that  create  incentives  to  increase 
efficiency,  including  improving  the  current 
DRG  system  to  better  reflect  actual  costs.  To 
this  end,  consider  whether 
remuneration 
mechanisms  of  hospital  staff  and  management 
could be better linked to performance. 

•  To  gradually 

increase 

the  use  of  cost-
effectiveness  information  in  determining  the 
basket of goods (by using HTA) and the extent 
of cost-sharing. 

258 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.25.1:  Statistical Annex – Slovenia 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

EU- latest national data

2005

29

23.2

3.8

:

2006

32

23.7

5.3

6.0

2007

35

24.3

6.4

4.5

2008

38

23.9

3.1

3.8

2009

36

20.7

-8.7

0.9

2010

36

21.2

0.9

-2.5

2011

37

21.5

0.5

0.7

2012

36

21.5

-2.9

0.3

2013

36

21.2

-1.3

-0.2

2014

38

21.9

2.9

2.2

2015

39

22.6

2.2

-1.9

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

8.3

8.0

0.4

8.4

8.1

0.3

8.3

7.9

0.3

8.3

8.0

0.3

9.2

7.8

1.4

8.9

7.5

1.4

8.9

7.8

1.0

9.2

8.6

0.6

9.3

8.6

0.7

9.2

8.5

0.8

8.9

8.5

0.4

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

1,466

1,588

1,731

1,881

1,961

1,886

1,920

1,935

1,962

2,021

2,002

2,745

2,895

6.1

5.8

6.0

5.7

5.6

5.3

6.1

5.8

6.7

6.3

6.6

6.3

6.5

6.3

6.7

6.3

6.5

6.2

6.3

6.0

6.5

6.1

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

1,067

1,130

1,184

1,372

1,426

1,406

1,412

1,403

1,375

1,379

1,460

2,153

2,263

2,324

2,609

0.26

72.8

14.7

99.0

13.2

0.32

71.2

14.6

99.0

12.5

0.33

68.4

15.5

99.0

13.8

0.29

72.9

14.8

100.0

12.8

0.41

72.7

14.4

100.0

12.7

0.35

74.6

14.2

100.0

12.7

0.29

73.5

13.8

100.0

12.2

0.40

72.5

14.0

100.0

11.9

0.29

70.1

11.0

100.0

12.6

0.28

68.2

12.8

100.0

13.0

0.38

72.9

13.7

100.0

12.5

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2.0

80.9

73.9

60.1

56.4

76

4.1

2.0

82.0

74.5

61.0

57.7

68

3.4

2.0

82.0

74.6

62.3

58.7

73

2.8

2.0

82.6

75.5

60.9

59.4

77

2.4

2.0

82.7

75.9

61.5

60.6

82

2.4

2.0

83.1

76.4

54.6

53.4

73

2.5

2.1

83.3

76.8

53.8

54.0

137

2.9

2.1

83.3

77.1

55.6

56.5

134

1.6

2.1

83.6

77.2

59.5

57.6

130

2.9

2.1

84.1

78.2

59.6

57.8

123

1.8

2.1

83.9

77.8

57.7

58.5

128

1.6

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

EU- latest national data

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.3

0.2

2.0

1.7

0.2

0.3

0.3

2.0

0.2

1.3

1.1

0.0

0.2

0.2

2.2

0.2

2.0

1.7

0.2

0.3

0.4

1.9

0.2

1.3

1.0

0.0

0.2

0.2

2.1

0.2

2.0

1.5

0.2

0.3

0.4

1.8

0.2

1.2

0.9

0.0

0.2

0.2

2.3

0.2

2.0

1.5

0.3

0.3

0.3

2.1

0.2

1.3

0.9

0.0

0.2

0.2

2.6

0.2

2.1

1.7

0.3

0.3

0.4

2.3

0.2

1.4

1.0

0.0

0.3

0.2

2.6

0.2

2.1

1.8

0.3

0.3

0.3

2.3

0.2

1.4

1.0

0.1

0.3

0.2

2.6

0.2

2.1

1.7

0.3

0.3

0.3

2.3

0.2

1.4

1.0

0.1

0.3

0.2

2.5

0.2

2.1

1.8

0.3

0.3

0.3

2.2

0.2

1.4

0.9

0.1

0.2

0.2

2.5

0.2

2.1

1.8

0.3

0.3

0.3

2.2

0.2

1.5

0.9

0.1

0.2

0.2

2.4

0.2

2.2

1.6

0.4

0.3

0.4

2.1

0.1

1.5

0.8

0.1

0.2

0.2

2.3

0.2

2.4

1.6

0.4

0.2

0.3

2.0

0.2

1.7

0.8

0.1

0.1

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

(1) All the figures under EU-latest national data are computed as weighted averages. 

Source:  EUROSTAT, OECD and WHO. 

2
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2
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Table 2.25.2:  Statistical Annex - continued – Slovenia 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

28.4%

2.4%

25.5%

21.8%

2.8%

3.8%

3.6%

34.9%

3.2%

21.6%

18.2%

0.7%

3.8%

3.1%

2005

:

0.5

1.0

0.1

:

23.0

11.1

2006

26.6%

2.2%

25.2%

20.9%

2.6%

3.7%

4.3%

33.9%

2.9%

23.3%

18.4%

0.7%

3.9%

3.0%

2006

0.55

0.5

1.1

0.1

:

18.5

12.3

2007

26.0%

2.2%

24.9%

19.4%

2.8%

3.7%

4.8%

34.2%

3.1%

22.9%

17.3%

0.8%

3.9%

3.2%

2007

0.60

0.5

1.1

0.1

16.4

18.9

11.0

2008

29.0%

2.5%

25.2%

19.3%

3.1%

3.8%

4.3%

35.5%

3.3%

22.9%

15.9%

0.7%

3.8%

2.8%

2008

0.69

0.5

1.2

0.1

16.8

18.7

10.9

2005

2006

2007

2008

235

748

38

690

2005

:

15

236

760

38

617

2006

6.6

16

239

775

41

608

2007

6.7

16

240

788

41

559

2008

6.7

16

2009

32.8%

2.7%

26.5%

22.2%

3.8%

4.1%

4.9%

36.4%

3.2%

22.2%

15.9%

0.6%

4.0%

2.9%

2009

0.69

0.6

1.2

0.1

:

:

10.5

2009

241

803

42

553

2009

6.6

17

2010

34.4%

2.8%

27.5%

23.4%

4.1%

4.4%

4.0%

36.5%

3.1%

22.2%

15.6%

0.8%

4.0%

2.9%

2010

0.73

0.9

1.3

0.1

:

:

10.3

2010

243

819

44

546

2010

6.4

16

2011

33.3%

2.6%

26.2%

21.9%

3.9%

4.3%

3.8%

37.1%

3.1%

22.7%

15.4%

0.8%

4.0%

2.6%

2011

0.83

0.9

1.3

0.1

:

:

10.6

2011

249

833

45

535

2011

6.5

17

2,026

2,142

2,243

2,484

2,566

2,229

1,950

70.0

5.8

11.7

2016

5.6

5.6

2016

2.1

72.0

5.8

11.8

2020

5.8

6.0

2020

2.1

69.7

6.8

12.1

2025

6.1

6.3

2025

2.1

71.5

6.9

13.3

2030

6.3

6.7

2030

2.1

71.2

6.9

13.4

2035

6.5

7.1

2035

2.1

69.7

6.7

12.0

2040

6.7

7.3

2040

2.1

68.9

7.3

10.5

2045

6.8

7.5

2045

2.1

2012

29.0%

2.4%

24.4%

20.6%

3.4%

3.9%

3.8%

34.9%

3.0%

22.2%

14.0%

1.0%

3.9%

2.6%

2012

0.87

0.8

1.3

0.1

:

:

11.0

2012

254

816

47

528

2012

6.3

:

:

68.8

7.5

:

2050

6.8

7.6

2050

2.0

2013

29.0%

2.1%

25.0%

20.8%

3.4%

3.9%

4.0%

34.7%

2.8%

23.4%

13.9%

0.9%

3.7%

2.6%

2013

0.87

0.8

1.2

0.1

:

:

9.5

2014

28.2%

1.9%

25.9%

18.6%

4.1%

3.1%

4.1%

34.4%

2.3%

25.4%

12.6%

1.7%

2.7%

2.8%

2014

0.87

0.8

1.3

0.1

18.6

18.9

10.5

2015

27.5%

2.2%

27.8%

18.4%

4.1%

2.6%

3.5%

33.1%

2.8%

27.8%

12.7%

1.8%

2.0%

2.3%

2015

0.87

0.8

1.3

0.1

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2013

2014

2015

2009

2011

2013

2015

263

832

50

523

2013

6.5

:

:

67.9

6.8

:

2055

6.8

7.7

2055

2.0

277

856

52

524

2014

6.6

18

2,047

68.4

6.9

10.4

2060

6.8

7.7

2060

2.0

283

878

55

518

2015

6.8

18

1,888

68.8

6.8

9.7

2065

6.8

7.7

2065

2.0

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

6,362

6,584

76.4

7.8

29.1

77.1

8.0

28.0

2070

6.7

7.6

2070

2.0

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Slovenia

1.0

2.0

EU

0.9

1.6

Change 2016-2070, in %

Slovenia

-5.2

EU

2.0

(1) All the figures under EU-latest national data are computed as weighted averages.  

Source:  EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.26. SPAIN 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

according  to  the  AWG  reference  scenario (394). 
When  taking  into  account  the  impact  of  non-
demographic  drivers  on  future  spending  growth 
(AWG  risk  scenario),  health  care  expenditure  is 
expected to increase by 1.2 pps of GDP from now 
until 2070 (EU: 1.6).   

in  2016 

(according 
the  next  decades, 

Spain  has  a  population  of  almost  46.4  million 
to  Eurostat 
inhabitants 
projections).  Over 
is 
this 
expected to increase to 49.9  million by 2070. With 
a  GDP  of  more  than  €1,080  billion,  or  €26.1 
thousand PPS per capita in 2015 it is below the EU 
average GDP per capita of €29.6 thousand.  

in 

the  medium 

Overall, for Spain no significant short-term risks of 
fiscal stress arise. Risks appear, on the contrary, to 
be  high 
term  from  a  debt 
sustainability analysis perspective due to the stock 
of debt still being high at the end of the projection 
(2028). High fiscal risks are expected in the long-
run (395). 

Total and public expenditure on health as % of 
GDP 

Health status 

Total expenditure (391) on health as a percentage of 
GDP  (9.3%  in  2015)  has  increased  over  the  last 
decade (from 7.9% in 2005), but is still below the 
EU  average  (392)  of  10.1%  in  2015.  Public 
expenditure  has  increased  though  to  a  smaller 
extent:  from  5.7%  in  2001  to  6.6%  of  GDP  in 
2015.  It  is  also  below  the  EU  average  of  8%  in 
2015.  Looking  at  health  care  without  long-term 
care(393)  reveals  a  different  picture,  with  public 
spending  still  below  but  sinificantly  closer  to  the 
EU average (5.9% vs 6.8% in 2015). 

When expressed in per capita terms, total spending 
on health at €2,268 PPS in Spain is below the EU 
average of 3,305 in 2015. So is public spending on 
health  care:  €1,617  PPS  vs.  an  average  of  €2,609 
PPS in 2015.  

Expenditure projections and fiscal sustainability 

As a consequence of population ageing, from 2016 
to  2070  health  care  expenditure  is  projected  to 
increase  by  0.5  pps  of  GDP  below  the  average 
growth  expected  for  the  EU  of  0.9  pps  of  GDP, 

(391) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(392) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions of units and units of staff where relevant. The EU 
average  for  each  year  is  based  on  all  the  available 
information in each year.  

(393) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

In  2015,  life  expectancy  at  birth  (85.8  years  for 
women  and  80.2  years  for  men)  and  healthy  life 
years  (64.1  years  for  women  and  63.9  years  for 
men)  are  among  the  highest  in  the  EU  and  well 
above  the  respective  EU  averages  (83.3  and  77.9 
years of life expectancy in 2015, 63.3 and 62.6 in 
2015  for  the  healthy  life  years)  (396).  An  infant 
mortality rate of 2.7 per thousand is lower than the 
EU average of 3.6%, having gradually  fallen over 
most of the last decade (from 3.7% in 2005). 

As for the lifestyle of the Spanish population, data 
indicates  a  considerable  fall  in  the  proportion  of 
regular smokers (from 26.4% in 2006 to 23.0% in 
2014),  although  the  share  is  still  above  the  EU 
average  of  21.8%.  Over  the  same  period  the 
proportion  of  the  obese  in  the  population  has 
increased (from 14.9% in 2006 to 16.2% in 2014), 
while the alcohol consumption shows a very small 
reduction from 10.2 litres per capita in 2003 to 9.3 
litres in 2013. 

System characteristics  

Overall description of the system 

The  Spanish  health  care  system  is  fully  devolved 
to  the  regions.  Despite  the  decentralised  character 

(394) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(395) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(396) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

261 

 
                                                           
                                                           
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of 

the  Central 

of  the  system,  eligibility  depends  on  the  general 
regulations 
government. 
Autonomous  communities  (ACs,  i.e.:  regional 
governments)  are  in  charge  of  the  process  of 
accreditation of coverage which is decided in each 
case  by  the  Social  Security  authorities  dependent 
on  Central  government.  All  of  them  respect  the 
principle  of  universality  of  health  care  in  the 
framework  of  the  Spanish  Constitution  and  State 
General  Health  Care  and  Social  Security  Laws, 
extending  it  not  only  to  the  Spanish  citizens 
contributing  financially  to  the  system,  but  also  to 
EU  temporary  residents  and  non-residents  (non-
EU residents, including illegal immigrants are not 
fully covered) . There is also a Common Basket of 
services of the National Health System that has to 
be delivered to the whole population covered. 

Coverage 

Through  the  Royal  Decree  16/2012,  the  Spanish 
health system was reformed to cover those who are 
insured  as  part  of  the  system  (including  both 
Spanish  and  overseas  citizens).  This  covers 
workers affiliated with the Social Security system, 
pensioners as  well as recipients of social benefits. 
Coverage  can  also  be  provided,  if  requested,  to 
non-insured  Spanish,  EU  and  EEA  citizens  who 
are  legal  residents  in  Spain  whose  annual  income 
is  below  100,000  euros  and  who  are  not  covered 
by  any  other  health  insurance. Through  the  Royal 
Decree 7/2018 the cover is extended to foreigners 
that,  while being in  Spain, do not have their legal 
residence  there.  This  implicitly  extends  cover  to 
illegal inmigrants.   

Administrative  organisation  and 
collection mechanism  

revenue 

The  system  is  a  unique  combination  of  central, 
regional  and  local  management  and  financing  of 
tax-funded.  Public 
health  care.  It 
expenditure 
total 
expenditure  on  health,  out-of-pocket  expenditure 
24.2%  and  the  rest  is  private  health  insurance 
(2015 figures).  

for  71.3%  of 

is  mostly 

accounts 

The reform in 2001 marked the finalisation of the 
devolution process, which meant that all of the 17 
regions were granted complete freedom to manage 
their  own  health  services.  Health  funding  was 
integrated  within  the  general  financing  system 
through tax cession; and ear-marking of funds was 

262 

phased out. The new system since the 2009 reform 
(397)  follows 
the  same  structure  of  regions 
implemented 
financing 
in  2001  aimed  at 
the  basic  principles:  elements  of 
reinforcing 
taxation  ceded  to  regional  administrations  and 
assignments  from  the  state’s  general  budget.  As  a 
result  of  this  reform,  90%  of  regional  revenues 
stem from taxes. 

Under  the  2009  reform  the  financing  of  health 
services is as follows: 

the  main  excise 

•  Specified shares of taxes are ceded to the ACs: 
50% of personal income tax and VAT and 58% 
of 
taxes  (hydrocarbons, 
alcohol,  and  tobacco).  The  system  since  2001 
includes  regional  direct  control  over  taxes  on 
gifts  and  inheritances,  properties  and  property 
transfers  and  gambling  taxes.  ACs  can  also 
raise their own taxes. 

•  The  Fundamental  Public  Services  Guarantee 
Fund guarantees that health care, education and 
social  services  are  equally  provided  regardless 
the place of residence. It is made up of 75% of 
the taxes ceded to ACs plus state transfer. This 
is distributed to ACs on the basis of population, 
extension,  dispersion,  insularity  (as  before) 
plus  the  equivalent  protected  population  (split 
into subgroups by age).  

•  The  Global  Sufficiency  Fund  guarantees  that 
ACs have enough resources to finance all their 
competences. It is fully financed by the central 
government.  Consequently,  ACs  can  use  the 
remaining  25%  of  ceded  taxes  plus  this  State 
fund to meet their competences.   

Finally, in order to promote economic convergence 
and development of those ACs with lower income 
per  capita, 
two  new 
the  system  relies  on 
Convergence  Funds  fully  financed  by  the  Spanish 
state’s  budget 
transfers  (the  Competitiveness 
Funds and the Cooperation Funds), over which the 
central administration holds more discretion. 

At  the  central  level  the  Ministry  of  Health  is 
responsible  for:  general  coordination  and  basic 
health  legislation;  definition  of  benefits  package 

(397) Law  22/2009  that  regulates  the  financing  system  of 
Autonomous  Communities  of  common  regime  and  Cities 
with Autonomic Statute. 

 
                                                           
guaranteed by the NHS; pharmaceutical policy and 
medical  education,  while 
Inter-territorial 
Council  of  the  NHS  has  a  coordination  role.  At 
regional  level,  the  ACs  hold  health  planning 
powers  and  the  capacity  to  organise  their  own 
health services in their regions.  

the 

and 

insurance 

administration 

The  level  of  expenditure  on  administration  is 
relatively  low.  Public  and  total  expenditure  on 
health 
a 
percentage of GDP (0.13% and 0.26%) are below 
the  respective  EU  averages  (0.26%  and  0.38% 
respectively  in  2015);  so  is  public  expenditure  
(2%) on health administration and health insurance 
as  a  percentage  of  total  public  current  health 
expenditure (EU average of 3.4% in 2015).  

as 

Budget  control  is  performed  the  same  as  in  any 
other  public  institution.  However,  in  the  public 
health sector the usual tool for management is that 
of contract-programmes or management contracts. 
In  the  health  system  these  contracts  have  the 
following  general  characteristics:  they  define  the 
quantitative  and  qualitative  objectives,  the  budget 
time  period 
and 
referred  to  in  the  contracts  tends  to  be  one  year. 
The  contracts  are  made  between  the  Regional 
Ministries  and  the  Health  Services,  and  between 
the  Health  Services  governing  bodies  and  the 
health care areas or facilities. 

the  evaluation  system.  The 

Role  of  private  insurance  and  out  of  pocket 
co-payments  

Private expenditure and out-of-pocket expenditure 
constitute  respectively  28.7%  and  24.2%  of  total 
expenditure on health in 2015. The share of out-of-
pocket  payments  shows  a  slightly  declining  path 
(22% in 2005) up to a low of 19.5% on 2009 but 
has  steadily  increased  since  then  up  to  24.6%  in 
2014, falling then to 24.2 in 2015. It remains above 
the EU average of 15.9%. This may be partly due 
to the 2012 reform to pharmaceutical co-payments 
explained in more detail below. Since primary and 
specialist  care  services  are  provided  without  cost 
sharing,  out-of-pocket  spending  accounts  mainly 
for  cost-sharing  in  the  area  of  pharmaceuticals, 
medical  aids  and  prostheses,  optical  and  dentist 
services, as  well as private  use of private  medical 
and hospital services.  

Cost-sharing from patients is limited to medicines. 
The  structure  of  pharmaceutical  co-payments  has 

Health care systems 

2.26. Spain 

been  reformed  in  2012  and  has  different  features 
for  pensioners  and  non-  pensioners,  although  in 
both  cases  there  are  three  bands  according  to 
income  (below  €18,000  annual  income,  between 
€18,000 and €100,000 and above €100,000). Non-
pensioners need to pay 40%, 60% and 80% of the 
price  of  medicines,  with  no  upward 
limit. 
Pensioners  pay  10%  for  the  first  two  bands  and 
60% for the upper band,  with an  upward  monthly 
limit  of  €8,  18  and  60.  There  are  exemptions  for 
those people on some social benefits, in receipt of 
non-contributory  pensions,  disabled,  unemployed 
not  on  receipt  of  unemployment  benefits  and 
persons who have suffered occupational accidents. 
There  is  no  reimbursement  system;  patients  pay 
their share at the pharmacy  which bills the rest to 
regional health services.  

Civil  servants'  mutual  funds  require  co-payments 
of  30%  of  the  price  of  pharmaceuticals  from  all 
their  beneficiaries  (including  the  retired  ones). 
Particular groups are always  exempt  from the full 
co-payments:  AIDS  patients  and  chronic  diseases 
(both 10%, with €2.64 ceiling).  

In  addition,  the  concerns  voiced  regarding  the 
length  of  the  waiting  lists  have  resulted  in  the 
implementation  of  indicators  and  minimum  basic 
and  (countrywide)  common  requirements  for 
waiting 
for  specialists,  diagnostic  and 
therapeutic trials and surgery. 

lists 

Types of providers, referral systems and patient 
choice 

The  Spanish  health  care  system  is  focused  on 
primary  and  ambulatory  care.  Primary  health  care 
(PHC)  is  an  integrated  system  composed  of  PHC 
centres  and  multidisciplinary 
teams  providing 
personal  and  public  health  services  in  well-
equipped  centres.  PHC  is  provided  by  general 
practitioners  (GPs)  and  primary  health  care 
paediatricians,  who  play  an  important  role  as 
gatekeepers  and  referral  points  to  specialists. 
These in turn refer patients to hospital care. Single-
handed  practices  are  restricted  to  small  villages 
and to the private sector. PHC is to a great extent 
publicly  funded  and  run  (398).  Inpatient  care  is 
provided  in  hospitals  which  are  mostly  publicly 

(398) The  only  public-private  mix  is  the  formula  of  health 
associations  used  in  Catalonia  by  delegating  powers  to 
private companies within certain geographic areas. 

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owned.  The  NHS  also  contracts  services  from 
private non-profit providers. 

The  number  of  practicing  physicians  per  100  000 
inhabitants  (385  in  2015)  is  above  the  average  in 
the EU (344 in 2015). In Spain, GPs are a type of 
specialist  (Family  and  Community  Medicine). 
There  are  about  75  GPs  per  100  000  inhabitants, 
below the EU average (78.3 in 2015). The average 
number  of  consultations  per  inhabitant  per  year 
(frequentation)  (399)  is,  at  7.6,  above  the  EU 
average of 6.2 (2014). 

The  number  of  practising  nurses  at  529  per 
100,000  inhabitants  in  2015  shows  a  significant 
increase (431 in 2003) but is far lower than the EU 
average (average of 833 in 2015). It should also be 
noted that the ratio of nurses to physicians is 1.37 
in the latest available year, one of the lowest in the 
EU (average 2.3), indicating a likely imbalance in 
the health care workforce. 

to 

inpatient  care 

Given two-stage referral procedure (GP-specialist-
hospital)  access 
is  closely 
controlled.  This  has  allowed  authorities  to  reduce 
capacity  and  activity  of  hospitals  over  the  last 
decade. In 2015, overall capacity of hospitals  was 
considerably 
in  most  other  EU 
than 
countries,  with  241  acute  hospital  beds  per 
100,000  inhabitants,  compared  to  the  EU  average 
of 402 beds.  

lower 

Inpatient hospital discharges per 100 inhabitants in 
2013 were, at 10.2, below the EU average of 17.1.  
There were 8,054 day case discharges per 100,000 
inhabitants  in  2015,  above  the  EU  average  of 
7,635. As a result, the ratio of day cases to longer 
stays is amongst the highest in Europe, evidence of 
a  relatively  efficient  use  of  hospital  resources. 
Acute  care  bed  occupancy  rates  in  2015  were 
75.8%,  slightly  above  the  EU  average  of  76.8%. 
Average length of stay has fallen from 8.2 in 2007 
to  7.3  in  2015,  slightly  below  the  EU  average  of 
7.6.  This  is  a  reflection  of  the  progressive  shift 
towards  ambulatory  specialised  care,  which  is 
resulting  in  procedures  being  performed  without 
overnight  stay  that  previously  required  admission 
to  the  hospital.  Such  an  increase  in  day-hospital 

(399) National  Health  System  of  Spain  Annual  Report  2011, 
page36;https://www.msssi.gob.es/organizacion/sns/planCal
idadSNS/pdf/equidad/informeAnualSNS2011/Informe_anu
al_SNS_2011.pdf. 

264 

places  is  found  in  both  absolute  numbers  and  in 
rates per 100,000 inhabitants. Note that in terms of 
hospital  activity  44.2%  of  all  discharges  are  day 
case  discharges,  far  above  the  EU  average  of 
32.3% in 2015. 

This  however  puts  pressure  on  the  GP  to  act  as 
effective  gatekeeper  and  also  to  co-ordinate  the 
care received by patients effectively.  

Treatment options, covered health services 

There  is  a  Common  Basket  of  services  of  the 
National Health System that has to be delivered to 
the  whole  population  covered.  Beyond 
that, 
specific  additional  services  may  be  provided  by 
different regions to their citizens. 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Primary  health  care  staff  are  paid  a  salary  plus  a 
capitation  component  (amounting  to  15%  of  the 
total),  which  takes  into  account  the  demographic 
structure  and  the  geographical  dispersion  of  the 
population covered by their services.  

Hospital doctors and specialists in ambulatory care 
units have a status similar to that of civil servants 
and are almost exclusively paid a salary. Both GP 
and hospital doctors have an additional component 
for professional development (professional career), 
and in some cases, a small additional productivity 
component  related  to  performance.  Other  health 
care professions (nurses, midwives, social workers 
and public health professionals) are paid by salary 
as well. 

The  basic  salary  is  regulated  by  the  national 
government,  although  each  AC  has  the  right  to 
vary some additional components.  

third-party  payer,  setting  out 

Public  hospital  funding  is  generally  carried  out 
prospectively  through  negotiation  of  a  contract 
programme  between  the  hospital  and  the  regional 
the 
authority 
objectives (in quantity and quality) to be achieved 
by the hospital and assigning financial resources to 
these  objectives.  The  purchasing  institution  then 
monitors  the  contracts  according  to  the  agreed 
timetable.  Until 
traditional 
retrospective 
reimbursement  with  no  prior 
negotiation  was  a  routine  mechanism.  Then,  from 

1990s 

the 

a 

 
                                                           
1991  first  aggregate  measures  of  activity  (e.g. 
weighted  health  care  unit)  were  defined  which 
enabled  comparison  among  hospitals.  Over  recent 
years some attempts have been made to develop a 
more  sophisticated  prospective  payment  system 
based  on  diagnosis-related  groups  or  Patient 
Management  Categories.  Some  elements  have 
been adopted in a few autonomous communities so 
far,  but  no  general  trend  can  be  specified.  Public 
hospitals  are  also  allowed  to  have  another,  albeit 
minor,  source  of  financing,  by  providing  services 
to people or schemes not covered by the NHS. On 
the  other  hand,  hospitals  functioning  outside  the 
NHS  may  provide  services  to  the  public  system, 
which  are  specifically  regulated  by  individual 
agreements or contracts. 

The market for pharmaceutical products 

and 

clinical 

The  Spanish  pharmaceutical  market  is  the  fourth 
largest  in  the  EU-28  and  eighth  in  the  world  by 
value. The pharmaceutical market is dominated by 
the  state  who  is  the  main  actor,  responsible  for 
regulating 
trials, 
authorising 
controlling the advertising of drugs, regulating the 
quality  and  manufacturing  of  pharmaceutical 
products,  fixing  the  price  of  drugs,  setting  co-
payments  and  establishing  the  list  of  publicly 
financed  medicines.  Once  authorities  decide  on 
which products are to be reimbursed, they regulate 
the price of reimbursed products. The initial price 
decision is based on clinical performance, the cost 
of  existing  treatments,  cost-plus  calculations  and 
international prices. International price referencing 
is  based  on  ex-factory  prices  of  all  EU  countries. 
Spain 
for 
reimbursement:  the  reimbursement  level  is  the 
lowest  price,  calculated  by  cost  of  treatment/day 
for  all  the  drugs  of  the  same  group  (400).  The 
reference pricing mechanism in Spain tries to give 
a  signal  to  the  market  by  the  regulator,  aiming  at 
manufacturers  adapting  their  prices.  Some  other 
regulations 
(profit  and  commercial  margins, 
limited  operating  hours)  have  been  adopted  to 
contain costs increase. Discounts and price freezes 
and  cuts  are  some  mechanisms  used  to  directly 
control  expenditure  (401).  The  use  of  generic 
medicaments  has  increased  in  recent  years  since 

reference 

pricing 

uses 

also 

(400) Royal Decree Law 4/2010, March 26th. 
(401) See "Analysis of differences and commonalities in pricing 
and  reimbursement  systems  in  Europe",  Jaime  Espin  and 
Joan Rovira, 2007 for DG Enterprise and Industry. 

Health care systems 

2.26. Spain 

the  regulation  regarding  the  reference  pricing 
system  was  adopted 
in  2003  which  meant 
important public savings.  

is 

an 

regulation 

exclusive 
Pharmaceutical 
responsibility  of 
the  national  administration, 
though  the  role  of  autonomous  communities  in 
modulating consumption is paramount, given their 
full responsibility for pharmaceutical management 
(through  programs 
improve  prescription’s 
to 
quality and the relationship with pharmacists).  

higher. 

slightly 

lower  and 

Public  expenditure  on  outpatient  pharmaceuticals 
(1%  of  GDP  in  2015)  has  fallen  from  its  peak  of 
1.24% in 2010. However, total expenditure is back 
at its 2013 peak of 1.7% as a proportion of GDP. 
Both  are  close  to  the  EU  average,  with  public 
total 
expenditure  being  slightly 
expenditure 
Outpatient 
pharmaceutical spending as a proportion of public 
health spending fell from 21% in 2005 to 15.1% in 
2015,  still  above  the  EU  average  of  12.7%. 
Surprisingly,  although  there  was  a  marked  fall  in 
outpatient  pharmaceutical  expenditure  after  the 
pharmaceutical 
economic 
expenditure,  which  was  less  closely  monitored  by 
the  authorities,  continued  to  increase  over  this 
period. The Spanish authorities have now required 
disclosure  on  hospital  expenditure  data  from  the 
regions,  a  welcome  step 
increase 
transparency in this sector.  

that  will 

hospital 

crisis, 

The regions have implemented several measures to 
promote  generics  prescription  among  physicians. 
However, despite these efforts, in 2017, according 
to  AESEG  (Spanish  association  of  producers  of 
generic  medicines),  the  generic  market  remains 
less  developed  than  in  other  EU  countries,  with  a 
generic  penetration  by  value  of  21  %  and  by 
volume  of  40  %  (compared  with  25%  and  65% 
respectively for the EU as a whole). 

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

Health Technologies Assessment (HTA) is present 
both  at  national  and  regional  level.  The  recent 
creation  of 
the  platform  of  HTA  agencies 
(AUnETS)  has  marked  a  turning  point  in  the 
direction of fostering coordination and synergies.  

The regulation of the inclusion of new items in the 
NHS common benefits basket explicitly requires as 

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a previous step the appraisal by the National HTA 
agency in cooperation with AUnETS.  

assessment  and  monitoring  at  national  level  and 
also manage the discretional funding linked to the 
development of the "National Quality Plan".  

E-Health, Electronic Health Record 

The  "Electronic  Health  Record  of  the  National 
Healthcare  System"  (Historia  Clínica  Digital  del 
Sistema  Nacional  de  Salud,  HCDSNS)  was 
initiated  in  2006  with  the  following  objectives  in 
mind: 

•  To guarantee citizens' electronic access to their 
own health data and to the health data of those 
they  represent  that  are  available  in  digital 
format  at  any  of  the  health  services  that  make 
up the NHS, as long as they  comply  with   the 
minimum  security  requirements  laid  down  to 
protect  their  own  data  against  illegal  intrusion 
by those who have not been duly authorised to 
access such data.  

•  To  ensure  the  healthcare  professionals  duly 
authorised  by  each  health  service  for  such  a 
function  can  access  specific  personal  health 
data  sets  generated  by  a  regional  authority 
other than the one requiring the information, as 
long  as 
the 
professional's  healthcare  services  at  a  public 
NHS health centre.  

the  user  or  patient  seeks 

•  To  provide  the  NHS  with  a  secure  access 
the 

system 
confidentiality of their personal health data.  

guarantees 

citizens 

that 

•  The  HCDSNS  system  should  be  dynamic  and 
simple  as  regards  access  and  be  at  the  service 
of citizens and professionals. 

• 

In June 2014, 20 million citizens from 15 of the 
17  Autonomous  Regions  have  shared,  at  least 
partially, their medical history, which could be 
consulted by healthcare professionals.  

Health  and  health-system 
reporting mechanisms 

information  and 

The "Dirección General de Salud Pública, Calidad 
e  Innovación"    includes  under  its  umbrella  the 
"Subdirección  General  de  Información  Sanitaria  e 
Innovación",  la "Subdirección  General  de  Calidad 
y  Cohesión"  and  the  Observatory  of  the  NHS. 
functions  of 
These  units 

concentrate 

the 

266 

Health  information  systems  have  been  developed 
and  are  trying  to  improve  coordination  among 
regions.  The  "Institute  of  Health  Information"  is 
the  repository  of  administrative  databases  and 
basic health-related statistics for the ACs, manages 
regional  health  data,  the  National  Health  Survey, 
the  "Health  Care  Barometer"  and  the  "National 
Mortality  Register".  All 
sources  of 
information  have  allowed  for  the  building  of  the 
"Set of Key Indicators for the SNS" (INCLASNS); 
the  chosen  indicators  cover  demographics,  health 
status  and  its  determinants,  health  care  resources 
supply,  activity,  quality,  expenditure  and  citizens’ 
satisfaction (402).  

these 

level, 

ICTs  are 

At  consultation 
improving 
coordination with the implementation of electronic 
medical records (currently implemented within the 
regions; there are pilot projects across the regions 
(403)  and 
the 
electronic  prescription  of  medicaments  (better 
follow- up of patients and avoiding misuse). 

improving  cost  savings  with 

Health  promotion  and  disease  prevention 
policies 

for 

instrument 

the  principal 

Health  planning  is  a  competence  of  the  regional 
health departments and as such, each one develops 
their regional health 4-5  yearly plans (HPs). They 
are 
identifying 
intended  courses  of  action  and  planning  resources 
towards  the  achievement  of  previously  defined 
health  goals.  All  share  the  purpose  of  responding 
to  identified  health  needs  and  offering  strategies 
for  health  systems  action,  inspired  by  “WHO’s 
Health  for  All”  and  HEALTH21  strategies.  These 
plans in turn materialise in regional strategic plans, 
infrastructure  plans,  regional  health  strategies  and 
health programmes. 

terms  of  public 

In 
lifestyle 
patterns,  Spain  has  been  quite  successful  in 

intervention  on 

(402) The  statistic  portal  of  National  Health  System  is  publicly 
available 
in 
http://www.msps.es/estadEstudios/estadisticas/sisInfSanSN
S/home.htm.  
in 

the  National  Health  System  Ed.  2010 

(403) ICT 

http://www.ontsi.red.es/articles/detail.action?id=4559&req
uest_locale=en. 

 
                                                           
accidents 

introducing  anti-tobacco  law  (strict  regulation  of 
advertising  and  places  to  smoke)  and  enacting 
stricter  rules  on  occupational  health  and  accident 
prevention  and  in  results  regarding  diminishing 
traffic 
and 
(through 
legislation).  In 
the  area  of  pharmaceuticals’ 
consumption, education is being improved by anti- 
self-medication  campaigns  and  the  new  adaption 
of 
prescription.  The 
dose 
pharmaceutical  co-payments  described  above  are 
also likely to reduce self-medication. 

campaigns 

packages 

to 

Recently 
reforms 

legislated  and/or  planned  policy 

A  new  voluntary  budget  rule  on  healthcare 
spending  for  application  at  regional  level  was 
approved  in  mid-June  2015.  The  new  budget  rule 
limits  growth  in  healthcare  and  pharmaceutical 
spending in 2015 and 2016 to the reference rate of 
medium-term  economic  growth  of  the  Spanish 
economy.  If  eligible  spending  exceeds  that  rate, 
then  the  region  concerned  would  be  prevented 
from offering health care services other than those 
included  in  the  national  basket  of  health  services 
and would be asked to apply efficiency-enhancing 
measures. Regional governments can comply with 
the  rule  on  a  voluntary  basis,  and  financial 
incentives to their participation have been devised 
by  the  Ministry  of  Finance  and  the  Ministry  of 
Health  in  consultation  with  the  health  industry.  It 
is however unclear at this stage how many regions 
will  comply  with  this  new  rule.  The  recent  Royal 
Decree  7/2018  extends  health  care  cover  to  all 
foreigners  that,  while  being  in  Spain,  do  not  have 
their legal residence here. This implicitly includes 
cover for all illegal immigrants. 

Challenges 

Over  the  years,  with  a  lower  share  of  GDP 
allocated  to  health  compared  to  other  European 
countries,  the  Spanish  NHS  has  shown  the  ability 
to  yield  sustained  good  results  measured 
in 
different dimensions of performance: 

•  Population  health  status  parameters  and  health 

care amenable outcomes. 

•  Coverage, 

access 

and 

financial 

equity 

parameters. 

Health care systems 

2.26. Spain 

•  Health care quality and safety. 

•  Users’  satisfaction  and  system  legitimated  by 

the population. 

Despite this positive achievement, the NHS is still 
striving to overcome certain challenges:  

•  Alignment  of  providers’  incentives  with  the 
system’s  quality  and  efficiency  objectives 
throughout  the  system  (different  levels  of 
management,  health  professionals,  non-health 
professionals,  external  providers  …).  For 
example,  staff  incentives  could  be  improved 
and  adapted  to  rise  in  chronic  diseases  and 
changes in demand. 

•  Transition  from  an  acute  care-driven  model  to 
the management of chronic diseases, including 
mental disorders. 

• 

Improve  the  integration  of  the  different  levels 
of  care,  increasing  the  resolution  capacity  of 
GP by boosting their case manager’s role. 

•  Shifting 

to  a  user-centred  model 

in  a 
predominantly  public  provision 
structure, 
staffed  mainly  by  civil  servants  and  statutory 
personnel.  It  is  necessary  a  cultural  change 
aimed to increase the productivity of the health 
sector,  and  so  on,  in  order  to  reduce  waiting 
lists and to cope with patient’s expectations.    

• 

Improve 
the  efficiency  of  pharmaceutical 
expenditure  by  increasing  generic  penetration 
and  improving  the  transparency  of  hospital 
pharmaceutical expenditure. 

•  The  issue  of  ageing  workforce  should  be 
tackled,  as  in  the  rest  of  the  EU,  through  the 
promotion  of  the  medical  education  and  more 
flexible salary regulation rewarding quality and 
efficient  work.  The  imbalances  in  the  health 
care workforce structure should also be tackled 
and  the  possibility  of  expanding  the  role  of 
nurses in the provision of care considered.  

267 

 
2
6
8

Table 2.26.1:  Statistical Annex - Spain 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

2005

931

25.9

1.8

:

2006

1,008

27.1

2.5

3.9

2007

1,081

27.5

1.8

2.7

2008

1,116

26.5

-0.5

5.4

2009

1,079

24.7

-4.4

3.5

2010

1,081

24.4

-0.4

-0.7

2011

1,070

24.2

-1.4

-1.0

2012

1,040

24.2

-3.0

-3.9

2013

1,026

23.9

-1.3

-2.0

2014

1,038

24.8

1.7

2.4

2015

1,080

26.1

3.5

4.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

7.9

7.7

0.2

8.0

7.8

0.2

8.1

7.8

0.2

8.5

8.3

0.3

9.2

9.0

0.3

9.2

9.0

0.2

9.3

9.1

0.2

9.2

9.1

0.1

9.1

9.0

0.1

9.2

9.1

0.1

9.3

9.2

0.1

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

1,784

1,928

2,050

2,199

2,272

2,256

2,235

2,143

2,103

2,153

2,268

2,745

2,895

2,975

3,305

5.7

5.5

5.9

5.6

5.9

5.7

6.4

6.1

7.0

6.8

6.9

6.8

6.9

6.7

6.6

6.6

6.5

6.4

6.4

6.4

6.6

6.5

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

1,295

1,412

1,506

1,635

1,729

1,700

1,661

1,554

1,500

1,514

1,617

2,153

2,263

2,324

2,609

0.20

72.6

15.4

:

22.0

0.24

73.2

15.3

98.3

21.3

0.23

73.5

15.4

:

21.0

0.26

74.4

15.3

:

21.0

0.26

76.1

13.8

:

19.5

0.20

75.4

13.5

:

20.7

0.17

74.3

12.6

99.9

21.1

0.10

72.5

12.1

99.9

22.8

0.08

71.3

13.0

:

23.9

0.09

70.3

13.0

99.9

24.6

0.10

71.3

13.5

:

24.2

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

43.3

83.6

77.0

63.4

63.3

61

3.7

44.0

84.4

77.8

63.5

63.9

57

3.5

44.8

84.4

77.9

63.2

63.5

56

3.4

45.7

84.6

78.3

63.7

64.0

53

3.3

46.2

85.0

78.8

62.1

63.1

51

3.2

46.5

85.5

79.2

63.8

64.5

49

3.2

46.7

85.6

79.5

65.6

65.4

97

3.1

46.8

85.5

79.5

65.8

64.8

95

3.1

46.7

86.1

80.2

63.9

64.7

91

2.7

46.5

86.2

80.4

65.0

65.0

89

2.8

46.4

85.8

80.1

64.1

63.9

88

2.7

Composition of total current expenditure as % of GDP

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

1.7

0.2

2.5

1.6

0.3

0.2

0.3

1.6

0.2

1.4

1.2

0.0

0.2

0.1

1.8

0.2

2.5

1.5

0.3

0.2

0.3

1.6

0.2

1.5

1.1

0.0

0.2

0.1

1.8

0.2

2.5

1.5

0.3

0.2

0.3

1.6

0.2

1.5

1.1

0.0

0.2

0.1

1.9

0.2

2.7

1.5

0.3

0.2

0.3

1.8

0.2

1.6

1.1

0.0

0.2

0.1

2.1

0.2

2.9

1.6

0.4

0.3

0.3

2.0

0.2

1.8

1.2

0.0

0.3

0.2

2.1

0.2

2.9

1.6

0.4

0.2

0.3

2.0

0.2

1.8

1.2

0.0

0.2

0.1

2.2

0.2

2.9

1.6

0.4

0.2

0.3

2.0

0.2

1.8

1.2

0.0

0.2

0.1

2.2

0.2

2.9

1.6

0.4

0.2

0.3

2.0

0.2

1.8

1.0

0.0

0.2

0.1

2.1

0.2

2.9

1.7

0.4

0.2

0.3

2.0

0.2

1.7

1.0

0.0

0.2

0.1

2.2

0.2

2.9

1.6

0.4

0.2

0.3

2.0

0.2

1.7

1.0

0.0

0.2

0.1

2.2

0.2

3.0

1.7

0.4

0.2

0.3

2.1

0.2

1.7

1.0

0.0

0.2

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

r

E
u
o
p
e
a
n
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s
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i
o
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i

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o
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t
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e
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o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

l

S
u
s
t
a
n
a
b

i

i
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t
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-

C
o
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n
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r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 2.26.2:  Statistical Annex - continued - Spain 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

22.4%

2.0%

32.6%

20.7%

3.3%

2.5%

3.3%

28.4%

2.7%

26.1%

21.0%

0.4%

3.3%

2.2%

2005

0.81

:

:

:

:

:

11.9

2005

357

439

72

267

2005

:

11

:

79.0

6.7

:

2016

5.9

5.9

2016

46.4

2006

22.6%

1.9%

32.5%

19.6%

3.5%

2.4%

3.4%

28.6%

2.7%

26.2%

19.9%

0.4%

3.4%

2.1%

2006

0.88

:

:

:

14.9

26.4

11.9

2006

365

449

73

263

2006

8.1

11

2007

22.6%

1.9%

32.4%

19.0%

3.8%

2.6%

3.4%

28.6%

2.6%

26.5%

19.3%

0.4%

3.3%

2.3%

2007

0.93

:

:

:

:

:

11.1

2007

359

464

70

262

:

11

2007

2008

3,026

4,382

78.0

6.6

22.0

2020

6.0

6.1

2020

46.6

78.2

8.2

29.1

2025

6.2

6.4

2025

46.8

2008

23.3%

2.1%

32.4%

18.5%

4.0%

2.4%

3.3%

29.5%

2.6%

26.9%

18.7%

0.3%

3.3%

2.1%

2009

23.4%

2.0%

31.7%

18.2%

3.9%

2.8%

3.3%

29.2%

2.7%

26.3%

18.3%

0.3%

3.7%

2.4%

2008

2009

:

:

:

:

15.7

25.2

10.2

:

:

:

:

15.7

26.2

10.0

2010

23.1%

2.0%

31.8%

18.2%

4.1%

2.3%

3.0%

29.0%

2.7%

26.1%

18.4%

0.3%

3.1%

2.1%

2010

1.21

0.5

1.6

0.1

:

:

9.8

2011

23.9%

2.0%

31.7%

17.8%

4.0%

2.2%

3.2%

30.1%

2.7%

26.4%

17.1%

0.3%

3.0%

2.1%

2011

1.39

0.5

1.7

0.1

16.6

23.9

9.6

2012

23.8%

2.0%

32.1%

17.6%

4.0%

2.1%

3.0%

30.7%

2.7%

26.7%

15.9%

0.3%

2.9%

2.1%

2012

1.48

0.6

1.7

0.1

..

:

9.3

2013

23.4%

2.0%

31.7%

18.6%

4.1%

2.0%

3.0%

30.9%

2.8%

26.7%

15.9%

0.2%

2.8%

2.2%

2013

1.53

0.6

1.8

0.2

:

:

9.3

2014

24.0%

2.0%

32.0%

18.0%

4.3%

2.0%

2.9%

31.3%

2.8%

26.6%

15.7%

0.3%

2.8%

1.9%

2014

1.55

0.6

1.8

0.2

16.2

23.0

:

2015

23.8%

2.1%

32.2%

18.0%

4.3%

2.0%

2.8%

31.8%

2.9%

26.6%

15.1%

0.3%

2.8%

2.0%

2015

1.59

0.6

1.8

0.2

:

:

:

EU- latest national data

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2009

2011

2013

2015

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

358

486

73

258

:

11

:

77.7

8.1

:

2030

6.4

6.6

2030

47.1

363

500

74

255

2009

7.5

10

380

521

75

251

2010

:

10

388

528

75

246

2011

7.4

10

382

524

75

238

381

514

75

236

2012

2013

:

10

:

10

380

515

75

237

2014

7.6

10

385

529

75

241

2015

:

10

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

5,784

6,206

4,069

7,216

6,465

8,001

8,054

6,362

6,584

77.6

8.0

35.7

2035

6.5

6.9

2035

47.6

76.4

7.9

37.7

2040

6.7

7.1

2040

48.2

75.4

7.7

28.7

2045

6.8

7.2

2045

48.9

75.8

7.6

42.1

2050

6.8

7.3

2050

49.3

75.8

7.6

39.4

2055

6.8

7.4

2055

49.5

75.7

7.4

44.1

2060

6.7

7.3

2060

49.6

75.8

7.3

44.2

2065

6.6

7.2

2065

49.6

77.1

8.0

28.0

2070

6.4

7.1

2070

49.8

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Spain

0.5

1.2

EU

0.9

1.6

Change 2016-2070, in %

Spain

7.3

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

H
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a

2
6
9

2
.
2
6
.

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p
a
n

i

r

l
t
h
c
a
e
s
y
s
t
e
m

s

 
 
 
 
 
 
 
   
 
 
 
2.27. SWEDEN 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  country  statistics:  GDP,  GDP  per 
capita; population 

Sweden  had  a  population  of  almost  9.9  million 
inhabitants  in  2016,  which  is  expected  to  reach 
13.9 million in 2070. This is a 40% increase that is 
contrast  with  the  2%  overall  increase  in  the  EU 
over  this  period.  With  a  GDP  of  more  than  €449 
billion,  or  33,700  PPS  per  capita,  it  is  above  the 
EU average of 29,600 PPS per capita in 2015.  

Total and public expenditure on health as % of 
GDP 

Total expenditure (404) on health as a percentage of 
GDP  (11.6%  in  2015)  is  above  the  EU  average 
(405) (10.2%). It has grown gradually from 8.7% in 
2005,  although  it  has  been  relatively  flat  since 
2012  (406).  Public  expenditure  on  health  as  a 
percentage of GDP is, at 9.6% in 2015 also above 
the  EU  average  of  8%.  Looking  at  health  care 
without  long-term  care  (407)  reveals  a  different 
picture,  with  public  spending  at  the  EU  average 
(6.9% vs 6.8% in 2015). 

Total  (4,314  PPS  in  2015)  and  public  (3,580  PPS 
in  2015)  per  capita  expenditure  is  above  the  EU 
average  (3,305  PPS  and  2,609  PPS  in  2015), 
having  consistently  increased  since  2005  (2,514 
PPS  and  1,985  PPS).  Again,  this  is  likely  to  be 
influenced  by  the  costs  of  LTC,  which  underlines 
the  importance  of  considering  this  when  making 
cross-country comparisons.  

(404) Data on health expenditure is taken from OECD health data 
and  Eurostat  database.  The  variables  total  and  public 
expenditure  used  here  follow  the  OECD  definition  under 
the  System  of  Health  Accounts  and  include  HC.1-HC.9  + 
HC.R.1. 

(405) The  EU  averages  are  weighted  averages  using  GDP, 
population, expenditure or current expenditure on health in 
millions  of  units  or  units  of  staff  where  relevant.  The  EU 
average  for  each  year  is  based  on  all  the  available 
information in each year. 

(406) Please note that there was a break in the series in 2011. 
(407) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 

270 

Expenditure projections and fiscal sustainability  

As a result of ageing ( 408), health care expenditure 
is projected to increase by 0.7 pps of GDP (much 
below  the  average  change  in  the  EU  of  0.9  pps). 
Good  health  (translated  by  a  constant  health 
scenario)  could  reduce  the  projected  expenditure 
increase  to  zero,  highlighting  the  importance  of 
improving health behaviour. 

Fiscal  sustainability  risks  appear  to  be  low  in 
Sweden over the low, medium and long-term (409). 

Health status  

Life  expectancy  (84.1  years  for  women  and  80.4 
years  for  men  in  2015)  is  above  the  EU  average 
(83.3  and  77.9)  and  among  the  highest  in  the 
world.  Healthy  life  years  (73.8  years  for  women 
and 74 for men in 2015) are above the EU average 
(63.3 and 62.6 respectively).  

two  major  causes  of  death 

There  are 
in 
Sweden (410).  Mortality  and  morbidity  due  to 
diseases  of 
the  circulatory  system  has  been 
significantly  reduced  during  the  last  30  years  and 
this is one of the  major causes contributing to the 
rise  in  life  expectancy  but  they  are  still  the  most 
common cause of death for both women and men, 
being  the  underlying  cause  in  37%  of  all  deaths 
among  women and 36% of all deaths among  men 
in 2014.  

The  second  most  common  cause  of  death  is 
neoplasm  (cancer),  corresponding  to  23%  of  all 
deaths  among  women  and  27%  among  men  in 
2014.  

Alzheimer's  and  other  dementia  conditions  have 
taken the place of stroke in the top three causes of 
death  in  Sweden.  To  some  extent  this  reflects  the 
in 
ageing  of 
diagnosis  of  these  conditions  but  not  in  terms  of 

the  population, 

improvements 

(408) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(409) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(410) State of Health in the EU: Sweden Country Health Profile 
2017,  European  Commission,  OECD  and  European 
Observatory on health systems and policies. 

https://ec.europa.eu/health/sites/health/files/state/docs/chp_sv_e

nglish.pdf. 

 
                                                           
                                                           
 
effective  treatments  to  cure  them  as  well  as  more 
precise coding as cause of death. 

System characteristics  

financing, 

System 
collection 
mechanism,  coverage  and  role  of  private 
insurance and out of pocket co-payments 

revenue 

is  defined  by 

the  county  councils  and 

The  level  of  taxes  to  be  earmarked  to  the  health 
sector 
the  central  government 
(general  taxation),  the  county  councils  or  regions 
(county  council  taxation)  and  the  municipalities 
(for  local  taxes).  The  Parliament,  the  central 
government, 
the 
municipalities  set  the  public  budget  for  health,  in 
each  respective  responsibility.  The  funds  to  be 
allocated 
type  of  care  are 
determined  by  the  counties  or  regions  and  the 
municipalities 
respective 
their 
responsibilities.  Hospitals 
autonomy to recruit medical staff and other health 
professionals  and  negotiate  salaries.  The  Ministry 
of Social Affairs and Health defines general policy 
guidelines and regulation. 

to  each  sector/ 

then  exercise 

given 

their 

the 

This  suggests  a  rather  complex  and  decentralised 
decision  making  and  resource  allocation  process, 
within  a  nationally  agreed  regulatory  framework 
but in the presence of a not explicitly defined basic 
benefit  package.  Nevertheless, 
level  of 
expenditure  in  administering  such  a  system  is  not 
high. Public (0.17%) and total (0.19%) expenditure 
on health administration and health insurance as a 
percentage  of  GDP  is  below  the  EU  average 
(0.26%  and  0.38%  respectively  in  2015),  as  is 
health 
public 
a 
as 
administration 
percentage of current health expenditure (1.7% and 
1.8%  vs.  3.8%  and  3.4%  in  2015),  falling  behind 
by a substantial margin as well. 

total 
and  health 

on 
insurance 

expenditure 

and 

This  decentralised  tradition  has  however  also  led 
to  regional  differences  in  terms  of  cost-sharing, 
type  of  treatment,  access  to  new  medicines  and 
inequalities in avoidable care and mortality. These 
regional  differences  as  well  as  care  coordination 
difficulties  between  counties  and  municipalities 
and  access  to  health  care  have  been  the  focus  of 
debate in the 2000s (411).  

(411) WHO/Europe (2012b). 

Health care systems 

2.27. Sweden 

Interestingly,  while  in  the  1990s  mostly  county 
councils  were  using  a  purchaser-provider  split, 
they  now  appear  to  have  gone  back  to  the  more 
and 
traditional  way 
administration.  In  some  counties  there  has  been  a 
move 
integrating  each  hospital  with 
primary care and municipal services. 

provision 

towards 

public 

of 

There is a strict health budget defined annually by 
regions  and  for  different  health  services.  Budget 
deficits in the sector have occurred in the past and 
have  resulted  in  several  cost-containment  policies 
and stricter budget rules ( 412). 

organisation: 

Administrative 
of 
government, levels and types of social security 
settings 
involved,  other 
institutions 

involved,  Ministries 

levels 

On  the  basis  of  legal  provisions  (harmonised 
the 
legislation  and  guidelines)  and  under 
supervisor  role  of  the  Government  through  the 
Ministry  of  Health  and  Social  Affairs,  the  county 
councils  or  regions  and  the  municipalities  are 
responsible for providing or funding a  wide range 
of  health-related  services.  Regionally  organised 
services  include  primary,  specialist  outpatient  and 
hospital care, health promotion, disease prevention 
and rehabilitation. 

Coverage (population) 

A  regionally  based  National  Health  Service 
(NHS),  funded  by  taxes  (central,  county  and 
municipal  taxes),  provides  universal  population 
coverage. 

To improve access and reduce the waiting times to 
health  care,  the  national  time  guarantee  for  care 
(i.e.  care  must  be  provided  within  3  months)  has 
been sharpened. The government has also invested 
SEK 2 billion between 2015 and 2018 to increase 
access to cancer care. The funds have been used to 
stimulate 
implementation  of  standardised 
patient pathways in cancer care. This builds on the 
Danish example with specially designed tracks for 
different kind of cancers.  

the 

(412) According  to  the  OECD,  Sweden  scores  6  out  of  6  in  the 
OECD  scoreboard  due  to  the  very  stringent  budget 
controls. 

271 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Hence,  some  efforts  to  improve  access  may  help 
explain the increase in public and total expenditure 
observed  since  2012  though  it  does  not  appear  to 
be the main explanation. 

Role  of  private  insurance  and  out  of  pocket 
co-payments 

care, 

dental 

dental 

prostheses 

Most  services  (primary,  outpatient  specialist  care, 
hospital  day  care  and  inpatient  care,  dental  care, 
physiotherapy)  involve  a  co-payment  at  the  point 
of  use.  This  fee  may  vary  across  services  and 
across  counties  or  regions.  In  addition,  eyeglasses 
and  contact  lenses  are  not  funded  or  provided  by 
counties  or  regions  and  high  cost-sharing  applies 
to 
and 
pharmaceuticals. It is not clear whether the current 
cost-sharing  design  induces  a  greater  use  of  more 
cost-effective  services  (e.g.  primary  care  vs. 
specialist  care  when 
is  not  necessary). 
Children,  those  with  certain  medical  conditions 
and those who have reached an upper limit for out-
of-pocket  payments  are  exempted  from  cost-
sharing. 
buys 
supplementary  private  insurance  (to  cover  the 
services not covered by public provision/ funding). 
In  2015,  private  expenditure  and  out-of-pocket 
expenditure  were  17%  and  15.2%  of  total  health 
expenditure  and  therefore  respectively  below  and 
above the EU average (21.6% and 15.9%).  

population 

2.3% 

this 

the 

of 

Types of providers, referral systems and patient 
choice 

As  care  provision  is  defined  at  the  county  level, 
there  are  some  differences  in  the  way  the  various 
types  of  care  are  organised.  In  general,  primary 
care  is  provided  by  general  practitioners  (GPs)  in 
public  health  centres  while  outpatient  specialist 
care  is  provided  in  outpatient  departments  in 
public  hospitals.  There  are  102  hospitals 
in 
Sweden,  many  of  which  are  local  hospitals  with 
limited  specialisation,  some  of  which  are  regional 
hospitals  offering  a  wider  range  of  specialties.  In 
addition,  7  are 
regional  highly  specialised 
university  hospitals.  About  98%  of  all  hospital 
beds  are  public.  Provision  has  traditionally  been 
public  but  private  provision  notably  in  terms  of 
private  primary  care  providers,  with  whom  the 
councils  or  regions  establish  contracts,  has  been 
encouraged.  Some  hospitals  are  run  by  private 
companies but are financed by public funds. There 
are also some private practices of physiotherapists 

272 

or  psychiatric  care.  Private  provision  is  more 
common  in  densely  populated  urban  areas.  Still, 
dual  practice  of  private  physicians  should  be  of 
minor significance, since private practitioners who 
are  reimbursed  according  to  a  national  tariff  are 
prevented  by  law  to  also  occupy  public-sector 
employment. 

The  number  of  practising  physicians  per  100  000 
inhabitants (419 in 2014) is above the EU average 
(343  in  2014)  and  showing  a  consistent  increase 
since 2005 (352). The number of GPs per 100 000 
inhabitants  (65  in  2014)  is  below  the  EU  average 
(79 the same year), but showing a gradual increase 
from  2005.  The  number  of  nurses  per  100  000 
inhabitants  (1,114  in  2014)  is  well  above  the  EU 
average (829 in the same year) having consistently 
increased  throughout  the  decade.  The  authorities 
acknowledge  shortages  of  physicians  in  some 
specialties and in some counties. In particular, they 
acknowledge a general shortage of GPs, especially 
significant  in  certain  municipalities,  which  results 
in  longer  waiting  times  to  see  a  GP.  As  a 
consequence, patients tend to see specialists or go 
to emergency care directly but unnecessarily. This 
has  forced  some  counties  to  recruit  GPs  from 
abroad or pay higher wages, increasing the costs of 
health  care  delivery.  The  government  have 
invested  several  billion  SEK  the  past  years  to 
strengthen  the  provision  of  skills  in  health  care. 
The funds can e.g. be used to improve the skill mix 
in health care. Staff supply is regulated in terms of 
quotas  for  medical  students  and  by  speciality  but 
not  in  terms  of  the  location  of  physicians,  which 
may help explain the disparities in staff availability 
across counties or regions. 

The  number  of  acute  care  beds  per  100  000 
inhabitants  (226  in  2015)  is  far  below  the  EU 
average  of  402  in  2015,  displaying  a  decreasing 
trend over the last decade and is one of the lowest 
in  the  EU  ( 413).  However,  structural  differences 
have to be taken into account when analysing these 
figures.  For  instance,  the  "Ädel-reform"  of  1992 
transferred  the  responsibility  for  those  considered 
the  social  care  sector 
medically 
(especially  the  elderly,  who  instead  receive  social 
care  in  the  elderly  care  sector),  which  had  a 
significant impact on demand for health care beds. 
In  addition,  the  average  length  of  stay  has  been 

treated 

to 

(413) This phenomenon has intensified in the last few years and 

the latest figures show even lower bed numbers.  

 
                                                           
Health care systems 

2.27. Sweden 

effectively  shortened  in  Sweden  by  utilising  open 
specialised care to a larger extent than previously. 
Still,  in  some  areas  there  may  be  a  shortage  of 
follow-up/long-term  care  beds/  facilities  which 
creates  bed-blockages  in  acute  care  (unnecessary 
and  long  use  of  acute  care  beds)  and  may 
contribute  to  longer  waiting  times  for  surgery. 
While  counties  or  regions  plan  for  the  number  of 
hospitals  and  the  provision  of  specific  specialised 
services, there appears to be no regulation in terms 
of  the  number  of  beds  or  the  supply  of  high  cost 
equipment  capacity,  which  may  explain  county/ 
regional  and  even  hospital  differences  in  the 
numbers of units of high-cost equipment. Hospitals 
have  autonomy  to  recruit  medical  staff  and  other 
health  professionals  and 
their 
remuneration level. 

to  determine 

increase  hospital 

the  way  surgical 

throughput/efficiency  by 
to 
improving 
treatments  are 
conducted (i.e. more use of day case surgery) and 
by  providing  alternative  care  services  for  long--
term care patients in particular psychiatric patients. 
These  figures  may  explain  why  waiting  times  for 
elective surgery may be deemed long.  

The market for pharmaceutical products 

Total  (1.1%)  and  public  (0.6%)  expenditure  on 
pharmaceuticals as a percentage of GDP (415) was 
below the EU average (respectively 1.4% and 1%) 
in  2015.  This  is  similar  for  total  (9.8%  vs.  the 
average  of  14.6%  in  2015)  and  public  (6.1%  vs. 
EU  average  12.7% 
in  2015)  pharmaceutical 
expenditure  as  a  percentage  of  total  and  public 
current health expenditure respectively.  

Pricing,  purchasing  and  contracting  of 
remuneration 
healthcare 
mechanisms 

services 

and 

Salaries  for  public  sector  physicians  (GPs  and 
specialists)  are  determined  at  hospital 
level. 
Physicians  appear  not  to  be  eligible  to  receive 
bonuses  regarding  their  activity  or  performance 
(414). It would perhaps be interesting to investigate 
if  an  element  of  performance-based  payment 
related  to  health  promotion,  disease  prevention  or 
disease  management  actions  or 
treatment  of 
vulnerable  patients  by  GPs  could  be  used  more 
widely,  to  render  primary  care  more  attractive  in 
general  and  in  the  regions  where  the  more  severe 
shortages are felt in particular. 

looking  at  hospital  activity, 

When 
inpatient 
discharges - per 100 inhabitants - are below the EU 
average (14.1 vs. 16.2) and the number of day case 
discharges is well below the EU average (1,364 vs. 
7,635 
in  2015).  The  proportion  of  surgical 
procedures  conducted  as  day  cases  (8.6%)  is  far 
below  the  EU  average  (32.3%  in  2015).  Overall 
hospital average length of stay (5.9 days in 2015) 
is  also  below  the  EU  average  (7.6  days  in  2015). 
These figures suggest that there may be some room 

(414) As  for  the  private  practitioners,  they  are  reimbursed 
according  to  a  national  tariff,  and  thus  compensated  on  a 
fee- for-service basis. A small portion of the private health 
care  production 
fact  conducted  by  private 
practitioners.  Other  private  health  care  production  is 
instead  based  on  local  contractual  arrangements  where 
decisions on doctors' payment in large are decentralised to 
the private healthcare provider. 

in 

is 

When  it  comes  to  the  out-patient  sector,  the 
authorities  have  implemented  several  policies  to 
control expenditure on pharmaceuticals. There is a 
positive  list  of  reimbursed  products.  Decisions  on 
pricing  and  reimbursement  of  pharmaceuticals 
need to be in-line with the ethical platform, which 
is  legislated  and  applies  to  all  prioritising  of 
publicly  funded  health  care  in  Sweden.  The  three 
principles: the human value principle, the need and 
the  cost-effectiveness 
solidarity  principle  and 
principle.  Managed  Entry  Agreements  between 
pharmaceutical companies and county councils are 
used  for  some  products  to  dampen  the  cost  and 
provide  better  conditions  for  early  and  equal 
access. Authorities promote rational prescribing of 
physicians 
treatment  and  prescription 
guidelines  complemented  with  monitoring  of 
prescribing 
and 
information campaigns on the prescription and use 
of  medicines.  There  are  monthly,  quarterly  and 
annual  evaluations  at  county  council  level  on 
prescriptions  and  co-payments  and  physicians 
feedback.  These  are  coupled  with 
receive 
pharmaceutical  budgets  at  county  level.  Patients 
pay  the  full  price  up  to  a  certain  cost  level 
(SEK 1125),  after  which  there  are  some  stepwise 
reductions  in  the  additional  costs.  In  a  year  the 
maximum  amount  a  patient  can  pay 
in 
reimbursable  medicines  is  SEK 2300.  There  is  an 

behaviour 

education 

through 

and 

(415) Expenditure  on  pharmaceuticals  used  here  corresponds  to 
category HC.5.1 in the OECD System of Health Accounts. 
Note 
records 
pharmaceuticals  in  ambulatory  care  (pharmacies),  not  in 
hospitals. 

this  SHA-based  estimate  only 

that 

273 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

explicit generics policy. Generic substitution takes 
place  i.e.  pharmacies  are  obliged  to  dispense  the 
cheaper product and to replace the prescription by 
a  generic  medicine  when  available.  If  patients 
refuse  a  generic  they  will  have  to  pay  the 
difference between the reimbursement price of the 
branded drug and the pharmacy retail price of the 
cheapest  available  generic.  Moreover,  this  cost  is 
deemed  extra  and  will  not  be  considered  in  the 
computation  of  the  maximum  costs  a  patient  can 
incur in a  year on  medicines. Generics  face a  fast 
track registration and speedy decision. 

recent years. Promotion and prevention are seen by 
the  authorities  as  a  means  to  ensure  long-term 
sustainability of the health budget: they reduce the 
development of disease and therefore the need for 
care and therefore the need for funding. Public and 
total  expenditure  on  prevention  and  public  health 
services  as  a  %  of  GDP  are  both  above  the  EU 
average (0.17% and 0.26% in 2015). Similarly, as 
a % of total current health expenditure, both public 
and  total  expenditure  on  prevention  and  public 
health  services  are  higher  than  the  EU  average 
1.8% for both vs. 3.4% in 2015).  

Use  of  Health  Technology  Assessments  and 
cost-benefit analysis 

Recently 
reforms  

legislated  and/or  planned  policy 

The  Swedish  Council  on  Health  Technology 
Assessment  conducts  and  gathers  information  on 
technology  assessment  and  conducts 
health 
economic 
cost-effectiveness 
analysis  which  is  used  to  define  whether  new 
medicines are covered by the health system and to 
what extent (level of reimbursement) as well as to 
define clinical guidelines for medicines. 

evaluation 

and 

Health  and  health-system 
reporting mechanisms 

information  and 

Sweden  has  extensive  information  management 
and  statistics  systems  and  comprehensive  data  is 
gathered  on  physician  and  hospital  activity  and 
quality  and  health  status.  Data  is  provided  at 
county/  region  and  municipal  level  and  compiled 
by  the  Swedish  Association  of  Local  Authorities 
and  Regions  (SALAR)  together  with  the  National 
Board  of  Health  and  Welfare.  Some  of  this 
information  is  published,  and  allows  for  public 
comparisons  of  counties/  regions  and  hospitals  in 
terms  of  both  activity  and  quality.  Physicians  are 
monitored  and  are  given  feedback  on 
their 
prescription behaviour. 

Public 
prevention policies 

health  promotion  and  disease 

The  central  Government,  through  the  Ministry  of 
Health and Social Affairs, sets and monitors public 
health priorities in terms of process, outcomes and 
the  reduction  of  health  inequalities.  As  section  1 
suggests  there  are  some  risk  factors  that  can 
translate  into  an  important  burden  of  disease  and 
financial costs. Authorities have emphasised health 
promotion  and  disease  prevention  measures  in 

274 

Recent policy response 

In  an  effective  healthcare,  patients  receive  care  at 
the  right  level.  The  structure  in  Swedish  health 
care has been a contributing  factor to inefficiency 
in the healthcare system. There has therefore been 
a need for profound structural changes in all levels 
of health care, and primary care has been needed to 
be  strengthened.  Less  focus  should  be  put  on 
hospital  care.  Primary  care  should  be  the  natural 
first  choice  for  anyone  seeking  care,  especially 
when in need for regular care contacts. To this end, 
primary care must be changed and be able to meet 
the  challenges  it  faces,  including  a  demographic 
development  with  an  aging  population  and 
increasing  numbers  of  people  living  with  chronic 
diseases.  In  order  to  achieve  increased  quality, 
better  accessibility  and  more  efficient  use  of 
resources, changes in the structure and the way of 
organising  care  are  being  put  forward.  The 
foundation is a good and close care that is based on 
the  patient's  needs.  The  “health  care  guarantee” 
has  also  been  strengthened,  as  stated  above.  The 
government  has  also  proposed  a  new  provision  in 
the Health Care Act regarding how the health care 
is organised. The Swedish parliament thas enacted 
this provision into new legislation. 

Furthermore,  the  government  has  taken  steps  to 
concentrate  highly  specialised  care on  fewer  units 
in the country. This type of care can be developed 
to  give  patients  access  to  a  more  equal  and  safe 
care  of  good  quality  regardless  of  their  place  of 
residence.  The  National  Board  of  Health  and 
Welfare  has  been  commissioned  to  lead  the  work 
with concentrating highly specialised health care. 

 
Health care systems 

2.27. Sweden 

appointed concerning how the coordination can be 
strengthened around the health around the children 
and the youth.  

The right to a permanent medical doctor should be 
secured.  It  should  become  more  attractive  for 
physicians  to  work  in  primary  care  and  thereby 
increasing  accessibility  and  freedom  of  choice.  It 
should  be  easier  to  be  care  provider  in  rural  parts 
of Sweden. 

A long-term plan for national coordination of skills 
supply in health care is implemented.  

Psychiatry  and  school  health  care  should  be 
strengthened.  A  public  inquiry  will  be  appointed 
into  how  to  create  a  new  type  of  care  where 
patients is provided help quicker for lighter forms 
of mental illnesses.  

Challenges 

the 

reduction  of  waiting 

The  analysis  above  has  shown  that  a  range  of 
reforms has been implemented in recent years.  For 
times, 
example, 
improvements  to  hospital  efficiency,  improved 
data  collection  and  monitoring  and  the  control  of 
pharmaceutical expenditure, some to a large extent 
successful,  and  which  Sweden  should  continue  to 
pursue.  The  main  challenges  for  the  Swedish 
health care system are as follows:  

A  top  priority  for  the  government  has  been  to 
strengthen the position of patients and to stimulate 
patient  engagement.  Taking  advantage  of  the 
opportunities provided by digitalisation, improving 
quality  registers,  strengthening  women’s  health 
and  maternity  care  have  been  other  important 
reform areas. 

Six  regional  cancer  centres  were  established  in 
2010. They work across counties to develop cancer 
care. This model is now serving as an example of 
how to improve care also for other patient groups.  

Policy changes under preparation/adoption 

A  primary  objective  of  the  Swedish  health  care 
system  is  the  provision  of  high-quality  care  on 
equal terms, irrespective of the person receiving it. 
Reception, care, and treatment shall be offered on 
equal  terms  to  everybody  –  irrespective  of  age, 
gender,  sexual  orientation,  disability,  place  of 
residence, education, social status, country of birth 
or religious beliefs. Equality and equity of care are 
at  the  very  heart  of  the  Swedish  Health  and 
Medical Services Act.   

A  new  government  took  office  in  Sweden  at  the 
end of January 2019. In the agreement between the 
new 
parliamentary 
government  there  are  several  points  concerning 
health care.  

supporting 

parties 

the 

An  updated  queue  billion  is  introduced  covering 
the entire care chain, taking special account of the 
needs of chronically ill patients. A master plan for 
shortening  queues  will  be  produced  together  with 
the  county  councils.  Ambulance  care,  cancer  care 
and maternity care should be strengthened. 

The system with patient contracts will continue to 
be  implemented.  The  aim  is  that  people  should 
know  who  to  contact  in  health  care  and  what  the 
plan for your treatment looks like.  

Transparency and follow-up regarding information 
on waiting times, availability and quality in health 
care  should 
to 
information  and  the  right  to  choose  should  be 
protected and developed.  

increase.  The  patients  right 

The  responsibility  for  children’s  health,  from 
maternity  care  until  18  years  old  need  to  be 
coordinated  better.  A  public  inquiry  is  to  be 

•  To ensure the coherence of resource allocation 
to  different  types  of  care  in  different  regions 
and 
controlling 
for 
mortality/morbidity 
the 
population. 

demographic 
characteristics  of 

•  To  ensure  consistency  in  access  to  health  care 
in different regions, ensuring that different fees 
and  remuneration  mechanisms  do  not  impact 
on the health outcomes of the population.  

•  More  generally,  to  develop  a  comprehensive 
human  resources  strategy  that  tackles  current 
shortages  in  primary  care  staff  and  ensures 
sufficient numbers of staff in general and in the 
future in view of staff and population ageing. 

•  To  enhance  primary  care  provision  by 
increasing the numbers and spatial distribution 
of  GPs  and  primary  care  nurses.  To  couple 

275 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

care 

either 

through 

takes  place)  or  by  making 

these  measures  with  a  referral  system  to 
specialist 
financial 
incentives  (reimbursement  levels  higher  if  a 
it 
referral 
compulsory.  At  the  same  time  exploring  if 
current  cost-sharing  arrangements  can  be 
adjusted to render primary care more attractive. 
This  could  improve  access  to  care  while 
reducing  unnecessary  use  of  hospital  care  and 
therefore overall costs.  

•  To  increase  hospital  efficiency  by  increasing 
the  use of day case surgery and increasing  the 
supply  of  follow-up  care  for  long-term  care 
patients so as to reduce the unnecessary use of 
acute  care  settings  for  long-term  care  patients, 
notably psychiatric patients. To consolidate the 
measures  pursued  in  recent  years  to  reduce 
duplication and improve efficiency and quality 
in  the  hospital  sector  (e.g.  concentration  and 
specialisation  of  hospitals  within  regions), 
notably  through  the  finalisation  of  the  current 
administrative reform.  

•  To  ensure  a  greater  use  of  health  technology 
assessment 
to  determine  new  high-cost 
equipment  capacity  as  well  as  the  benefit 
basket  and  the  cost-sharing  design  across 
medical interventions as is currently done with 
medicines.  

•  To  consider  whether  it  is  worth  introducing 
some  element  of  performance  related  payment 
in  physicians'  remuneration  (e.g.  through  the 
use  of  mixed  payment  schemes)  to  encourage 
health  promotion,  disease  prevention  and 
disease management activities or the treatment 
of  vulnerable  populations 
increase 
outpatient output. 

and 

•  To  take  into  account  the  potential  drivers  of 
fiscal  sustainability  particularly  with  ageing 
potentially 
healthcare 
increasing 
spending in the long-run. 

public 

276 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.27.1:  Statistical Annex - Sweden 

General context

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.

System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source: EUROSTAT, OECD and WHO. 

2
7
7

2005

313

32.3

2.4

:

2006

335

34.0

4.1

2.5

2007

356

35.7

2.6

1.9

2008

352

34.2

-1.3

2.0

2009

310

30.5

-6.0

1.1

2010

369

31.8

5.1

0.4

2005

2006

2007

2008

2009

2010

8.7

8.3

0.4

8.6

8.2

0.4

8.5

8.1

0.4

8.8

8.3

0.5

9.4

8.9

0.5

9.0

8.5

0.5

2011

405

32.6

1.9

27.2

2011

11.3

10.7

0.6

2012

423

33.0

-1.0

1.0

2012

11.5

10.9

0.6

2013

436

32.5

0.4

1.8

2013

11.7

11.1

0.6

2014

433

32.6

1.6

2.0

2014

11.7

11.1

0.6

2015

449

33.7

3.4

2.3

2015

11.6

11.0

0.6

EU- latest national data

2009

12,451

2011

13,213

2013

13,559

2015

14,447

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

28.0

0.1

0.2

2013

10.1

9.9

0.2

29.6

2.0

4.1

2015

10.2

9.9

0.3

2,443

2,562

2,688

2,726

2,555

2,883

3,918

4,150

4,297

4,246

4,314

2,745

2,895

2,975

3,305

7.1

6.8

7.0

6.7

6.9

6.6

7.2

6.8

7.7

7.3

7.4

7.0

9.4

9.0

9.6

9.1

9.7

9.3

9.7

9.3

9.6

9.2

8.0

7.7

7.8

7.6

7.8

7.6

8.0

7.8

1,985

2,081

2,187

2,223

2,086

2,349

3,276

3,454

3,571

3,514

3,580

2,153

2,263

2,324

2,609

0.29

81.3

12.7

100.0

17.1

0.27

81.2

12.9

100.0

17.0

0.31

81.4

12.8

100.0

16.9

0.36

81.5

12.0

100.0

16.9

0.38

81.6

14.8

100.0

16.9

0.40

81.5

14.3

100.0

16.9

0.45

83.6

14.0

100.0

15.0

0.43

83.2

13.6

100.0

15.4

0.42

83.1

12.9

100.0

15.5

0.39

82.7

13.2

100.0

15.5

0.40

83.0

13.4

100.0

15.2

2005

2006

2007

2008

2009

2010

2011

9.0

82.9

78.5

63.2

64.5

57

2.4

9.0

83.1

78.8

67.5

67.3

56

2.8

9.1

83.1

79.0

66.8

67.7

53

2.5

9.2

83.3

79.2

69.0

69.4

55

2.5

9.3

83.5

79.4

69.6

70.7

52

2.5

9.3

83.6

79.6

66.4

67.0

49

2.5

9.4

83.8

79.9

65.5

67.0

106

2.1

2012

9.5

83.6

79.9

:

:

102

2.6

2013

2014

2015

9.6

83.8

80.2

66.0

66.9

102

2.7

9.6

84.2

80.4

73.6

73.6

98

2.2

9.7

84.1

80.4

73.8

74.0

97

2.5

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

EU- latest national data

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

2.3

0.2

2.9

1.2

0.3

0.3

0.1

2.3

0.2

2.2

0.7

0.1

0.2

0.1

2.3

0.2

2.9

1.1

0.3

0.2

0.1

2.2

0.2

2.2

0.7

0.1

0.2

0.1

2.2

0.2

2.9

1.1

0.3

0.3

0.1

2.2

0.2

2.2

0.7

0.1

0.2

0.1

2.2

0.2

3.0

1.1

0.3

0.3

0.1

2.2

0.2

2.3

0.7

0.1

0.2

0.1

2.4

0.2

3.2

1.2

0.3

0.3

0.1

2.4

0.2

2.5

0.7

0.1

0.3

0.1

2.3

0.2

3.1

1.1

0.3

0.3

0.1

2.2

0.2

2.4

0.7

0.1

0.2

0.1

2.3

0.2

3.1

1.1

0.3

0.3

0.1

2.2

0.2

2.4

0.6

0.1

0.3

0.1

2.3

0.2

3.2

1.1

0.3

0.3

0.2

2.3

0.2

2.5

0.6

0.1

0.3

0.2

2.3

0.2

3.2

1.1

0.3

0.4

0.2

2.3

0.2

2.5

0.6

0.1

0.3

0.2

2.3

0.2

3.3

1.1

0.3

0.3

0.2

2.3

0.2

2.5

0.6

0.1

0.3

0.2

2.3

0.2

3.2

1.1

0.3

0.3

0.2

2.2

0.2

2.5

0.6

0.1

0.3

0.2

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

H
e
a

r

l
t
h
c
a
e
s
y
s
t
e
m

s

2
.
2
7
.

S
w
e
d
e
n

 
 
 
 
 
 
 
 
 
 
 
2
7
8

Table 2.27.2:  Statistical Annex - continued – Sweden 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

27.8%

1.8%

34.9%

13.9%

3.3%

3.3%

1.1%

33.2%

2.2%

32.1%

10.5%

1.6%

3.1%

1.3%

2005

:

:

:

:

10.9

15.7

6.5

2005

352

1074

59

690

2005

2.8

15

2006

27.9%

2.0%

35.0%

14.0%

3.2%

2.9%

1.1%

33.5%

2.4%

32.5%

10.3%

1.5%

2.8%

1.3%

2006

:

0.1

:

:

9.0

15.2

6.5

2006

361

1089

61

617

2006

2.8

15

2007

27.4%

2.1%

35.6%

13.8%

3.1%

3.2%

1.4%

32.8%

2.4%

33.0%

10.1%

1.5%

3.2%

1.5%

2008

27.0%

2.2%

35.9%

13.6%

3.0%

3.4%

1.3%

32.5%

2.6%

33.4%

9.9%

1.5%

3.4%

1.5%

2009

26.8%

2.3%

35.9%

13.5%

3.0%

3.7%

1.6%

32.3%

2.7%

33.4%

9.5%

1.4%

3.7%

1.8%

2010

26.7%

2.2%

36.6%

13.3%

3.1%

3.4%

1.5%

32.2%

2.7%

34.1%

9.5%

1.4%

3.5%

1.7%

2011

21.3%

1.9%

29.1%

10.2%

2.3%

2.9%

1.2%

25.0%

2.2%

26.4%

7.1%

1.1%

2.8%

1.3%

2012

21.1%

1.9%

29.3%

10.1%

2.4%

2.9%

1.5%

24.8%

2.2%

26.8%

6.7%

1.1%

2.8%

1.6%

2013

20.8%

2.0%

29.2%

9.8%

2.4%

3.2%

1.4%

24.5%

2.3%

26.6%

6.3%

1.2%

3.1%

1.6%

2014

20.8%

1.7%

29.6%

9.8%

2.3%

3.0%

1.5%

24.5%

2.0%

27.3%

6.0%

1.1%

3.0%

1.6%

2015

20.6%

1.8%

29.2%

9.8%

2.5%

3.1%

1.7%

24.3%

2.2%

27.1%

6.1%

1.2%

3.1%

1.8%

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

EU- latest national data

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

EU- latest national data

2007

2008

2009

2010

2011

2012

2013

2014

2015

2009

2011

2013

2015

:

:

:

:

10.6

13.8

6.9

2007

369

1099

62

608

2007

2.8

15

:

:

:

:

10.3

14.6

6.9

2008

375

1102

62

559

2008

2.9

15

:

:

:

:

10.9

14.0

7.3

2009

382

1102

63

553

2009

2.9

15

:

:

:

:

11.3

13.6

7.2

2010

389

1109

63

546

2010

2.9

15

1,296

1,291

1,334

1,335

1,391

1,398

:

6.3

8.2

2016

6.9

6.9

2016

9.8

:

6.3

8.1

2020

7.0

7.1

2020

10.3

:

6.5

:

2025

7.1

7.3

2025

10.8

:

6.5

:

2030

7.2

7.5

2030

11.2

:

6.5

8.4

2035

7.3

7.7

2035

11.6

:

6.0

8.4

2040

7.4

7.8

2040

12.0

:

:

:

:

11.0

13.1

7.4

2011

397

1111

63

535

2011

3.0

:

:

:

5.9

:

2045

7.4

8.0

2045

12.3

:

:

:

:

11.8

12.8

7.2

2012

405

1114

64

528

2012

2.9

:

:

:

5.8

:

2050

7.5

8.1

2050

12.7

:

:

:

:

11.7

10.7

7.3

2013

413

1116

65

523

2013

2.9

15

:

:

:

:

13.4

11.9

7.3

2014

419

1114

65

524

2014

2.9

15

:

:

:

518

2015

2.9

14

2,038

1,392

1,364

:

5.8

12.0

2055

7.5

8.2

2055

13.0

:

5.8

8.7

2060

7.6

8.3

2060

13.3

:

5.9

8.6

2065

7.6

8.4

2065

13.6

:

:

:

:

12.3

11.2

:

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2015

2009

2011

2013

2015

324

837

77

416

2009

6.2

17

6,362

77.1

8.0

28.0

2070

7.7

8.5

2070

13.8

330

835

78

408

2011

6.2

16

6,584

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

Sweden

0.7

1.5

EU

0.9

1.6

Change 2016-2070, in %

Sweden

40.5

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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2.28. UNITED KINGDOM 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

General  statistics:  GDP,  GDP  per  capita; 
population 

In  2015,  the  UK  had  a  GDP  per  capita  of  29,112 
PPS (in thousands), slightly below the EU average 
of  29,610  PPS.  Population  was  estimated  at  64.9 
million in 2015. According to Eurostat projections, 
total  population 
is 
projected  to  increase  from  around  65.4  million  in 
2016  to  81  million  in  2070,  with  an  increase  of 
23.8%, well above EU average level of 2.0%.  

the  United  Kingdom 

in 

Total and public expenditure on health as % of 
GDP 

Total  expenditure  on  health  as  a  percentage  of 
GDP (10.2% in 2015) has increased over the past 
decade (7.6% of GDP in 2005), and is currently in 
line  with  the  EU  average  of  10.2%  for  the  same 
year. Public (total) expenditure is at 8.1% of GDP, 
in  line  with  the  EU  average  (8.0%  in  2015)  and 
similarly  it  has  increased  throughout  the  past 
decade (6.1 % in 2005). 

When expressed in per capita terms, total spending 
on health at 3,223 PPS in the UK was only slightly 
below the EU average of 3,271 PPS in 2015. The 
opposite applies to public spending on health care, 
which  was  above  the  EU  average  value  in  2015, 
with  3,041  PPS  vs.  an  average  of  2,609  PPS. 
Looking at health care without long-term care (416) 
reveals a similar picture,  with spending at the EU 
average (6.8% vs 6.8% in 2015). 

Expenditure projections and fiscal sustainability 

As a consequence of demographic changes, health 
care expenditure is projected to increase by 1.4 pps 
of  GDP,  above  the  average  growth  expected  for 
the  EU  (0.9  pps),  according 
the  "AWG 
reference scenario"(417). When taking into account 
the  impact  of  non-demographic  drivers  on  future 
spending  growth  ("AWG  risk  scenario"),  health 

to 

(416) To derive this figure, the aggregate HC.3 is subtracted from 

total health spending. 
The 

(417) See 

2018 
https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

Ageing 

Report 

at 

care expenditure is expected to increase by 2.4 pps 
of GDP from now until 2070 (EU: 1.6 pps). 

Sustainability  risks  emerge  in  the  medium  term, 
with the S1 indicator at 1.3 pps of GDP. These are 
primarily  related  to  the  current  high  level  of 
government  debt  (contributing  1.7  percentage 
points  of  GDP)  and  projected  ageing  costs  (0.7 
percentage  point  of  GDP).  The  long-term  fiscal 
sustainability  risk  indicator  S2  is  at  3%  of  GDP. 
Compounding  this  result  with  the  vulnerabilities 
linked  to  historical  behaviour,  captured  by  the 
DSA risk assessment, the United Kingdom appears 
to face high fiscal sustainability risks, also related 
to  projected  ageing  costs,  which  contribute  3.3 
percentage points of GDP (418). 

Health status 

Life expectancy at birth (82.8 years for women and 
79.2 years for men in 2015) is, respectively, below 
and above EU averages (83.3 for women and 77.9 
for  men  in  2015)  (419).  In  the  same  year,  healthy 
life years, at 63.3 years for women and 63.7 years 
for  men,  are  slightly  above  the  EU  average  for 
men, compared to, respectively, 63.3 and 62.6 for 
the EU in 2015. The infant mortality rate of 3.9‰ 
is  higher  than  the  EU  average  of  3.6‰  in  2015, 
having gradually fallen over the last decade (from 
5.1‰ in 2005). 

As  for  the  lifestyle  of  the  UK  population,  the 
proportion of regular smokers of 19.0% in 2014 is 
below the EU average (21.8% in 2013 and 20.9% 
in  2015).  Obesity  rates  in  the  population  are,  at 
19.8%  (latest  available  figure  for  2014),  well 
above the EU average of 15.4% in 2015 (15.5% in 
2013).  Alcohol  consumption  is,  at  10.7  litres  per 
capita, slightly higher than the EU average of 2015 
(10.2 litres per capita) (420). 

(418) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(419) Data on health status including life expectancy, healthy life 
years  and  infant  mortality  is  from  the  Eurostat  database. 
Data  on  life-styles  is  taken  from  OECD  health  data  and 
Eurostat database. 

(420) However  the  OECD  reports  the  UK  as  characterised  by 
levels of alcohol consumption to have increased during the 
last  30  years.  http://www.oecd.org/unitedkingdom/Health-
at-a-Glance-2015-Key-Findings-UK.pdf. 

279 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

System characteristics  

Coverage 

Services  are  free  at  the  point  of  need  to  all 
residents.  Cost-sharing  is  limited  and  applies  to 
some prescription drugs (90% of prescriptions are 
dispensed  with  no  charge),  optical  and  dental 
services.  Cost-sharing  schemes  vary  across  the 
four countries (e.g. there are no prescription fees in 
Wales  and  reduced  prescription  fees  in  Scotland). 
Eyeglasses  and  contact  lenses  are  mostly  not 
funded or provided by the NHS. Children, elderly, 
pregnant  women, 
those  with  certain  medical 
conditions,  those  with  an  income  below  a  certain 
threshold, beneficiaries of social benefits and those 
who have reached an upper limit for out-of-pocket 
payments  are  exempted  from  cost-sharing.  In 
addition,  dental  charges  are  regulated  to  limit  the 
overall  cost  of  a  course  of  treatment.  As  for 
prescriptions,  these  cost  £8.20  per  item.  It  is 
however possible to purchase coverage for all such 
costs incurred over a 3-month o 12-month period. 

Current government policy is to increase access by 
increasing  the  choice  of  primary  care  physicians 
by  extending  service  opening  hours  to  evenings 
and weekends. This is seen as a means to improve 
access  and  reduce  the  waiting  times  for  primary 
care  visits.  There  are  also  targets  to  receive 
treatment  following  a  GP  referral  (such  as  an  18-
week  target  in  England).  Patients  waiting  longer 
than 
target  were  sometimes  referred  for 
treatment  to  private  hospitals  or  hospital  abroad. 
Both 
time 
inpatient  and  outpatient  waiting 
statistics are published across the four countries in 
the  UK.  In  addition,  public  comparisons  of 
terms  of  several 
different  health  services 
performance 
to  help 
patients  exercise  choice  and 
to  encourage 
providers to improve their activities.  

indicators  are  available 

the 

in 

Surveys  show  that  patients  are  generally  satisfied 
with the NHS, especially those who have received 
NHS care.  

Administrative  organisation  and 
collection mechanism  

revenue 

The total budget of public funds to be allocated to 
the health sector is defined by the UK Parliament, 
the  UK  government  and  the  Scottish,  Welsh  and 
Northern  Ireland  governments.  Scotland,  Wales 

280 

their 

respective 

and Northern Ireland receive a funding block from 
HM Treasury and are responsible for the resource 
allocation in their respective countries. The central 
government  determines  resource  allocation  across 
countries  and  regions  based  on  demographic  and 
mortality/morbidity  data  and  historic  costs.  The 
funds  to  be  allocated  to  each  sector/  type  of  care 
are  determined  by  the  UK  government  and  the 
Scottish, Welsh and Northern Ireland governments 
given 
responsibilities.  The 
Department  of  Health  and  Social  Care  (DHSC) 
defines general policy guidelines and priorities for 
the  NHS  in  England,  to  which  it  allocates  the 
budget. DHSC uses part of the budget received by 
the Treasury to cover running costs, finance arms' 
length  bodies  and  other 
issues  of  national 
relevance  such  as  public  health.  The  rest  flows  to 
NHS  England,  responsible  for  the  national-level 
commissioning  of  a  restricted  set  of  services 
(specialised  services,  primary  care,  offender 
healthcare and some services for the armed forces) 
that allocates resources to Clinical Commissioning 
Groups  (CCGS,  formerly  PCTs),  responsible  for 
the local commissioning of healthcare services. 

The head of the DHSC, the  Secretary of  State  for 
health  responds  to  the  UK  Prime  Minister.  The 
basic benefit package is not explicitly defined but, 
the  National 
through  periodic  assessments, 
Institute for Health and Care Excellence evaluates 
some 
and 
pharmaceuticals  on  the  grounds  of  their  clinical- 
and cost-effectiveness. 

interventions,  medical 

devices 

Although data is available on public/governmental 
spending on healthcare (both through the Estimates 
process,  public  expenditure  transparency  systems 
like  OSCAR  and  through  NHS  England’s  Board 
papers),  there  is  no  Government  information  on 
total 
administration 
(incorporating  both  health  insurance  and  public 
spending).  

expenditure  on  health 

There is a strict health budget defined annually by 
country  and  for  different  health  services.  Overall 
health spending for England and the overall block 
grants to the Scotland, Wales and Northern Ireland 
are fixed in advance in spending reviews. Based on 
the  latest  announcements  in  June  2018,  a  real 
terms  increase  of  £20.5  billion  will  take  place  in 
NHS funding in England by the end of five years. 
This implies an average yearly increase in funding 
of  3.4  per  cent  in  real  terms.  The  funding  will  be 

 
front-loaded,  with  an  increase  of  £4.1  billion 
envisaged  for  2019  (a  steeper  increase  of  3.6%  is 
planned in the first two years).  

Role  of  private  insurance  and  out  of  pocket 
co-payments  

9.9%  of  the  population  buys  duplicative  private 
insurance  (to  cover  the  same  services  that  are 
publicly  provided/  funded).  In  2015,  private  and 
out-of-pocket  expenditure  were  20.5%  altogether 
and out-of-pocket alone represented 14.8% of total 
health  expenditure,  both  below  the  EU  average 
(21.6% and 15.9% in 2015). 

Types of providers, referral systems and patient 
choice 

As care provision is defined at country level, there 
are  some  differences  between  England,  Wales, 
Scotland  and  Northern  Ireland  in  the  way  care  is 
purchased and delivered.  

independent  general  practitioners 

In England, NHS Trusts (Acute Trusts, Foundation 
Trusts,  Ambulance  Trusts,  Mental  Health  Trusts, 
and Care Trusts) are responsible for providing care 
to  all  residents.  Clinical  Commissioning  Groups 
(209)  are  the  local  organisations  in  charge  of 
ensuring residents are provided much of secondary 
care.  Indeed  CCGs  control  the  large  majority  of 
the NHS budget by commissioning secondary care 
for  their  local  population  through  contracts  with 
Trusts  and  other  providers.  Primary  care, 
commissioned  by  NHS  England  (421),  is  provided 
by 
(GPs), 
dentists,  or  opticians  working  mostly  in  private 
group  practices.  NHS  walk-in  centres  provide 
primary  care  during  out-of-office  hours  as  they 
have  longer  opening  hours  than  most  independent 
GPs,  while  the  NHS  Choices  website  and  NHS 
111  phone  line  provide  information  on  health, 
allowing  people  to  conduct  an  initial  disease 
assessment  and 
information  on  health 
providers.  NHS  Foundation  Trusts  in  England 
(152) (a type of hospital with large autonomy and 
run  by  local  managers,  staff  and  the  public)  and 
NHS Trusts (88) provide outpatient specialist care 
and  day  case  and  inpatient  hospital  care.  Trusts 
oversee NHS hospitals and specialist care centres. 
Some  of  these  are  regional  or  national  centres  for 

find 

(421) CCGs  are  increasingly  being  delegated  responsibility  for 

this area. 

Health care systems 

2.28. United Kingdom 

more  specialised  care.  The  large  majority  of  all 
acute  care  hospital  beds  are  public.  Private 
provision  mostly  relates  to  common,  non-elective 
surgical  treatments  as  well  as  dental  and  optical 
care.  Salaried  public  hospital  physicians  are 
allowed to conduct private practice on a part-time 
basis but only under certain circumstances so as to 
reduce  possible  perverse  incentives  to  reduce 
public sector activity and increase demand for their 
private practice.  

of 

health 

health 

support 

community 

improvement 

Scotland,  Wales  and  Northern  Ireland  have 
different models. In Scotland, 14 NHS Boards are 
responsible for the provision of health services by 
creating 
partnerships. 
Community  health  partnerships  work  with  local 
authorities, clinical teams and the voluntary sector 
to 
local 
communities.  In  2009, 
the  Welsh  Assembly 
launched a consultation to end the internal market 
in  Wales  and  create  a  unified  health  system 
through  the  Public  health  Wales  National  Health 
Service  Trust.  This  resulted  in  the  redesign  of 
healthcare  delivery  in  Wales.  The  twenty-two 
Local  health  Boards  who  were  responsible  for 
commissioning  health  services  for  their  residents 
were  reduced  to  seven.  The  thirteen  NHS  Trusts 
that  provided  hospital  care  were  reduced  to  three. 
In  Northern  Ireland,  four  Health  and  Social 
Services Boards are responsible for commissioning 
health  services  from  a  range  of  providers.  Five 
(formerly  nineteen)  Health  and  Social  Services 
Trusts are the main service providers.  

in  2015) 

The  number  of  practising  physicians  per  100  000 
inhabitants (279 in 2015) is below the EU average 
(344 
though  showing  a  consistent 
increase since 2005 (239). The number of GPs per 
100 000 inhabitants (79 in 2015) is just above the 
EU  average  (78  in  2015).  On  the  contrary,  the 
number  of  nurses  per  100  000  inhabitants  (790  in 
2015)  is  below  the  EU  average  (833  in  2015), 
showing  a  consistent  year-on-year  reduction  since 
the peak value of 1024 in 2005.  

Changes in remuneration and wage increases have 
been  used  to  attract  licensed  but  not-practicing 
physicians  back  into  the  sector.  In  addition, 
authorities  have  hired  foreign  staff.  They  have 
used  national  procurement  to  have  more  GPs  in 
areas  where  shortages  were  perceived.  These 
suggests  the  need  to  continue  a  comprehensive 
human  resources  strategy  to  ensure  that  the  skill 

281 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

mix  goes  in  the  direction  of  a  primary  care 
oriented  provision,  which  authorities  wish  to 
pursue,  that  training,  recruitment  and  attracting 
licensed staff back into the sector can compensate 
for  staff  shortages  and  losses  due  to  retirement. 
Staff  supply  is  regulated  in  terms  of  quotas  for 
medical  students  but  not  by  speciality  or  in  terms 
of  the  location  of  physicians,  which  may  explain 
some  of  the  disparities  in  staff  availability  across 
geographic  areas.  Current  government  policy 
focuses  on  increasing  access  to  primary  care  by 
extending  service  opening  hours  to  evenings  and 
weekends. 

Authorities  have  always  strongly  encouraged  the 
use of primary care vis-à-vis specialist and hospital 
care. Patients are encouraged to register with a GP 
and  there  is  a  compulsory  referral  system  to 
specialist  and  hospital  care 
i.e.  GPs  are 
gatekeepers  to  most  (422)  specialist  and  hospital 
care.  While  choice  of  GP  has  been  limited  in  the 
past,  authorities  (old  and  new)  have  made  patient 
choice  over  primary  care  providers  a  priority  and 
as a result patient choice of GP has been increasing 
though  limited  to  a  geographic  area.  Choice  of 
specialist  and  hospital  is  allowed,  and  there  is  a 
large amount of information explaining to patients 
how to exercise their choice.  From October 2014, 
GPs  in  England  are  able  to  register  patients  from 
outside  of  their  practice  area.  Where  they  do  so, 
they are not obliged to provide home visits, out of 
hours  care.  In  these  circumstances,  responsibility 
for  ensuring  the  patient  has  access  to  urgent  care 
when away from the practice area, rests with NHS 
England. 

The  number  of  acute  care  beds  per  100  000 
inhabitants  (287  in  2006,  latest  available  value) 
seems  to  be  below  the  EU  average,  compared  to 
the EU level of 416 in 2009). Authorities indicate 
that while there are no shortages of non-acute care 
beds, patients may at times create bed-blockages in 
acute  care  while  awaiting  appropriate  follow-up 
care  contributing  to  lengthen  waiting  times  for 
elective surgery. It is for the central government to 
plan the opening of new public hospitals, but there 
appears to be no regulation in terms of the number 
of  beds,  the  provision  of  specific  specialised 
services  or  the  supply  of  high  cost  equipment 
capacity.  This  has,  however,  not  contributed  to 
excessive  capacity  in  terms  of  beds  or  high-cost 

(422) There are some self-referring secondary services. 

282 

equipment.  Hospitals  have  autonomy  to  recruit 
medical  and  other  health  staff,  while  their  pay 
scale is determined at national level. 

Treatment options, covered health services 

and 

clinical 

through 

The basic benefit package is not explicitly defined 
cost-effectiveness 
but 
assessments,  the  National  Institute  for  Health  and 
interventions, 
Care  Excellence  assesses  some 
medical  devices  and  pharmaceuticals  on 
the 
grounds of their clinical- and cost-effectiveness. 

Price  of  healthcare 
contracting and remuneration mechanisms 

services,  purchasing, 

Primary care practitioners, grouped in primary care 
practices,  are  mostly 
independent  contractors. 
Primary  care  practices  are  paid  for  a  mix  of 
capitation,  additional  funding  for  the  provision  of 
enhanced  services,  services  related  to  preventive 
care,  chronic  disease  management  and  patient 
satisfaction. For the provision of preventative care 
and  patient  satisfaction  primary  care  practices  are 
and  Outcomes 
the  Quality 
paid 
Framework.  This 
in 
England,  but  the  vast  majority  of  practices  in 
England  take  it  up.  It  ensures  that  practices  are 
rewarded  for  providing  systematic  quality  of  care 
for patients, not just for the number of patients on 
their list.  

is  a  voluntary  scheme 

through 

Outpatient and inpatient specialists working in the 
public sector are paid a salary but are also eligible 
to  receive  bonuses  related  to  preventive  care  and 
chronic disease activities and targets. 

services  or 

Hospital doctor salaries are determined at hospital 
level. Private sector doctors are paid on a fee-for-
service  basis.  Hospital  doctors  can  carry  out 
private  professional 
fee-paying 
services, in line  with the provisions governing the 
relationship  between  NHS  work,  private  practice 
and  fee-paying  services 
terms  and 
conditions  of  service.  This  means  doctors  are 
required  to  inform  their  clinical  managers  of  any 
regular  commitments 
respect  of  private 
in 
professional services or fee-paying activity. Where 
there  is  a  conflict  in  scheduling  work,  NHS 
commitments  must  take  precedence  over  private 
work.  

their 

in 

 
                                                           
An  NHS  GP  is  free  to  operate  a  private  practice 
with  private  patients  if  they  wish  to  do  so.  There 
are  heavy  restrictions  on  a  GP’s  ability  to  charge 
fees to their NHS registered patients, but there are 
exceptions  for  procedures  outside  the  General 
Medical  Services  Contracts  Regulations  such  as 
signing 
holiday 
insurance claims which GPs can issue a charge for. 

applications 

passport 

and 

looking  at  hospital  activity, 

When 
inpatient 
discharges  per  100  inhabitants  are  below  the  EU 
average  (12  vs.  16 
in  2015)  but  day  case 
discharges,  on  the  contrary,  are  more  than  double 
the  EU  average  (16,636  vs.  7,635  in  2015).  The 
proportion of surgical procedures conducted as day 
cases  (57.5%)  is  considerably  above  the  EU 
average  (almost  twice  the  EU  level  of  32.3%  in 
2015)  and  indeed  one  of  the  EU  highest.  Overall 
hospital average length of stay (7.0 days in 2015) 
is  slightly  below  the  EU  average  (7.6  days  in  the 
same  year).  These  figures  suggest  that  hospital 
throughput/efficiency is overall very high.  

The market for pharmaceutical products 

are 

price 

controlled 

The  Drug  Tariff  sets  out  what  NHS  dispensing 
contractors  will  be  paid  for  the  drugs  supplied. 
There 
amendments 
(increases/decreases).  There  is  a  list  of  products 
that cannot be supplied by prescribers as well as a 
list  of  products  which  will  only  be  reimbursed  if 
the  listed  conditions  are  fulfilled.  Authorities 
promote rational prescribing by physicians through 
treatment  and  prescription  guidelines 
(NICE 
guidance on clinical and cost-effectiveness effects 
of  interventions,  making  prescribing  measures 
available  for  primary  care.  Information  is  also 
the  British  National 
in 
available  via  NICE 
Formulary  (BNF)  and  the  BNF  for  Children) 
complemented  with  monitoring  of  prescribing 
behaviour 
information 
education 
and 
and 
the  prescription  and  use  of 
campaigns  on 
medicines.  

are 

These  are  coupled  with  pharmaceutical  budgets. 
For example, CCGs commonly define local lists of 
recommended  drugs  which 
considered 
sufficient  to  meet  the  needs  of  patients  as  cost-
effectively as possible and prescribers (in the UK, 
nurses,  pharmacists  and  other  allied  health 
professionals  can,  and  have,  trained  to  become 
prescribers)  may  be  asked  to  justify  prescribing 
outside  the  recommendations.  There  are  also 

Health care systems 

2.28. United Kingdom 

prescribing 

prescribing advisers employed at various levels of 
healthcare organisations to encourage rational and 
cost-effective 
reviewing 
prescribing  behaviour.  Some  CCGs  also  run 
prescribing  incentives  schemes  with  GPs  so  that 
they  receive  a  (modest)  bonus  if  they  use  cost-
effective clinically appropriate prescribing.  

and 

substitution  cannot 

In  England,  patients  pay  a  flat  rate  prescription 
charge  for  each  item  dispensed  via  an  NHS 
prescription,  unless  one  qualifies  for  exemption. 
There  is  an  explicit  generics  policy  although 
i.e. 
generic 
pharmacies  are  obliged  to  dispense  the  product 
prescribed by the doctor. However, prescribers are 
strongly  encouraged  to  prescribe  by  their  generic 
(so 
for  good  professional  practice 
name 
pharmacists  can  provide  the  patient  the  cheapest 
product  available)  and  for  value  for  money 
reasons. 

take  place 

eHealth, Electronic Health Record 

ten-year 

framework 

set  out  a 

The  Department  of  Health  and  Social  Care 
published  an  Information  Strategy  (May  2012) 
which 
for 
transforming  information  for  health  and  care. 
Working  with  stakeholders  DHSC  are  in  the 
process  of  implementing  this  vision  and  making 
progress.  A  key  commitment  was  to  give  patients 
online  record  access  to  their  GP  record by  March 
2015. 

In England resources have been made available to 
help the service accelerate progress towards a fully 
integrated  health  and  care  service-  over  £500 
million  available  to  NHS  trusts  to  accelerate 
progress  to  towards  use  of  integrated  digital  care 
records by 2018, and over £100 million to support 
nurses, midwives and health visitors to make better 
use  of  digital  technology  in  all  care  settings.  In 
addition,  in  2013,  the  government  allocated  £5.3 
billion  to  support  the  transformation  in  integrated 
health  and  social  care  through  the  Better  Care 
Fund. 

NHS  England’s  Business  Plan  2014/15  -  2016/17 
outlined  that  by  March  2015  patients  would  be 
able  to  order  repeat  prescriptions  online,  book 
appointments online and have online access to GP 
records available in 95% of GP practices. 

283 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Health  and  health-system 
information  and 
reporting  mechanisms/  Use  of  Health 
Technology  Assessments  and  cost-benefit 
analysis 

A  large  amount  of  prescribing  data  is  available, 
practice by practice, to prescribers and advisers to 
allow  benchmarking  and  encourage  improvement. 
information  and  education 
There  are  also 
campaigns  directed  at  patients  and  cost-sharing  to 
encourage  a  rational  use  of  medicines  on  the 
patients'  side.  For  many  years, 
the  DHSC 
published  the  share  of  generic  prescribing  as  an 
indicator  but  the  focus  has  now  developed  in  one 
of making the best use of medicines. This is called 
Medicines Optimisation and it works to make sure 
that  the  right  patient  gets  the  right  choice  of 
medicine  at  the  right  time.  The  Medicines  and 
Prescribing Centre (part of NICE) provides a wide 
range  of  material  and  training  to  promote  good 
quality  prescribing.  Prescribing  advisers  also 
encourage generic prescription. 

Within  the  Quality  Outcomes  Framework,  an 
annual  reward  scheme,  detailed  information  is 
provided  in  the  form  of  indicators  to  assess  the 
performance  of  each  GP  at  the  national  level. 
Capturing GPs' performance is also GPOS (general 
practice outcome standards). 

The  HS  Outcomes  Framework  includes  a  set  of 
system  performance  indicators  that  contribute  to 
the evaluation of the performance of NHS England 
in  managing  the  health  care  sector  so  that  it 
generates improvements in health outcomes. 

Further  measures  to  improve  quality  will  include 
implementing a  monitoring and evaluation system 
based on defined indicators. Major IT development 
plans  include  establishing  a  database  for  the 
personal 
insurance 
remote 
identification 
diagnostics and telemedicine.  

a 
improving 

developing 

system, 

system, 

Healthy  lifestyle  and  disease  prevention  activities 
have  received  a  lot  of  attention  mainly  through 
programmes aiming at improving the health status 
and quality of life of the population.  

284 

Recently 
reforms 

legislated  and/or  planned  policy 

The NHS in England has undergone major changes 
in its core organisational and governance structure; 
most changes took effect on April 1 2013(423). The 
Department  of  Health  and  Social  Care  (DHSC)  is 
still responsible for strategic leadership of both the 
health and social care systems, but is no longer the 
headquarters  of  the  NHS,  nor  will  it  directly 
manage 
This 
responsibility  has  shifted  to  the  new  organisation 
NHS England.  

organisations. 

any  NHS 

NHS England is responsible for: 

•  using its national remit to secure improvements 
in  population  health  (variously  improvements 
in  NHS  outcomes,  and  national  priorities 
identified in the NHS Mandate);   

•  national  commissioning  of  primary  care 
(general 
community 
pharmacy, and ophthalmology) and specialised 
services;  

dentistry, 

practice, 

•  allocation  of  funds  between  services  and  to 

local Clinical Commissioning Groups; 

•  oversight  of 

the 

activities  of  Clinical 

Commissioning Groups. 

Primary  care  trusts  (PCTs)  and  strategic  health 
authorities  (SHAs)  have  been  abolished  and  new 
organisations,  clinical  commissioning  groups 
(CCGs),  were  established.  Primary  care  trusts 
(PCTs)  used  to  commission  most  NHS  services 
and controlled 80% of the NHS budget. On April 1 
2013,  PCTs  were  abolished  and  CCGs  were 
established.  All  GP  practices  must  now  be  a 
member  of  a  CCG  and  the  groups  also  include 
other  health  professionals,  such  as  nurses.  CCGs 
commission  most  services  and  can  commission 
any service provider that meets NHS standards and 
costs.  These  can  be  NHS  hospitals,  social 
enterprises,  charities,  or  private  sector  providers. 
However,  they  must  be  assured  of  the  quality  of 
services they commission, taking into account both 
National  Institute  for  Health  and  Care  Excellence 
the  Care  Quality 
and 
(NICE)  guidelines 

(423) For  an  overview  of  the  most  important  changes  see 
http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhsstr
ucture.aspx; accessed November 1, 2013. 

 
                                                           
Commission's (CQC) data about service providers. 
A  new  regulator  (Monitor)  oversees  and  regulates 
these  new  arrangements ( 424).  As  of  January  2016 
the vast majority of hospitals and other NHS trusts 
have  become  foundation  trusts  (425);  foundation 
trust  will  have  more  ‘freedom’  and  a  different 
structure than NHS trusts (426). 

to 

are 

intended 

authorities 

In addition, local authorities are tasked to take on a 
bigger role, which is in line with the political aim 
of  greater  overall  responsibility  at  the  local  level. 
Local 
assume 
responsibility for budgets for public health. Health 
and  wellbeing  boards  have  duties  to  encourage 
integrated  working  between  commissioners  of 
services  across  health,  social  care,  public  health 
and  children’s  services.  With  the  aim  to  support 
the  joint  effort  of  NHS  and  local  government  in 
working around people, placing their well-being as 
the  focus  of  health  and  care  services,  the  Better 
Care fund created a local single pooled budget. A 
new  organisation,  Public  Health  England  (PHE), 
provides national leadership and expert services to 
support public health. 

for 

The  authorities  have  implemented  a  number  of 
policies to control expenditure on pharmaceuticals. 
There  are  no  separate  pricing  and  reimbursement 
reimbursed  medicines.  The 
decisions 
Pharmaceutical  Price  Regulation  Scheme  controls 
the  price  of  branded  medicines  and  the  profits 
pharmaceutical  companies  can  make  on  selling 
drugs  to  the  NHS.  If  companies  make  too  high  a 
profit on NHS reimbursed drugs, they  must either 
reduce the price or repay the NHS.  

The  2014  Pharmaceutical  Price  Regulation 
Scheme  (PPRS)  was  introduced  on  1  January 
2014.  The  scheme  will  provide  assurance  on 
almost all the branded medicines bill for the NHS. 
The  bill  will  stay  flat  over  the  first  2  years  of  the 
scheme  and  will  grow  slowly  after  that.  The 

(424) For 

more 

information 

see 

https://www.gov.uk/government/organisations/monitor; 
accessed April 12, 2019. 

(425) 101 foundation trusts out of 154 acute trusts; 
       43 foundation trusts out of 56 mental health trusts;  
       3 foundation trusts out of  37 community providers; 
       5 foundation trusts out of 10 ambulance trusts. 
 http://www.nhsconfed.org/resources/key-statistics-on-the-nhs, 

accessed March 2 2016. 

(426) For 

more 

details 

see 

https://www.mcht.nhs.uk/members/what-is-a-foundation-
trust/; accessed April 12, 2019. 

Health care systems 

2.28. United Kingdom 

industry will make payments to the Department of 
Health  and  Social  Care  if  NHS  spending  on 
branded  medicines  exceeds  the  allowed  growth 
rate. 

The  NHS  Long  Term  Plan,  released  in  January 
2019, sets out a clearly defined list of ambitions up 
to  2028  to  ensure  the  NHS  can  successfully 
improve  quality  and  respond  to  the  challenges  in 
the decade ahead. The delivery of this plan will be 
supported  by  an  increased  funding  (3.4%  yearly 
vs. the 2.2% average over the past five years) that 
will total £20.5 billion by the end of the next five 
years. 

The  priorities  focus  both  on  the  service  model, 
with increased emphasis on “out-of-hospital” care, 
integrated  care,  personalised  care  and  patient 
empowerment  supported  by  digital  solutions, 
reduced  pressure  on  emergency  hospital  services; 
on  increasing  prevention  and  reducing  health 
inequalities;  on  increasing  the  quality  of  care  and 
improving  care  outcomes;  on  supporting  NHS 
staff;  on  expanding  the  use  of  digital  solutions  to 
increase the effectiveness of the whole system and, 
in  general,  by  maximising  efficient  spending.  By 
focusing  on  these  priorities  for  improvement,  the 
aim to deliver to its citizens a stronger start of life, 
higher quality care to tackle major health problems 
and better support for a healthy ageing. 

and 

Sustainability 

Following the publication of  the NHS Long Term 
Transformation 
Plan, 
Partnerships  (STPs)  and  Integrated  Care  Systems 
(ICSs),  which  are  groups  of 
local  NHS 
organisations  working  together  with  each  other, 
local  councils  and  other  partners,  will  need  to 
develop  strategies  to  implement  the  national  plan. 
Yearly  strategic  implementation  plans  will  be 
available  by  April  2019,  whereas  five-year  plans 
will be formulated by Autumn 2019. 

Challenges 

implemented 

The analysis above shows  that a range of reforms 
in  recent  years,  for 
have  been 
example, to ensure access to a wide range of care, 
to  improve  the  quality  of  care,  to  increase  patient 
choice, to reduce waiting times, to increase activity 
and  efficiency  and  to  control  pharmaceutical 
expenditure. They were to a large extent successful 
and  the  UK  should  continue  to  pursue  them.  The 

285 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

electronic exchange of medical data (including 
patient  electronic  medical  records)  to  support 
choice,  reduce  medical  errors  and  increase 
cost-efficiency  such  that  general  practitioners, 
municipalities  and  hospitals  work  closely 
together to give citizens a coordinated package 
of treatment. 

•  To  further  enhance  health  promotion  and 
disease  prevention  activities  i.e.  promoting 
healthy  life  styles  and  disease  screening  given 
the recent pattern of risk factors (diet, smoking, 
alcohol, obesity) in various settings (at work, in 
school).  

•  To ensure equal access to health promotion and 
disease  prevention  activities  to  help  reducing 
health  inequalities  between  UK  countries  and 
regions. 

main challenges for the UK health care system are 
as follows:  

quality 

spending, 

promoting 

•  To continue increasing the efficiency of health 
care 
and 
integrated  patient  packages  as  well  as  a 
focusing  on  productivity  and  costs  in  order  to 
avoid the  mismatch between  health care needs 
and  resources  and  ensure  consistency  with  a 
challenging  overall  budgetary  framework,  in 
view  of  the  future  projected  increase  in  health 
care expenditure over the coming decades, due 
to  population  ageing  and  non-demographic 
factors. 

increasing 

the  numbers  and 

•  To continue to enhance primary care provision 
spatial 
by 
distribution  of  GPs  and  primary  care  nurses, 
investing  more  in  training  and  developing 
options to increase retention as envisaged in the 
Forward  View.  Additional  numbers  of  needed 
primary  care  staff  can  render  the  referral 
system  to  specialist  care  more  effective  and 
increase actual patient choice.  

between 

difference 

•  To  enact  the  commitment  to  remove  the 
barriers 
healthcare 
providers  so  that  care  is  shifted  towards 
community  settings,  care  is  delivered  in  an 
integrated  way  and  patients,  especially  those 
with  chronic  conditions,  are 
increasingly 
empowered.  Consistently,  to  shift  resources 
from acute to primary and community services 
to  strengthen  and  further  develop  community-
based care. 

•  To  reinforce  the  existing  human  resources 
strategy  to  tackle  current  shortages  in  staff, 
including  in  primary  care  staff,  and  ensure 
sufficient numbers of staff in the future in view 
of staff and population ageing. 

•  To  continue  to  monitor  the  coherence  of 
resource  allocation  to  different  types  of  care 
across  geographic  areas  following  devolution 
and  decentralised  commissioning  of  care  to 
CCGs,  to  avoid  possible  variations  in  care 
availability and quality. 

•  To further the efforts to improve information in 
a number of areas and further introducing ICT 
and  eHealth  solutions  to  allow  for  nationwide 

286 

 
Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, such as in the System of Health Accounts. Total expenditure includes current expenditure plus capital investment.

Table 2.28.1:  Statistical Annex – United Kingdom 

General context

GDP
GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total per capita PPS 

Public total as % of GDP

Public current as % of GDP

Public total per capita PPS 

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total current expenditure on health

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 live births

Notes: Amenable mortality rates break in series in 2011.
System characteristics

Composition of total current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public current expenditure as % of GDP

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Source:  EUROSTAT, OECD and WHO.  

2
8
7

EU- latest national data

2005

2,027

30.9

2.3

:

2006

2,147

31.1

1.8

3.7

2007

2,245

30.8

1.5

4.5

2008

1,975

29.5

-1.3

2.0

2009

1,717

26.7

-4.9

4.9

2010

1,842

27.4

0.9

-1.1

2011

1,884

27.1

0.6

-1.0

2012

2,078

27.5

0.8

1.4

2005

2006

2007

2008

2009

2010

2011

2012

7.6

6.6

1.0

7.8

6.9

0.9

8.0

7.1

0.9

8.2

7.2

1.0

9.1

7.4

1.7

8.9

7.5

1.4

8.8

7.7

1.0

8.8

8.6

0.3

2013

2,064

27.4

1.4

16.5

2013

10.1

9.9

0.3

2014

2,279

27.9

2.3

1.7

2014

10.1

9.8

0.3

2015

2,602

29.1

1.5

2.7

2015

10.2

9.9

0.3

2009

12,451

2011

13,213

26.8

-4.7

3.7

2009

10.2

9.3

0.9

28.1

1.5

0.2

2011

10.1

9.4

0.6

2,399

2,567

2,743

2,472

2,353

2,457

2,452

2,701

3,061

3,339

3,827

2,745

2,895

6.1

5.9

6.3

6.1

6.3

6.1

6.7

6.4

7.5

7.2

7.4

7.1

7.3

7.0

7.2

6.9

8.1

7.8

8.1

7.8

8.1

7.9

8.0

7.7

7.8

7.6

2013

13,559

28.0

0.1

0.2

2013

10.1

9.9

0.2

2,975

7.8

7.6

2015

14,447

29.6

2.0

4.1

2015

10.2

9.9

0.3

3,305

8.0

7.8

1,934

2,089

2,175

2,006

1,950

2,043

2,026

2,201

2,445

2,676

3,042

2,153

2,263

2,324

2,609

0.25

80.6

16.5

100.0

9.5

0.24

81.4

16.2

100.0

9.9

0.23

79.3

14.4

100.0

10.0

0.30

81.1

14.6

100.0

9.0

0.37

82.8

16.7

100.0

8.9

0.35

83.2

15.6

100.0

9.6

0.26

82.6

17.4

100.0

9.3

0.25

81.5

15.7

100.0

10.6

0.26

79.9

18.3

100.0

14.8

0.28

80.1

17.0

100.0

14.7

0.24

79.5

17.3

100.0

14.8

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

60.2

81.3

77.0

65.5

64.2

68

5.1

60.6

81.6

77.3

64.9

64.8

63

4.9

61.1

81.8

77.6

66.0

64.6

60

4.7

61.6

81.8

77.7

66.3

65.0

58

4.6

62.0

82.4

78.3

66.1

65.0

54

4.5

62.5

82.6

78.6

65.6

64.9

52

4.2

63.0

83.0

79.0

65.2

65.2

126

4.2

63.5

82.8

79.1

64.5

64.6

122

4.0

63.9

82.9

79.2

64.8

64.4

119

3.9

64.4

83.2

79.5

64.2

63.4

116

3.9

64.9

82.8

79.2

63.3

63.7

117

3.9

0.2

78.1

14.8

99.6

14.6

2009

502.1

82.6

76.6

62.0

61.3

64

4.2

0.2

77.5

14.8

99.1

14.9

2011

503.0

83.1

77.3

62.1

61.7

138

3.9

0.2

79.4

15.2

98.9

15.9

2013

505.2

83.3

77.7

61.5

61.4

131

3.7

0.2

78.4

15.0

98.0

15.9

2015

508.5

83.3

77.9

63.3

62.6

127

3.6

2005

1.8

2006

1.8

2007

1.8

2008

1.8

2009

2.1

2010

1.9

2011

1.9

2012

1.9

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

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:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

:

2013

2014

2015

2009

2011

2013

2015

EU- latest national data

2.3

0.5

2.4

1.2

0.3

0.5

0.3

2.2

0.4

2.1

0.8

0.0

0.4

0.1

2.3

0.5

2.4

1.2

0.3

0.5

0.2

2.2

0.4

2.1

0.8

0.0

0.4

0.1

2.3

0.5

2.5

1.2

0.2

0.5

0.2

2.2

0.4

2.1

0.8

0.0

0.4

0.1

2.7

0.2

2.5

1.2

0.3

0.3

0.4

2.6

0.1

1.8

0.9

0.1

0.2

0.3

2.6

0.2

2.5

1.2

0.3

0.2

0.4

2.5

0.2

1.8

0.9

0.1

0.2

0.3

2.7

0.3

2.4

1.5

0.4

0.3

0.4

2.5

0.3

1.7

1.0

0.2

0.2

0.3

2.7

0.3

2.4

1.4

0.4

0.3

0.4

2.5

0.3

1.8

1.0

0.2

0.3

0.3

2
.
2
8
.

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2
8
8

Table 2.28.2:  Statistical Annex - continued – United Kingdom 

Composition of total as % of total current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Composition of public as % of public current health expenditure

Inpatient curative and rehabilitative care

Day cases curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

2005

26.8%

2006

26.5%

2007

24.7%

2008

25.2%

2009

28.2%

2010

25.9%

2011

24.4%

2012

21.8%

:

:

:

:

:

:

:

:

:

:

:

:

:

2006

0.56

:

0.8

:

24.0

22.0

11.6

:

:

:

:

:

:

:

:

:

:

:

:

:

2007

:

0.1

:

:

24.0

21.0

11.8

:

:

:

:

:

:

:

:

:

:

:

:

:

2008

0.55

:

0.7

:

24.5

21.0

11.5

:

:

:

:

:

:

:

:

:

:

:

:

:

2009

:

:

:

:

:

21.0

10.8

:

:

:

:

:

:

:

:

:

:

:

:

:

2010

0.66

:

0.8

:

:

20.0

10.9

:

:

:

:

:

:

:

:

:

:

:

:

:

2011

0.70

:

0.9

:

:

20.0

10.7

:

:

:

:

:

:

:

:

:

:

:

:

:

2012

0.72

:

0.9

:

:

20.0

10.4

:

:

:

:

:

:

:

:

:

:

:

:

:

2005

0.54

:

0.8

0.1

23.0

24.0

12.1

2005

239

1024

72

690

2005

5.0

13

2013

23.6%

4.8%

24.8%

12.2%

2.7%

5.0%

2.5%

27.8%

5.2%

26.8%

10.2%

0.5%

5.0%

1.8%

2013

0.72

:

0.9

:

:

19.0

10.3

2014

23.5%

4.9%

24.8%

12.0%

2.7%

5.1%

2.4%

27.7%

5.3%

26.9%

10.1%

0.5%

5.0%

1.7%

2014

0.72

:

1.0

:

19.8

19.0

10.4

EU- latest national data

2015

23.7%

5.0%

25.3%

12.0%

2.4%

5.2%

2.2%

28.0%

5.3%

27.2%

10.2%

0.5%

5.1%

1.5%

2009

29.1%

1.7%

26.8%

13.1%

3.6%

2.8%

4.5%

33.9%

1.9%

22.9%

11.8%

1.8%

2.9%

4.1%

2011

27.9%

1.7%

26.3%

12.8%

3.6%

2.5%

4.3%

33.6%

2.0%

23.5%

11.9%

1.9%

2.5%

4.0%

2013

27.1%

3.0%

23.7%

14.7%

4.1%

3.0%

3.9%

32.1%

3.4%

22.2%

12.6%

2.0%

3.2%

3.6%

2015

27.0%

3.1%

24.0%

14.6%

4.1%

3.1%

3.8%

31.9%

3.5%

22.5%

12.7%

2.1%

3.2%

3.4%

2015

2009

2011

2013

2015

EU- latest national data

1.0

0.9

2.1

0.1

15.0

23.2

10.4

1.4

0.9

1.9

0.1

15.1

22.3

10.3

1.5

0.9

2.1

0.2

15.5

21.8

10.1

1.9

1.0

2.3

0.2

15.4

20.9

10.2

2009

2011

2013

2015

:

:

:

:

:

:

10.7

2015

279

790

79

518

2006

2007

2008

2009

2010

2011

2012

2013

2014

245

991

73

617

2006

5.1

12

249

963

73

608

2007

5.0

12

258

967

75

559

2008

5.9

13

267

983

79

553

2009

5.0

13

272

960

80

546

276

841

81

535

275

821

80

528

277

818

80

523

279

819

80

524

2010

2011

2012

2013

2014

2015

:

13

:

13

:

12

:

12

:

12

:

12

324

837

77

416

2009

6.2

17

330

835

78

408

2011

6.2

16

11,667

12,358

13,152

14,009

14,487

14,826

15,059

15,086

15,607

16,155

16,636

6,362

6,584

84.0

6.9

:

2016

7.9

7.9

2016

65.4

83.0

6.6

50.2

2020

8.1

8.1

2020

67.2

83.7

8.1

51.7

2025

8.2

8.4

2025

69.5

84.8

8.0

:

2030

8.4

8.7

2030

71.6

84.2

7.8

53.2

2035

8.6

9.0

2035

73.4

84.4

7.7

53.9

2040

8.8

9.3

2040

75.0

:

7.3

54.6

2045

8.9

9.6

2045

76.4

:

7.3

54.8

2050

9.1

9.8

2050

77.6

:

7.2

55.8

2055

9.2

10.0

2055

78.5

:

7.1

56.6

2060

9.2

10.1

2060

79.3

:

7.0

57.5

2065

9.3

10.2

2065

80.1

77.1

8.0

28.0

2070

9.4

10.3

2070

81.0

76.4

7.8

29.1

338

825

78

407

2013

6.2

16

7,143

76.5

7.7

30.9

344

833

78

402

2015

6.3

16

7,635

76.8

7.6

32.3

Change 2016-2070, in pps.

UK

1.4

2.4

EU

0.9

1.6

Change 2016-2070, in %

UK

23.8

EU

2.0

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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3. 

LONG-TERM CARE SYSTEMS 

3.1. 

AUSTRIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

Austria,  federal  republic  consisting  of  nine  states 
(“Bundesländer”)  has  a  population  of  about  8.6 
million  inhabitants,  which  accounts  for  slightly 
more  than  1.7%  of  the  EU  population  in  2016, 
which  is  projected  to  reach  10.2  million  by 
2070 (427).  With  a  GDP  of  about  €340  billion 
(2015), or 34,230 PPS per capita, it is also among 
the  richest  EU  member  states  (EU  average 
29,610).  Based  on  the  Ageing  Report  2018,  total 
public  expenditure  on  long-term  care  (health  and 
social part) (1) is with 1.9% of GDP in 2016 above 
the EU average in the same year (1.6%).  

Health status 

Life expectancy at birth for both  women and  men 
in 2015 was 83.7 and 78.8 years and lies above the 
EU  average  values 
(83.3  and  77.9  years 
respectively  in  2015).  Nevertheless,  the  healthy 
life  years at birth, 58.1 years  for  women and 57.9 
years  for  men,  are  well  below  the  EU-average 
(63.3  and  62.6  respectively) (428).The  percentage 
of  the  Austrian  population  having  a  long-standing 
illness or health problem is slightly above, though 
broadly  in  line  with  the  figures  for  the  EU  as  a 
whole  (34.8%  vs  EU  34.2%  respectively).  The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  their  activities  of 
daily living has been slightly decreasing in the last 
few years, from 10.2 in 2007 to 9.2 in 2015, but is 
still higher than the EU-average of 8.1%.  

Dependency trends 

The number of people depending on others to carry 
out  activities  of  daily  life  is  projected  to  increase 
significantly over the coming 50 years. From 0.81 
million residents living with strong limitations due 
to health problems in 2016, an increase of 49% is 
envisaged  by  2070  to  reach  around  1.22  million. 
That  is  a  steeper  increase  than  in  the  EU  as  a 
whole (25% on average across the EU). Also as a 
share  of 
the  dependents  are 
becoming  a  bigger  group,  going  from  9.3%  to 
12.0%, an increase of 28%, slightly higher than the 
EU average (EU: 21%). 

the  population 

Expenditure projections and fiscal sustainability  

With the demographic changes, public expenditure 
on  long-term  care  as  a  percentage  of  GDP  is 
projected  to  steadily  increase.  In  the  "AWG 
reference  scenario",  public  long-term  expenditure 
is  driven  by  the  combination  of  changes  in  the 
population  structure  and  a  moderately  positive 
evolution of the health (non-disability) status. The 
joint impact of those factors is a projected increase 
in  spending  of  about  1.9  pps  of  GDP  by  2070 
(going  from  1.9%  to  3.8%),  an  increase  of  100% 
well  above  the  EU  average  of  73%  ( 429).  The 
"AWG risk scenario", which  in comparison to the 
"AWG  reference  scenario"  captures  the  impact  of 
additional  cost  drivers  to  demography  and  health 
status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending  of  3.4 pps of  GDP by  2070,  an  increase 
of  almost  180%,  slightly  higher  than  the  EU 
average of 170%. Overall, the projected long-term 
care  expenditure  increase  is  expected  to  add  to 
budgetary  pressure.  Over  the  long  run,  medium 
sustainability  risks  appear  for  Austria.  These  are 
primarily related to the strong projected impact of 
age-related public spending (mainly healthcare and 
long-term care) (430). 

System Characteristics  

The  Austrian  federal  constitution  attributes  public 
responsibilities  in  social  care  to  both  the  federal 
republic  and  to  the  nine  states.  According  to  the 
constitution, the federal republic is responsible for 
developing  the  framework  legislation  relating  to 
social  welfare  and  nursing  homes,  whereas 
defining  the  specific  measures  within  the  broader 
framework,  implementing  and  executing  laws  is 
defined  as  a  competence  of  the  states  (art.  12  B-
VG).  

According  to  the  Agreement  between  the  Federal 
Government and the states, in accordance with Art. 
15a  B-VG  on  common  measures  of  the  Federal 
Government and the states  for dependent persons, 
BGBl. No 866/1993, the Parties agree, on the basis 

(429) The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(430) European Commission, Fiscal Sustainability Report (2018) 

(427) Based on Eurostat projections. 
(428) Figures in this section have been extracted from Eurostat. 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

289 

 
                                                           
 
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

of  Austria’s  federal  structure,  that  provision  for 
persons  reliant  on  care  throughout  Austria  should 
follow 
identical  aims  and  principles.  This 
agreement obliges the states to provide a minimum 
standard of long-term care services such as mobile 
care  services,  residential  care  facilities,  part-time 
short-term  care 
care 
in 
facilities  and  case  &  care 
residential  care 
management. 

services, 

services 

Types of care 

The  system  of  care  provision  is  mainly  based  on 
three  pillars.  The  first  pillar  provides  the  care 
allowances,  the  second  pillar  consists  of  the  care 
services and the third pillar consists of measures to 
support carers. 

Cash  benefits  As  from  the  beginning  of  2012 
long-term  care  cash  benefits 
(“Pflegegeld”), 
originally  introduced  in  1993,  fall  within  the  sole 
competency  of  the  federal  republic.  The  benefit 
currently amounts to €157.30 per month in level 1 
(the  lowest  level),  but  it  may  be  as  high  as 
€1,688.90 in level 7 (the highest level) ( 431). These 
cash benefits are intended to be used to buy formal 
care services from public or private providers or to 
reimburse  informal  care  provision.  However,  it  is 
not  being  controlled  for  what  purposes  long-term 
care  benefits  are  actually  used  by  the  benefit 
recipients. 

and 

homes 

supervised 

In-kind  care  The  types  of  in-kind  care  provided 
range  from  proper  institutional  care  to  hybrid 
forms  of  short-term  institutional  care  and  semi-
institutional  care.  Institutional  care  is  typically 
provided  in  ad-hoc  institutions  such  as  nursing 
residential 
care 
communities  for  the  elderly.  There  are  forms  of 
short-term  institutional  care,  within  the  same 
settings but for a  maximum time of three  months, 
conceived  to  offer  support  or  a  back-up  to  family 
carers who provide care at home. For patients who 
are  not  based 
in  residential  facilities,  semi-
inpatient  care  offers  half-day  or  full  day  support 
(care  and  social  care)  including  transportation  to 
the  care  facility.  Lastly,  there  are  forms  of  long-
term care delivery, outpatient/mobile care, offering 

home  help  and  or  nursing  depending  on  the 
individual need (432). 

As  far  as  expenditure  is  concerned,  based  on 
available  figures,  the  focus  on  in-kind  services 
seems to be slightly above the average, with 89.8% 
of total long-term care spending against 84.4% for 
the EU in 2016. Conversely, the proportion of the 
long-term  care  budget  spent  on  cash  benefits 
seems to be below average for the same year, with 
10.2%  against  15.6%  for  the  EU.  Combined  with 
the relatively low unit costs per capita as a share of 
GDP  per  capita,  this  suggests  that  shifting  more 
resources  to  cash  allowances,  where  appropriate, 
may increase cost-efficiency. 

Measures  to  support  family  carers  Currently, 
there  are  a  large  number  of  options  to  support 
family 
improving 
including 
compatibility between care and work, such as: 

carers, 

by 

•  carer’s 

leave 

part-time  working 
arrangements, the entitlement to a carer’s leave 
allowance; 

and 

• 

financial  contributions  towards  the  cost  of 
substitute  care  in  case  of  unavailability  of  the 
primary caregiver; 

•  social insurance for family carers; 

•  advisory  services  to  citizens  provided  by  the 

Ministry of Social Affairs; 

•  counselling for family members; 

•  measures under the strategy for dementia; 

•  young carers; 

•  visits  within 

the 

framework  of  quality 

assurance in home care. 

24-hour  care  Under  the  initiative  of  the  Ministry 
of  Social  Affairs,  a  legal  framework  for  quality-
assured  24-hour  care  was  established  and  a 
corresponding  subsidy  scheme  was  developed  in 
2007.  According  to  this  scheme,  caring  in  private 

(431) Source: 

https://www.sozialministerium.at/site/Pension_Pflege/Pfleg
e_und_Betreuung/Hilfe_Finanzielle_Unterstuetzung/Pflege
geld/#intertitle-3 (accessed on 19/03/2019). 

(432) Fink, M.  (2018).  ESPN  Thematic Report  on  challenges  in 
long-term  care,  Austria,  2018,  Report  to  the  European 
Commission,  DG  EMPL,  via  the  European  Social  Policy 
Network (ESPN). 

290 

 
                                                           
                                                           
homes  can  be  regulated  as  self-employed  or 
employed work. 24-hour home-care is an essential 
tool for people in need of care and their families to 
ensure  a  legitimate,  quality-assured  home  care.  In 
accordance with Section 21b of the Federal Long-
Term Care Act, the Ministry of Social Affairs has 
developed  a  model  that  finances  benefits  for 
dependents  and  their  family  members.  Provided 
the  conditions  for  funding  are  met  ( 433) 
in 
accordance  with 
the  Home  Care  Act 
(Hausbetreuungsgesetz),  a  maximum  amount  of 
€550  per  month  (when  two  self-employed  carers 
are  deployed)  or  €1,100  per  month  (when  two 
employed 
The 
are 
responsibilities in the financing of this scheme are 
split  between  the  federal  government,  financing 
60%, and the states, responsible for 40%. 

deployed). 

carers 

Long-term  care  fund  In  the  field  of  long-term 
care the Federal Government plays a major role in 
securing  funding  to  support  regional  governments 
to  cover  expenditure  for  long-term  services  and 
facilities,  alongside  supporting  the  provision  of 
benefits. 

In  2011,  the  long-term  care  fund  was  introduced 
by the Ministry of Social Affairs and was followed 
by an amendment of the care-fund in August 2013.  
The  purpose  of  grants  from  the  fund  is  to  ensure 
the  provision  and  sustainability  of  long-term  care 
services,  which  are  provided  by  states  and 
in  cooperation  with  non-profit 
municipalities 

(433) In  order  to  obtain  financial  support  for  24  hour  care,  the 

following conditions have to be fulfilled:  

•A need for (up to) 24-hour care 

•Receipt of long-term care benefit at Stage 3 or higher 

•Existence of a care relationship (i.e. a formal or informal 
contract) between a carer and the person in need of care or 
a  family  member,  or  a  contract  between  either  of  these 
persons and a non-profit organisation offering care services 

(which 

theoretical 

training  course 

•Carers  need  to  be  able  to  prove  that  they  have  either 
completed  a 
is 
essentially the same as that for a home help), or have cared 
for the person applying for the subsidy in a proper manner 
for  at  least  six  months.  Alternatively,  the  carer  must 
possess official authorisation for carrying out care work or 
nursing  work.  There  are  also  income  thresholds  for 
entitlement set at €2,500 net per month, excluding benefits. 
Assets  are  not  taken  into  account.  Increases  of  €400  for 
every  family  member  who  is  dependent  or  entitled  to 
maintenance,  and  by  €600  for  family  members  who  are 
disabled  and  entitled  to  maintenance  are  established. 
https://www.sozialministerium.at/siteEN/Pension_Nursing/
Long_term_Care_Benefit/24_hour_care. 

Long-term care systems 

3.1. Austria 

is  primarily  used 

long-term  care-fund 

organisations.  The 
sets 
priorities  for  nationwide  expansion  of  mobile 
services  and 
for  non-
stationary (434)  services.  The  majority,  i.e.  two 
thirds,  of  the  long-term  care-fund  is  financed  by 
the federal republic and one third by the states and 
the municipalities. Between 2011 and 2016 a total 
amount  of  €1.335  billion  had  been  transferred  to 
this purpose.  

In  January  2017  the  long-term  care-fund  was 
extended from 2017 to 2021 and increased up to a 
total of €1,914 million. The amendment introduced 
an  expenditure  path  following  the  model  of  the 
health reform, which sets a maximum of 4.6% for 
the  annual  percentage  increases  in  the  total  gross 
expenditures  of  all  states  in  the  area  of  long  term 
care provision. Additionally €18 million per year is 
dedicated 
the  expansion  of  hospice  and 
palliative care for 2017-2021. 

to 

Role of the private sector  

Provision of social care is not exclusively managed 
by  public  entities  and  social  care  services  can  be 
offered  by  other  organisations  as  long  as  they  are 
suitable to the needs of dependent people and they 
are  cost-effective.  Hence,  Austria  has  a  mix  of 
public  and  private  providers,  with  services 
provided by municipalities and both for-profit and 
non-profit 
so-called 
intermediary  sector,  i.e.  social  NGOs  of  different 
types.  The  role  of  the  private  sector  is  non-
negligible, with more than 50% of residential care 
and  nursing  homes  run  by  private  organisations 
back  in  2008.  Accordingly,  cash  benefits  can  be 
used  to  buy  formal  care  services  from  public  or 
private  providers  or  to  reimburse  informal  care 
giving. 

organisations 

the 

of 

user 
Eligibility 
dependency, care needs, income 

criteria 

and 

choices: 

In the Austrian long-term care system no definition 
of  “need  of  care”  exists,  but  eligibility 
requirements for cash allowances could be seen as 
a  partial  substitute  for  such  a  definition.  The 
assessment of the need for long-term care is rather 
based  on  individual  requirements  for  personal 
services and assistance. The need for both personal 
services  and  assistance  is  necessary  in  order  to 

(434) Non-inpatient. 

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qualify  for  federal  or  provincial  long-term  care 
allowances. 

Needs  assessment  is  based  on  a  doctors’  expert 
opinion.  Representatives  of  other  fields  (e.g. 
nursing)  are  also 
involved  for  an  extensive 
assessment  of  the  situation.  The  expert  opinion  is 
usually drawn up after an examination at home. It 
is  possible  for  a  trusted  third  party  to  be  present 
during  the  examination,  if  desired  by  the  person 
applying  for 
long-term  care  allowance.  The 
eligibility decision is made by means of an official 
notification  with  the  possibility  to  appeal  against 
this decision at the appropriate Labour and Social 
Court. The examination, the classification, as well 
as  the  payment  of  the  long-term  care  allowance, 
are  carried  out  by  social  insurance  institutions, 
specifically  pension 
insurance  and  accident 
insurance. 

The  specific  provisions  regarding  the  assessment 
of need of care are laid down in an ordinance. This 
ordinance defines care and assistance and the time 
allotted  to  individual  tasks,  e.g.  dressing  and 
undressing,  care  of  the  body,  preparation  of  food, 
feeding as  well as  mobility assistance. In addition 
to  that,  the  Main  Association  of  Austrian  Social 
Security  Institutions (435)  has  the  right  to  define 
national  guidelines  for  assessing  needs  of  care. 
Such  guidelines  were  issued  and  updated  several 
times in order to assure the uniform interpretation 
of  the  respective  laws  also  in  practice  and  over 
different decision makers. 

Co-payments, out of the pocket expenses and 
private insurance 

Access  to  long-term  care  benefits  in-kind  and 
services is in principle not free of charge and users 
need  to  pay  a  co-payment.  Where  own  resources 
and  cash  benefits  were  not  sufficient  to  cover  the 
expenses,  the  cost  difference  is  compensated  by 
states  and  municipalities.  Here,  means-testing 
applies,  whereby  all  kinds  of  personal  income  are 
taken  into  account,  including  long-term  care  cash 
benefits  and  except  for  assets,  due  to  the  recent 
abolition of recourse to personal and family assets 
to finance inpatient long term care  (Pflegeregress). 

(435)

http://www.hauptverband.at/cdscontent/?contentid=

10007.754040. 

292 

Long-term  care  cash  benefits  are  granted  without 
means-testing (against income or assets) and based 
on care needs categorised in seven different levels 
of need. 

Social  services  can  be  provided  by  entities  under 
private  law.  Persons  in  need  of  care  may  be 
requested  to  make  contributions  to  the  costs  of 
social  services  but  the  social  aspects  have  to  be 
taken  into  consideration  in  assessing  the  share  to 
be  borne  by  them.  Thus,  there  is  in  general  some 
kind of means testing regarding social services, but 
the concrete form differs by state.  

eHealth 

social 

application 

of  Austrian 

The  Federal  Ministry  for  Labour,  Social  Affairs 
and  Consumer  Protection,  has  commissioned  the 
“PFIF 
computer 
Pflegegeldinformation”  used  by 
the  Main 
insurance 
Association 
institutions.  With  the  introduction  of  PFIF  the 
existing  system  has  been  strengthened  and 
upgraded. This application provides a valuable tool 
to improve the situation for dependent people and 
their families, by monitoring the overall process of 
all 
including 
application  and  payment,  as  well  as  by  providing 
comprehensive  statistical  evaluation  of  available 
options.  In  addition,  this  database  is  constantly 
updated to account for changes to the existing legal 
framework. 

in  Austria, 

allowances 

care 

In  order  to  enhance  the  transparency,  validity  and 
comparability  of  the  data  in  terms  of  care  and 
long-term  care  and  to  increase  the  quality  of  care 
supply,  a  national 
long-term  care  database 
"Pflegedienstleistungsdatenbank"  was  launched  at 
the beginning of July 2012 by the Austrian Federal 
Statistics  Office,  on  behalf  of  the  Ministry  of 
Social  Affairs.  This 
the  2012 
related  statistics 
legislation  on  care-services 
(BGBl.  II  No  302/2012).  This  database  covers  all 
long-term  care  services  including  mobile,  semi-
residential and residential care services for elderly 
and dependent population. 

is  based  on 

Formal/informal caregiving 

Most persons in need of care prefer staying in the 
private  environment  and  receiving  informal  care 
from relatives or family members over formal care. 
Consequently,  roughly  80%  of  persons  in  need  of 

 
                                                           
 
Long-term care systems 

3.1. Austria 

care  do  receive  informal  care.  By  providing  the 
cash  allowance  irrespective  of  the  chosen  care 
setting  (formal/informal,  institution/home  based), 
the  philosophy  of  the  system  again  is  one  of 
supporting the possibility of individual choice. 

Recently  legislated  and/or  planned  policy  reforms 
The  Working  Group  on  Long-term  Care  Reform, 
established  by 
to  deal  with 
the  government 
respective  problems  and  to  develop  a  strategy  for 
the  future,  suggested  inter  alia  introducing  a  care 
leave or part-time care leave for care-giving close 
relatives.  This  care  leave  has  the  aim  to  support 
working  relatives  during  the  first  stage  of  care  to 
better coordinate work and care. 

Care 

Allowance 

The  care  leave  and  part-time  care  leave  was 
implemented in 2014, the provisions in the Federal 
Long-term 
Act 
(“Bundespflegegeldgesetz”)  entered  into  force  on 
January 1, 2014. Since then workers can take care 
leave or part-time care leave waiving income from 
employment  in  order  to  care  and  nurse  family 
members  in  need  of  care.  Persons  can  also  take 
family  hospice  leave  or  part-time  family  hospice 
leave  for  the  purpose  of  nursing  a  dying  close 
family member or a seriously ill child.  

family  members  can,  under  certain 
These 
conditions, claim care leave benefits (certain level 
of long-term care benefit of the family member in 
need of care, employment contract in place since at 
least  three  months  -  comprehensive  insurance).  A 
close  family  member  may  receive  care  leave 
benefits for one to three months during care leave 
or part-time care leave, depending on the period of 
leave agreed with the employer. If the level of the 
long-term  care  benefit  is  raised,  employer  and 
employee  may  agree  on  one  single  additional 
period of care leave or part-time care leave. In case 
of family hospice leave for the purpose of nursing 
a  dying  close  family  member  (a  long-term  care 
benefit  is  not  required  in  this  case)  the  care  leave 
benefits  can  be  drawn  for  up  to  six  months 
(typically  three  months  with  the  possibility  of 
prolongation up to six months).  In case of family 
hospice  leave  for  the  purpose  of  nursing  a 
seriously  ill  child  (a  long-term  care  benefit  is  not 
required  in  this  case),  the  care  leave  benefits  can 
be  drawn  for  up  to  nine  months  (typically  five 
months  with  the  possibility  of  prolongation  up  to 
nine months).  

approximately 

The  rate  of  care  leave  benefits  is  income-related 
and 
rate  of 
equal 
unemployment  benefits  (55  %  of  the  daily  net 
income) plus children’s allowance. 

the 

to 

The  situation  of  care-giving  relatives  has  been 
evaluated in the context of the quality assurance of 
home care and the results show that relatives often 
indicate  emotional  stress  because  of  their  caring 
responsibilities  and  should  therefore  be  supported 
as  much  as  possible.  After  pilot  testing,  the 
initiative  “dialogue  with  relatives”  has  been 
carers, 
support 
established. 
psychologists  or  professional  social  workers 
provide  free  counselling  services,  offering  advice 
and  psychological  support  to  prevent  any  health 
consequence due to mental stress. 

family 

To 

It  is  estimated  that  between  115,000  and  130,000 
people  in  Austria  are  currently  living  with  some 
form  of  dementia.  Due  to  population  ageing  and 
increasing  life-expectancy  the  number  of  people 
suffering  from  dementia  is  expected  to  increase. 
Accordingly,  the  Federal  Government  assigned  a 
high  priority  to  the  development  of  a  dementia 
strategy “Demenzstrategie”. 

The  first  step  towards  the  strategy  was  the  2014 
report  on  dementia,  "Österreichischer  Demenz-
bericht 2014", based on research carried out by the 
Austrian  Public  Health 
(Gesundheit 
Österreich  GmbH),  on  behalf  of  the  Ministry  of 
Social  Affairs  and  the  Ministry  of  Health.  The 
report covers the status quo as regards the situation 
of people with dementia impairments and contains 
epidemiological key messages on the prevalence of 
dementia in Austria. 

Institute 

The  technical  work  has  been  carried  out  by  six 
working  groups 
in  a  participative  process, 
emphasising  the  importance  of  a  common  cross-
policy approach in long-term care. Representatives 
of  the  provincial,  municipal  and  local  federations, 
social  security  institutions,  scientific  community, 
key  stakeholders,  developed  recommendations 
targeting those seen as key issues. 

A  total  of  twenty  one  recommendations  reflect 
seven main targets: 

• 

involvement  and  empowerment  of 
affected; 

those 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  developing  wide  and 

target-group  specific 

information; 

reach a total of €1,914 million (with an increase of 
4.5% per year starting from 2018). 

•  developing knowledge and enhancing skills; 

•  uniforming conditions; 

•  ensuring availability of dementia care; 

•  developing coordination and cooperation; 

•  quality  assurance  and  improvement  through 

research. 

the 

2015 

report 

In 
experts 
“Demenzstrategie  —  Living  well  with  dementia” 
the 
the 
was 
implementation has started. 

presented 

public 

and 

the 

by 

to 

The future of long-term care has gained increased 
political  attention  in  Austria  over  the  last  few 
years.  To  deal  with  respective  problems  and  to 
develop  a  strategy  for  the  future,  the  above-
mentioned  Working  Group  on  Long-term  Care 
into  account  an 
taking 
Reform 
amendment  of  the  Act  on  Long-term  Care  Funds, 
which was adopted in 2013.  

suggested 

rising 

demand 

(and  without 

Overall, these developments do not point towards a 
structural  change  of  the  main  features  of  the 
Austrian  long-term  care  system.  The  aim  appears 
to  be  to  safeguard  financial  sustainability  in  view 
reduced 
of 
accessibility).  Within  this  context,  the  Reform 
Working  Group  rejected  the  idea  of  a  separate 
contribution-financed long-term care insurance and 
clearly  stated  that  long-term  care  services  should 
remain  tax-financed.  Furthermore,  the  currently 
existing model of a combination of universal cash 
long-term  care 
benefits  and 
(means-tested) 
services 
and 
states 
municipalities has not been put into question. It is, 
however, 
to 
harmonise the access to available services, to focus 
on  the  further  development  of  mobile/outpatient 
services (also for reasons of cost containment) and 
to promote innovative approaches.  

the  declared  aim 

to  do  more 

administered 

the 

by 

Negotiations  on  the  budget  redistribution  between 
the federal government and the states, including in 
the area of long-term care, led to the extension of 
the  long-term  care-fund  from  2017  to  2021,  to 

294 

On 29 June 2017 the Austrian Parliament passed a 
Constitutional 
Provision 
(Verfassungsbestimmung),  prohibiting  recourse  to 
the assets of people in inpatient long-term care (so-
called  Pflegeregress) (436).  The  recently  voted 
Constitutional  Provision  (amending  sections  §§ 
330a,  330b  and  707a    of  the  General  Law  on 
Social  Insurance/ASVG)  prohibits  recourse  to  the 
assets of persons living in inpatient long-term care 
facilities, as  well as recourse to the assets of their 
relatives, heirs or gift-recipients, to cover costs for 
long-term  care  otherwise  to  be  borne  by  Social 
Assistance.  

Since then, compensation claims may no longer be 
asserted;  ongoing  proceedings  are  or  were  to  be 
discontinued. Insofar as provincial laws precluded 
this,  the  relevant  provisions  expired  on  1  January 
2018.  In  order  to  cover  the  revenues  which  the 
states  are  now  facing  because  of 
the  new 
regulations, the Federal Minister of Finance has to 
provide at least 100 million euros from the general 
federal  budget  annually.  Due  to  the  “Verbot  des 
Pflegeregresses”, 
law 
(Zweckzuschussgesetz)  has  been  adopted  on  21 
December  2018 (437).  This  is  intended  to  create  a 
legal basis that will enable the federal government 
to provide the states with further 240 million euros 
for  the  year  2018  as  compensation  for  the  effects 
of the ban of the Pflegeregress in accordance with 
§ 330a ASVG. The maximum sum of 340 million 
Euros will be evaluated in the first half of 2019, to 
get  a  baseline  for  a  settlement  for  the  following 
years. 

subsidy 

special 

the 

(436) In  Austria,  up  to  now,  it  had  been  in  principle  the 
individual  in  need  of  long-term  care  who  was  responsible 
for financing his/her stay in a residential or nursing home. 
Personal  income  used  for  this  purpose  typically  consisted 
of a retirement pension plus “long-term care cash benefit” 
(Pflegegeld). Furthermore, personal assets (such as savings 
or real  estate) had to be used for financing inpatient long-
term  care  before 
the  respective  provider  of  Social 
Assistance  (Sozialhilfe)  steps  in  to  bear  uncovered  costs. 
This  long-term  care  recourse-to-assets  was  then  subject  to 
specific 
states 
(Bundesländer),  which  are  responsible  both  for  long-term 
care services and for Social Assistance. 

in  each  of 

regulations 

the  nine 

(437)

https://www.parlament.gv.at/PAKT/VHG/XXVI/I/I

_00327/index.shtml. 

 
                                                           
 
Long-term care systems 

3.1. Austria 

people in need of care and their relatives have the 
highest priority in Austria. By the end of the  year 
2019  a  comprehensive  concept  based  on  the 
masterplan  will  be  developed.  The  master  plan 
addresses the following topics: 

−  control/organisation; 

−  caring relatives; 

−  caregivers; 

−  digitalisation; 

−  financing. 

Challenges 

Austria has a relatively fragmented system of long-
term  care,  with  unequal  coverage  across  regions 
and  a  large  provision  of  informal  care  that  is 
privately  financed.  The  main  challenges  of  the 
system appear to be: 

efficiency: 

administrative 

long-term  care  services; 

•  Improving  the  governance  framework  and 
to 
increase 
strengthen  the  existing  legal  and  governance 
framework 
for  a  clearer  delineation  of 
responsibilities  of  states  with  respect  to  the 
provision  of 
to 
integrate  medical  and  social 
strategically 
services via such a legal framework; to define a 
comprehensive approach covering both policies 
for  informal  (family  and  friends)  carers,  and 
policies  on  the  formal  provision  of  LTC 
services  and  its  financing;  to  establish  good 
information  platforms  for  LTC  users  and 
providers;  to  share  data  within  government 
administrations to facilitate the management of 
potential  interactions  between  LTC  financing, 
targeted  personal-income  tax  measures  and 
transfers  (e.g.  pensions),  and  existing  social-
assistance or housing subsidy programmes. 

•  Improving financing arrangements: to foster 
pre-funding  elements,  which  implies  setting 
aside some funds to pay for future obligations. 

Another possible future policy challenge are care-
giving  children  and  adolescents  (‘young  carers’). 
Care-giving  children  are  a  social  phenomenon, 
which  was  given  little  credit  so  far.  In  December 
2012 the results of a study, which was financed by 
the Federal Ministry of Labour, Social Affairs and 
Consumer  Protection,  were  published  under  the 
informal 
title  “Children  and  Adolescents  as 
caregivers; an inside look into the past and present 
situation  of  young  carers  in  Austria”.  This  study, 
which was carried out by the Institute for Nursing 
Science, shows for the first time figures about how 
many care-giving children exist in  Austria and on 
the  other  hand  also  shows  the  way  and  frequency 
of assistance by these children.  According to this 
study  there  are  42,700  care-giving  children  and 
adolescents between the age of 5 and 18 in Austria.  

Building  on  the  results  of  the  previous  study, 
raising  awareness  on  young  carers,  a  follow-up 
study "Children and young people as family carers: 
insight  on  the  condition  and  possible  support 
measures" was carried out in 2014 (438). This study 
developed  a  basic  framework  focused  on  young 
carers  (e.g.  the  need  to  support  young  carers, 
information and advice, expert views, resources) as 
well as with focus on their family (coordination of 
assistance within the family.). This study provides 
evidence  on  which  particular  programmes  can  be 
applied to support young carers and their families 
and  it  serves  as  guidance  for  those  institutions 
intending  to  implement  support  programmes  in 
this area. 

in 

cooperation  with 

In the years 2017 and 2018 a study on Family care 
in  Austria  was  carried  out  by  the  Department  of 
Nursing  Science 
the 
Department  of  Sociology  (University  of  Vienna) 
commissioned  by  the  Ministry  of  Labour,  Social 
Affairs,  Health  and  Consumer  Protection.  The 
study examines the situation of caregiving relatives 
and the development of informal care networks. 

With  the  long-term  care  Master  Plan  adopted  by 
the  Council  of  Ministers  on  5  December  2018, 
another  step  was  taken  to  tackle  this  important 
future  challenge.  Ensuring  adequate  and  high-
quality  care  according  to  the  state  of  nursing 
science  and  medicine  as  well  as  the  support  of 

(438)

http://www.studienreihe.at/cs/Satellite?pagename=Z

02/index&n=Z02_0. 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 

295 

 
                                                           
 
 
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

coverage schemes, setting a homogenous need-
level triggering entitlement to coverage and the 
depth of coverage, that is, setting the extent of 
user  cost-sharing  on  LTC  benefits;  and  the 
scope  of  coverage,  that  is,  setting  the  types  of 
services included into the coverage. 

•  Continue  to  encourage  home  care  and  to 
support  family  carers  to  continue  to  monitor 
and  evaluate  alternative  services,  including 
incentives  for  use  of  alternative  settings;  to 
strengthen  policies  for  supporting  informal 
incentives  for 
carers,  while  ensuring 
employment  of  carers  are  not  diminished  and 
women  are  not  encouraged  to  withdraw  from 
the labour market for caring reasons. 

that 

through 

future  needs 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care; to improve recruitment efforts, 
including 
the  migration  of  LTC 
workers and the extension of recruitment pools 
to 
of  workers; 
the  retention  of 
increase 
recruited  LTC  workers,  by 
successfully 
improving  the  pay  and  working  conditions  of 
the  LTC  workforce,  training  opportunities, 
more 
feedback 
support and supervision. 

responsibilities  on-the-job, 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use for LTC. 

•  Changing payment incentives for providers: 
to consider a focused use of budgets negotiated 
ex-ante  or  based  on  a  pre-fixed  share  of  high-
need users. 

•  Improving  value  for  money:  to  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 

296 

 
 
Table 3.1.1:  Statistical Annex –Austria 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2011 EU 2013 EU 2015

254
32.5
8.2

1.0
:
2.0

82.2
76.6
60.1
58.2
:
:

268
33.4
8.3

1.0
:
2.1

82.8
77.1
61.0
58.7
21.9
9.4

284
34.0
8.3

1.0
:
2.1

83.1
77.4
61.4
58.7
23.9
10.2

294
33.6
8.3

1.1
:
2.2

83.3
77.7
59.9
58.5
32.3
10.3

288
31.4
8.3

1.2
:
2.3

83.2
77.6
60.8
59.5
31.8
9.7

296
32.2
8.4

1.2
:
2.3

83.5
77.8
60.8
59.4
34.8
9.5

310
32.9
8.4

1.2
394.5
2.3

83.8
78.3
60.1
59.5
34.1
9.7

319
33.8
8.4

1.2
417.5
2.3

83.6
78.4
62.5
60.2
33.1
9.6

324
33.3
8.5

1.2
420.7
2.4

83.8
78.6
60.2
59.7
34.5
9.7

333
33.4
8.5

1.2
430.6
2.3

84.0
79.1
57.8
57.6
35.8
9.8

344
34.2
8.6

1.2
438.8
2.3

83.7
78.8
58.1
57.9
34.8
9.2

13,213
28.1
503

13,559
28.0
505

14,447
29.6
509

1.2
283.2
1.8

1.2
352.1
2.5

1.2
373.6
2.5

83.1
77.3
62.1
61.7
31.7
8.3

83.3
77.7
61.5
61.4
32.5
8.7

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
:
Number of people receiving care at home, in thousands
:
% of pop. receiving formal LTC in-kind 
:
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

290
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2
9
7

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2011 EU 2013 EU 2015

19
87
1.3

:
:

42
116
1.9

:
:

66
145
2.5

:
58

89
174
3.2

:
61

91
177
3.2

:
66

93
179
3.2

:
67

74
166
2.8

:
64

75
168
2.9

:
64

77
171
2.9

:
:

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

3
.
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.

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2
9
8

Table 3.1.2:  Statistical Annex - continued – Austria 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

8.7

0.81

9.3

1.9

1.9

90,721

174,506

465,342

8.4

89.8

89.8

10.2

70.6

29.4

115.8

25.0

3.6

2020

9.0

0.85

9.4

2.0

2.0

96,029

185,519

498,105

8.6

91.2

89.8

10.2

70.6

29.4

117.3

25.3

3.6

2030

9.7

0.97

10.0

2.3

2.5

117,209

222,102

605,641

9.7

97.9

90.0

10.0

70.9

29.1

120.3

26.1

3.7

2040

10.1

1.07

10.6

2.6

3.0

138,489

260,109

719,119

11.1

100.0

90.0

10.0

71.1

28.9

122.1

26.4

3.7

2050

10.2

1.17

11.4

3.2

3.9

171,718

308,505

866,740

13.1

100.0

90.3

9.7

71.8

28.2

124.0

27.0

3.7

2060

10.2

1.19

11.7

3.6

4.6

186,788

326,460

925,118

14.1

100.0

90.6

9.4

72.4

27.6

128.3

28.0

3.7

2070

10.2

1.22

12.0

3.8

5.3

194,537

340,764

968,725

14.8

100.0

90.8

9.2

72.3

27.7

131.0

28.6

3.7

MS Change 2016-
2070

EU Change 2016-2070

16%

49%

28%

101%

178%

114%

95%

108%

77%

11%

1%

-10%

2%

-6%

13%

14%

1%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

r

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3.2. 

BELGIUM 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

Belgium  has  a  population  of  just  over  11  million 
inhabitants.  According 
the  base  Eurostat 
scenario  this  number  will  grow  to  reach  13.9 
million  by  2070,  an  increase  of  23%,  well  above 
EU average for the same period (2%). 

to 

With a GDP of €410 bn, or 32,170 PPS per capita 
in 2015, it scored above the EU average of 29,610 
PPS for the same year. With public expenditure on 
long-term care (health and social) (439) of 2.3% of 
GDP  in  2016,  Belgium  spent  almost  1.5  times  as 
much  as  the  share  of  GDP  of  the  EU  average 
(1.6% in the same year). 

Health status 

Life  expectancy  at  birth  for  women  and  men  is 
respectively 83.4  and 78.7 years and it is broadly 
in line with the EU average, though slightly above 
for males (83.3 and 77.9 years respectively for the 
EU  in  2015).  The  healthy  life  years  at  birth  are 
64.0  years  for  women  and  64.4  years  for  men, 
slightly higher than the EU-average (63.3 and 62.6 
respectively).  The  percentage  of 
the  Belgian 
population having a long-standing illness or health 
problem is significantly lower than in the EU as a 
whole (24.6% and 34.2% respectively in 2015). On 
the  contrary,  the  percentage  of  the  population 
indicating  a  self-perceived  severe  limitation  in  its 
daily  activities  has  been  fluctuating  over  the  last 
few years, and the latest available figure is slightly 
higher than the EU-average (8.6% against 8.1%). 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living is expected to increase 
significantly  over  the  coming  50  years.  From  940 
thousand  residents  living  with  strong  limitations 
due to health problems in 2016, an increase of 42% 
is  projected  up  to  2070  to  around  1.33  million. 
That  is  a  steeper  increase  than  in  the  EU  as  a 
whole (EU 25%). Also as a share of the population 
the  dependents  are  projected  to  become  a  bigger 
group, going from 8.3% in 2016 to 9.6% in 2070. 

(439) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

However, the increase in this case is less steep than 
EU  average,  with  a  projected  15%  against  a  21% 
projected increase for the EU. 

Expenditure projections and fiscal sustainability  

is  projected 

is  driven  by 

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 
percentage  of  GDP 
to  steadily 
increase. In the "AWG reference scenario", public 
long-term  care  expenditure 
the 
combination of changes in the population structure 
and  a  moderately  positive  evolution  of  the  health 
(non-disability)  status.  The  joint  impact  of  those 
factors is a projected increase in spending of about 
1.7  pps  of  GDP  by  2070,  bringing  Belgium  from 
2.3% to 4.0% of GDP. This represents an increase 
of 73%, which is in line with the EU average ( 440). 
The  "AWG  risk  scenario",  which  in  comparison 
captures  the  impact  of  additional  cost  drivers  to 
demography  and  health  status,  i.e.  the  possible 
effect of a cost and coverage convergence, projects 
an  increase  in  spending  of  3.5  pps  of  GDP  by 
2070. This  increase  of  150%  is  higher,  but  below 
the EU average of 170%. Overall, projected long-
term  care  expenditure  increase  is  expected  to  add 
to  budgetary  pressure.  There  are  high  medium-
term  fiscal  sustainability  risks,  with  the  indicator 
S1 at 4.3 pps of GDP, primarily related to the high 
level of government debt and the projected ageing 
costs,  which  contribute  3.1  and  1.2  percentage 
points  of  GDP  respectively  to  the  indicator.  Over 
the long-term, fiscal sustainability risks are high as 
well,  with  the  indicator  S2  is  at  4.3  percentage 
points  of  GDP  driven  by  the  projected  ageing 
costs,  contributing  3.5  percentage  points  of  GDP, 
primarily  related  to  pensions  and  long-term  care 
expenditure (441). 

System Characteristics  

Long-term  care  is  part  of  an  integrated  system  of 
health  care,  complemented  by  social  service 
provision.  Not  unique  to  Belgium,  long-term  care 
is  approached  as  a  mix  of  different  services  and 

(440) The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(441) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

299 

 
                                                           
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

measures,  funded  through  different  sources  and 
organised at different levels. 

The  organisational  landscape  of  long-term  care 
provisions  is  fragmented  because  of  a  division  of 
competencies  between  the  Federal  Government 
(responsible  for  medical  care  through  the  health 
care system) and the Communities (responsible for 
non-medical  care).  One  level  further  down  in  the 
organisational  landscape,  cities  and  municipalities 
have a responsibility as far as the financing of the 
construction  of  residential  facilities  are  concerned 
(with  financial  support  from  the  Communities  in 
the form of investment subsidies). 

that  applies 

At the same time it must be mentioned that there is 
no specific federal legislation relating to long-term 
care. The legislative framework is the same as the 
one 
the  health  care  system. 
Regulations  at  community  level  deal  with  a  wide 
range  of  aspects  of  provision  of  long-term  care 
services,  such  as  the  recognition  of  providers,  the 
integration  of  services  and  the  monitoring  of 
quality. 

to 

Policy aims at supporting dependent older persons 
in their home environment for as long as possible. 
Should  limitations  in  activities  of  daily  living 
become  too  severe  and  adequate  informal  or 
professional  support  at  home  not  be  available  or 
sufficient,  dependent  persons  should  have  access 
to suitable and affordable residential care facilities. 

Types of care 

There are many different long-term care benefits in 
kind. Although formally not part of long-term care, 
it  is  worth  mentioning  that  medical  services  are 
organised  and  paid  for  by  the  federal  health 
insurance  system,  while  more  personal  care  is 
organised  and  paid  for  on  a  regional  level.  How 
these services are provided depends on the specific 
care setting. 

The  structure  of  long-term  care  in  Belgium  has  a 
strong  focus  on  in-kind  services,  accounting  for 
99.7%  of  total  public  spending  in  2016.  This  is 
well  above  the  EU  average  for  the  same  year,  at 
84.4%.  This  also  implies  that  the  role  of  cash 
benefits  is  compressed  with  respect  to  other  EU 
member states, with 0.3% of total public spending 
on long-term care against the EU average of 15.6% 
for  the  same  year.  This,  combined  with  the  fact 

300 

that unit costs of cash benefits measured as a share 
of GDP per capita are relatively cheaper, suggests 
that  there  may  be  scope  to  increase  the  focus  on 
cash benefits and gain in terms of cost-efficiency. 
Out  of  in-kind  spending,  a  relatively  low  share 
goes  to  institutional  care.  This  accounted  for 
56.3%  in  2016  against  the  EU  average  of  66.3%. 
However,  the  unit  costs  of  institutional  care  as  a 
share  of  GDP  per  capita  appear 
to  be 
comparatively  high,  with  an  above  average  value 
of 102.5 against 77.1 for the EU in 2016. Looking 
at  the  same  indicator  for  home  care,  standing  at 
20.4  (below  the  EU  average  of  33.9  in  the  same 
year, suggests that home care may be directed only 
at  cases  with  very  low  long-term  care  needs. 
Therefore  it  may  be  the  case  that  the  system  may 
gain  in  terms  of  cost  efficiency  or  level  of  care 
through  a  stronger  focus  on  home  care,  though 
currently  this  already  represents  a  higher  share  of 
in-kind spending than it is for the average (43.7% 
vs. 33.7 for the EU in 2016).  

Home care includes medical care and non-medical 
services.  Medical  home  nursing  care,  which 
consists  of  services  such  as  wound  dressing  and 
drug  administration,  is  provided  as  part  of  the 
social security scheme and is currently reimbursed 
at  the  Belgian  Federal  level  through  the  National 
Institute  for  Health  and  Disability  Insurance 
(NIHDI).  Non-medical  home  care  services  are 
regulated  and  organised  by  the  Communities. 
These  services  include  help  with  personal  care 
tasks  (e.g.  help  with  eating  or  moving  around, 
hygienic  help)  along  with  instrumental  help  (e.g. 
light  housework,  preparing  meals).  The  services 
offered  under  the  health  insurance  scheme  and 
those  provided  for  by  the  Communities  partially 
overlap. 

Since 2002 service provision entities have been set 
up both in  Flanders and in the French community 
to  make  sure  that  all  disciplines  involved  in  the 
care  for  patients  for  a  specific  geographical  area 
are  provided  in  a  coordinated  manner.  Care 
support  and  coordination 
towards 
keeping patients at home for as long as possible. 

is  geared 

In  centres  for  day  care  and  “short-stay”  care, 
nursing  care  and  personal  care  are  provided  to 
elderly persons for whom home care is temporarily 
unavailable.  This  is  meant  for  people  who  do  not 
need  intensive  medical  care  but  who  require  care 
or  supervision  and  aid  in  the  activities  of  daily 

 
Long-term care systems 

3.2. Belgium 

living.  A  fixed  daily  compensation  (depending  on 
the  severity  of  the  limitations)  is  paid  by  the 
compulsory health insurance. 

measures  rendering  the  system  less  attractive  is 
thought to be limited. 

environment  where 

A  residential  home  for  the  elderly  is  a  home-
replacing 
the  medical 
responsibility rests with a general practitioner. The 
cost of stay is paid by the occupant, while medical 
costs  and  the  cost  of  care  are  taken  by  the 
compulsory  health  insurance  scheme  based  on  an 
objectively assessed degree of care needed. 

Patients  with  moderate  to  severe  limitations,  but 
who  do  not  need  hospital  treatment,  are  admitted 
in  nursing  homes.  Legislation  requires  each 
nursing home to have a coordinating and advisory 
physician  who  is  responsible  for  the  coordination 
of  pharmaceutical 
and 
physiotherapy. 

care,  wound 

care 

Each nursing home must always have a functional 
link with a hospital. They must cooperate with the 
geriatric  service  of  the  hospital  and  a  specialised 
service  of  palliative  care.  While  residents  must 
finance the cost of stay themselves, nursing care is 
reimbursed by the compulsory health insurance. 

Role of the private sector  

increase 

Many who make use of home care services pay for 
this  by  using  “service  coupons”.  “Service 
coupons”  were  introduced  in  2003  as  a  system  of 
consumer subsidies for domestic services. It aimed 
to 
low-qualified 
the  employment  of 
labour,  and  at  moving  certain  activities  out  of  the 
black  economy  into  the  legal  circuit.  The  system 
works  by  offering  individuals  a  chance  to  buy 
vouchers  which  can  be  used  to  pay  those  who 
deliver domestic services such as cleaning, ironing 
and  occasional  child-care.  From  the  supplier  side, 
local  work  agencies  coordinate  those  who  deliver 
the  service.  A  coupon  can  be  used  to  pay  a  work 
hour  at  a  reduced  rate  and  offers  an  additional 
fiscal reduction.  

While  “service  coupons”  were  never  meant  to  be 
used  for  the  provision  of  care,  the  reality  is 
different:  the  system  is  especially  popular  in  the 
provision  of  home  care.  The  number  of  vouchers 
used (counted per hour) per person for this purpose 
seems  to  level  at  around  110  per person  per  year, 
or  220 per  family  per  year.  The  impact  of  budget 

As  a  result  of  the  sixth  round  of  state  reform,  the 
system  of  service  coupons  have  become  the 
responsibility of the regions. As of this writing, the 
usability  of  the  system  for  the  purchase  of  non-
medical care has been largely unchanged. 

Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

Since  nursing  care  is  covered  by  the  compulsory 
health insurance system, every elderly person with 
functional  impairments  is  eligible  to  receive  care. 
The  level  of  care  is  determined  by  the  severity  of 
disability, determined by an assessment tool based 
on  the  Katz  scale.  This  principle  holds  both  in 
home and in residential care. 

Eligibility  criteria  for  personal  care  and  family 
care  differ  slightly  between  regions.  In  principal, 
everyone  in  need  of  care  is  eligible  to  receive  it. 
The  type  and  amount  of  care  as  well  as  the  co-
payment  to  be  paid  depend  on  the  severity  of  the 
problem  and  the  social  situation  of  the  applicant 
(family  composition,  income,  type  of  residence 
etc.). 

Co-payments, out of the pocket expenses and 
private insurance 

The  costs  for  medical  care  are  reimbursed  to  the 
individual  by  the  health  insurance  organisation, 
out-of-pocket payments are never higher than what 
is allowed subject to the system of the “maximum 
billing  system”  (described  above,  chapter  2.3). 
Moreover,  co-payments  for  some  home  nursing 
services  were  reduced  from  15%  to  10%  as  of 
February 2010. 

Expenses  related  to  non-medical  long-term  care 
are borne by the individual but are at least partially 
offset  by  several  cash  benefits.  On  the  federal 
level,  a  monthly  allowance  for  disabled  older 
aan 
persons 
bejaarden;  Allocation  pour  l’aide  aux  personnes 
âgées) is granted to persons aged 65 and older for 
whom a severe need for care is ascertained. 

(Tegemoetkoming 

voor 

hulp 

This  allowance  is  means-tested.  Several  other 
topical  allowances  exist,  aimed  at  specific  costs 

301 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

(e.g.  incontinence  material)  or  circumstances  (e.g. 
for palliative care at home). 

Insurance” 

Flanders  has  introduced  an  additional  “Flemish 
Care 
in  1999, 
covering  some  of  the  costs  of  non-medical  help 
and  services  borne  by  people  with  reduced  self-
sufficiency. 

(Zorgverzekering) 

in  Flanders 

The  system  is  organised  as  a  residence-based 
compulsory  insurance-type  scheme:  every  person 
residing 
is  obligatorily  covered; 
persons  residing  in  Brussels  are  allowed,  but  not 
obliged,  to  join.  Note  that  the  Zorgverzekering 
only  provides  financial  benefits;  insurance  under 
the scheme is not a requirement for receiving long-
term care services. Patients in residential care who 
do  not  have  the  means  to  pay  for  board  and 
lodging may receive help through social assistance 
services  which  are  provided 
the 
municipalities.  However,  spouses,  children  and 
grandchildren have a legal maintenance obligation 
toward  the  person  in  residential  care  and  as  such 
they may be requested to bear (part of) the costs. 

for  by 

Formal/informal caregiving 

Belgium’s  elderly  citizens  use  both  formal  and 
informal  care  rather  frequently  compared  with 
most other European countries. Data from the 2004 
Survey  of  Health  Ageing  and  Retirement 
(SHARE)  indicate  that  the  share  of  users  of 
professional  nursing  care  and  professional  home 
care is among the highest in Europe (13.4 and 16.6 
percent  respectively)  (see  Geerts,  2009).  Despite 
the  high  reliance  on  formal  care  there  is  also 
substantial  use  of  informal  care.  For  example,  45 
percent  of  moderately  or  severely  dependent 
elderly  persons  living  at  home  receive  informal 
care from someone outside the household (SHARE 
2004  data,  see  Willemé  et  al.  2012).  The 
caregivers  are  predominantly  partners  and  adult 
children.  The  frequent  combination  of  formal  and 
informal  care  is  rather  exceptional,  since  in  most 
other countries the two forms of care appear to be 
substitutes rather than complements. 

Recently 
reforms  

legislated  and/or  planned  policy 

Prevention and rehabilitation measures 

fall 

to 
to 

(especially 

prevention, 
influenza), 
infectious  diseases, 

Prevention is a regional responsibility in Belgium. 
In  Flanders,  its  goals  have  been  defined  in  a 
‘’Flemish Policy Plan  for the Elderly 2015-2020’. 
They  include  initiatives  to  promote  a  healthy 
lifestyle  (diet,  smoking  cessation)  and  physical 
increased 
activity/sports, 
reduce 
vaccination 
hospital-borne 
reduce 
medical  overconsumption  (especially  in  nursing 
homes),  to  improve  early  detection  of  cancer  and 
to improve monitoring of mental well-being. In the 
French-speaking  Community,  fall  prevention  was 
explicitly stated as a target in the Communal Plan 
for  Health  Promotion  2008-2013.  Particular 
attention  has  also  been  paid  to  malnutrition  in 
residential care in the ‘Plan Wallon nutrition Santé 
et  bien-être  des  aînés’  (‘Walloon  Nutrition  and 
Well-Being Plan’) which is part of a wider national 
nutrition plan launched in 2004. More recently, in 
2017, a new plan for prevention and promotion of 
health has been launched by the Walloon Minister 
of  Health  (Plan  Prévention  et  Promotion  de  la 
Santé  en  Wallonie  -  Horizon  2030),  with  aims 
similar  to  those  of  the  Flemish  government, 
although this plan is not specifically targeted at the 
elderly population. 

302 

not 

undergo  major 

In recent years, the Belgian long-term care system 
reforms.  Some 
did 
developments 
system 
nevertheless  have  had  an  impact  on  the  provision 
of long-term care. 

the  health 

care 

in 

Billing 

“Maximum 

The  co-payments  that  an  individual  using  care 
would  need  to  pay,  were  limited  through  the  so 
System” 
called 
(Maximumfactuur, introduced in 2001). In addition 
various allowances  help people (in particular  with 
lower  incomes)  cope  with  the  financial  burden  of 
yearly 
expenses.  Also 
non-medical 
allowances  were  introduced,  especially  for  long-
term  care  patients,  for  example  for  the  use  of 
incontinence material.  

some 

The  extension  of  compulsory  coverage  for  self-
employed  persons  from  January  2008,  can  be 
recognised  as  an  important  development.  Before 
2008,  the  compulsory  health  insurance  for  self-
employed  persons  consisted  only  of  a  minimal 
basic  package,  covering  only  "major  risks”.  Since 
2008, the self-employed have a compulsory health 
insurance with the same coverage as civil servants 
or  employees,  which  means  for  example  that 
former  self-employed  in  need  for  nursing  care  in 
homes  for  the  elderly  are  now  covered  for  such 

 
services.  However,  the  extension  of  insurance 
coverage  for  the  self-employed  mainly  affects 
acute health care expenditures. 

In order to cope with a  future increase in demand 
for  long-term  care,  which  is  certain  but  the  exact 
magnitude  of  which  is  difficult  to  predict,  more 
diverse  and  integrated  long-term  care  services  are 
being  developed  in  Belgium.  More  and  better 
cooperation  should  allow  dependent  persons  to 
stay at home longer and to only move to residential 
care  when  absolutely  necessary.  Organising  the 
move of patients between care facilities remains a 
difficult challenge. 

The main change in health care policy legislated in 
the  devolution  of 
the  recent  years  concerns 
responsibilities  (and  shifts  in  associated  budgets) 
for a number of health care tasks from the federal 
to  the  regional  level  (Flanders,  Wallonia  and 
Brussels)  as  a  consequence  of  the  6th  Reform  of 
the  State.  The  reform  was  signed  into  law  on 
January  31  2014  and  became  effective  on  July  1 
2014. While the transferred responsibilities mainly 
concern  care  for  the  elderly,  some  may  be 
classified  as  acute  care  expenditures  (see  country 
fiche on health care). A few notable examples are 
geriatric  hospital  services,  revalidation,  mobility 
aides, prevention and the maximum billing (MAB) 
payments.  The  total  budget  shift  from  the  federal 
to 
to  be 
approximately  3.4  billion  euros  in  2015,  almost 
88%  (3  billion  euros)  of  which  will  be  long-term 
care expenditures. At the time of writing, there has 
not  been  any  substantial  change  in  the  rules  that 
govern  the  use  of  services  and  the  associated 
expenditures.  Consequently,  the  current  Belgian 
projections  at  the  national  level  assume  that  the 
regionalised  health  care  expenditures  will  evolve 
according  to  the  same  mechanisms  that  pertained 
at the federal level. 

is  estimated 

regional 

level 

the 

Challenges 

Belgium  has  a  relatively  fragmented  system  of 
long-term  care.  The  main  challenges  towards  the 
goal of a sustainable long-term care system appear 
to be: 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
regional 
of 

responsibilities  of  state  and 

Long-term care systems 

3.2. Belgium 

and 

authorities  with  respect  to  the  provision  of 
long-term  care  services;  to  use  care  planning 
individualised  need 
processes,  based  on 
care 
involving  health 
assessments, 
providers  and  linking  need  assessment  to 
resource  allocation;  to  strategically  integrate 
medical  and  social  services  via  such  a  legal 
comprehensive 
framework; 
approach  covering  both  policies  for  informal 
(family and friends) carers, and policies on the 
formal  provision  of  LTC  services  and  its 
financing. 

to  define 

a 

•  Encouraging  independent  living:  to  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

future  needs 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term  care;  to  increase  the  retention  of 
successfully 
recruited  LTC  workers,  by 
improving  the  pay  and  working  conditions  of 
the  LTC  workforce,  training  opportunities, 
more 
feedback 
support  and  supervision;  to  seek  options  to 
increase the productivity of LTC workers. 

responsibilities  on-the-job, 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons. 

the 

•  Ensuring  coordination  and  continuity  of 
care:  to  continue  to  promote  coordination  of 
care  pathways  and  along  the  care  continuum, 
such  as  through  a  single  point  of  access  to 
information, the allocation of care coordination 
to  care 
responsibilities 
managers,  via  dedicated  governance  structures 
for  care  co-ordination  and  the  integration  of 
health and care to facilitate care coordination. 

to  providers  or 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  create  better 

303 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

and 

improving  (and  securing)  safe  care 
rules, 
pathways 
to 
chronically-ill people or circulated through the 
system; to steer LTC users towards appropriate 
settings. 

information  delivered 

•  Improving  value  for  money:  to  invest  in 
assistive devices,  which for example,  facilitate 
self-care, 
and 
coordination between health and care services.  

centeredness, 

patient 

•  To  further  the  efforts 

in  the  area  of 
improve  administrative 

prevention  and 
efficiency. 

to 

304 

 
 
Table 3.2.1:  Statistical Annex – Belgium 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2011 EU 2013 EU 2015

311
30.9
10.4

1.4
394.4
2.7

81.9
76.2
62.3
62.4
:
:

327
31.3
10.5

1.7
489.6
3.5

82.3
76.6
63.2
63.0
24.7
7.8

345
31.8
10.6

1.7
511.0
3.5

82.6
77.1
63.9
63.5
24.8
7.4

354
30.9
10.7

1.8
532.6
3.6

82.6
76.9
64.1
63.4
24.7
6.9

349
29.5
10.8

2.0
563.6
3.7

82.8
77.3
63.7
63.9
25.1
7.6

365
30.6
10.8

2.0
596.0
3.7

83.0
77.5
62.6
64.0
25.6
7.9

379
30.7
11.0

2.0
616.9
3.7

83.3
78.0
63.6
63.4
26.2
8.4

388
30.9
11.1

2.1
650.5
3.7

83.1
77.8
65.0
64.2
24.7
7.6

392
30.6
11.1

2.1
672.8
3.8

83.2
78.1
63.7
64.0
25.9
8.1

400
31.2
11.2

2.2
720.1
4.0

83.9
78.8
63.7
64.5
25.0
9.5

410
32.2
11.2

2.3
763.7
4.2

83.4
78.7
64.0
64.4
24.6
8.6

13,213
28.1
503

13,559
28.0
505

14,447
29.6
509

1.2
283.2
1.8

1.2
352.1
2.5

1.2
373.6
2.5

83.1
77.3
62.1
61.7
31.7
8.3

83.3
77.7
61.5
61.4
32.5
8.7

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
:
Number of people receiving care at home, in thousands
:
% of pop. receiving formal LTC in-kind 
:
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

420
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
0
5

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2011 EU 2013 EU 2015

118
130
2.3

:
:

125
248
3.5

:
:

132
365
4.6

:
:

139
483
5.7

:
:

144
491
5.8

:
:

149
500
5.9

:
:

143
728
7.8

:
:

145
737
7.9

:
:

148
745
7.9

:
:

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

3
.
2
.

l

B
e
g
u
m

i

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o
n
g

r

-
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3
0
6

Table 3.2.2:  Statistical Annex - continued – Belgium 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

11.3

0.94

8.3

2.3

2.3

143,673

560,004

293,450

8.8

100.0

99.7

0.3

56.3

43.7

102.5

20.4

0.2

2020

11.6

0.97

8.4

2.4

2.5

153,410

583,338

308,682

9.0

100.0

99.7

0.3

56.5

43.5

102.4

20.7

0.2

2030

12.3

1.06

8.6

2.6

2.8

175,120

655,063

350,573

9.6

100.0

99.7

0.3

56.2

43.8

103.3

21.5

0.2

2040

12.9

1.17

9.1

3.2

3.6

224,244

741,893

412,796

10.7

100.0

99.8

0.2

57.7

42.3

104.8

23.2

0.2

2050

13.3

1.25

9.4

3.6

4.4

268,384

803,977

465,175

11.6

100.0

99.8

0.2

59.1

40.9

105.5

24.4

0.2

2060

13.6

1.28

9.4

3.8

5.0

285,620

832,465

491,501

11.8

100.0

99.8

0.2

59.4

40.6

106.8

25.0

0.2

2070

13.9

1.33

9.6

4.0

5.8

306,942

871,072

520,105

12.2

100.0

99.8

0.2

59.7

40.3

107.9

25.7

0.2

MS Change 2016-
2070

EU Change 2016-2070

23%

42%

15%

73%

150%

114%

56%

77%

39%

:

0%

-13%

6%

-8%

5%

26%

4%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

(1) Cash benefits numbers not available as these benefits are recorded as benefits in-kind in the Belgian SHA. 

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.3. 

BULGARIA 

General 
expenditure, 
sustainability and demographic trends 

context: 

fiscal 

GDP per capita in Bulgaria in PPS is at 12,500 and 
around half of the EU average of 29,600 in 2015. 
Bulgaria  has  a  population  of  7.1  million 
inhabitants.  During 
the 
population will steadily decrease, from 7.1 million 
inhabitants  in  2016  to  4.9  million  inhabitants  in 
2070. Thus, in Bulgaria the population is expected 
to  decrease  by  32%,  while  it  is  expected  to 
increase at the EU level by 2%.  

the  coming  decennia 

Health status 

Life expectancy at birth (78.2 years for women and 
71.2 years for men in 2015) are one of the lowest 
in  the  EU.  In  contrast,  healthy  life  years,  an 
indicator  with  a  self-reported  component,  with  65 
years  for  women  and  61.5  years  for  men  in  2015 
are above the respective EU  averages of 63.3 and 
62.6.  The  percentage  of  the  Bulgarian  population 
having  a  self-reported  long-standing  illness  or 
health  problem  is  considerably  lower  than  in  the 
Union (21.6% in Bulgaria versus 34.2% in the EU 
in 2015). In 2014, the percentage of the population 
indicating  a  self-perceived  severe  limitation  in  its 
daily activities stands at 4.6%, which is lower than 
the EU-average of 8.1%. 

Dependency trends 

The number of people depending on others to carry 
out  activities  of  daily  living  increases  over  the 
coming  50  years.  From  280  thousand  residents 
living  with  self-reported  strong  limitations  due  to 
health  problems  in  2016,  a  decrease  of  3%  is 
envisaged until 2070 to 270 thousand, which is in 
contrast to the steep increase expected in the EU as 
a  whole  (25%).  However,  due  to  the  population 
decline, as a share of the population, in the period 
2016-2070, the dependents are becoming a bigger 
group,  from  3.9%  to  5.6%,  an  increase  of  43%. 
This is more than the EU average increase of 21%. 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
"AWG  reference  scenario",  public 
long-term 
expenditure  is  driven  by  the  combination  of 
the  population  structure  and  a 
changes 

in 

moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 0.1 pps 
of GDP in Bulgaria by 2070 (442). The "AWG risk 
scenario",  which  in  comparison  to  the  "AWG 
reference  scenario"  captures 
impact  of 
additional  cost  drivers  to  demography  and  health 
status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending  of  1.0  pp  of  GDP  in  Bulgaria  by  2070. 
This  reflects,  that  coverage  and  unit  costs  of  care 
are  comparatively  low  in  Bulgaria,  and  may 
experience  an  upward  trend  in  future,  driven  by 
demand side factors. 

the 

Bulgaria  does  not  appear 
fiscal 
sustainability  risks  in  the  short  run.  The  medium 
and long-term risks are low as well ( 443).  

face 

to 

System Characteristics  

There  is  no  well-defined  long-term  care  (LTC) 
system  in  Bulgaria.  Instead,  LTC  health  and  LTC 
social  services  are  regulated  by  different  bodies 
and  legislation.  Depending  on  the  specific  case, 
LTC  is  provided  by  the  state,  the  municipal 
authorities or private providers or social welfare.  

The  organisation  and  the  provision  of  social 
services,  including  long-term  care  services,  are 
regulated by the Law on Social Assistance and the 
Regulations  on  its  Implementation (444).  Social 
services  in  Bulgaria  are  decentralised  and  are 
managed  by 
respective 
the  mayors  of 
municipalities. The mayors are also responsible for 
fulfilling 
the  standards  for 
provision  of  social  services.  Municipalities  are 
authorised  to  initiate  the  establishment  of  new 
social  services  in  line  with  the  national  priorities 
and to develop these services according to the local 
community needs. 

the  criteria  and 

the 

(442) The 

2018 

Ageing 

Report,  

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(443) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(444) According  to  the  Law,  social  services  are  activities 
assisting  persons  for  social  inclusion  and  independent 
living,  which  are  based  on  social  work  and  these  services 
are  provided 
in  specialised 
institutions. 

the  community  and 

in 

307 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

and 

Social  services  are  provided  upon  request  of  the 
potential  beneficiary 
after  undergoing  
individual need's assessment and the establishment 
of an individual plan for support. Social services in 
specialised  institutions  are  provided  only  after 
exhaustion of the opportunities for providing social 
services in the community.   

In  2015,  municipalities  provided  long-term  care 
social services at the amount  of BGN 206 million 
(€105  million),  accounting  for  67%  of  overall 
spending  on  long-term  care  social  services.  The 
most of the services were targeted to persons with 
disabilities.  They  included  in-kind  benefits  for 
accommodation, 
in 
rehabilitation, 
carrying out daily tasks and home help provided to 
sick  or  injured  people  to  assist  them  with  their 
daily tasks ( 445) . 

assistance 

and 

the  Regulations 

People  with  disabilities  are  supported  financially 
under  the  Law  on  the  Integration  of  Persons  with 
Disabilities 
its 
implementation,  the  new  Law  on  Persons  with 
Disabilities in force since January 2019 and under 
in-kind 
other 
rehabilitation  services  accounting  for  0.5%  of 
public expenditure on LTC social services. 

legislative  acts.  They 

receive 

on 

In addition, under the Law on Family Allowances 
all family allowances are provided to children with 
disabilities  regardless  of  the  family  income.  In 
2015,  families  were  paid  cash  benefits  amounting 
at BGN 9.3 million (€4.7 million).  

As  of  January  2017  a  new  monthly  allowance  for 
raising  a  child  with  a  permanent  disability  was 
introduced with amendments to the Law on Family 
Allowances,  affecting  more  than  26,000  disabled 
children. The allowance is differentiated according 
to the degree of the disability or the degree of the 
reduced  capacity  of  the  child  and  according  to  its 
purpose, ranging from BGN 350 (€178.5) to BGN 
930  (€474)   (446).  It  is  not  means-tested  and  is 

(445) Data  based  on  selected  expenditure  categories  of  the 
following  ESSPROS  functions:  Old  age,  Disability  and 
scheme 
Sickness,  Eurostat,  ESSPROS 
https://ec.europa.eu/eurostat/web/social-
protection/data/data-by-scheme. 

data 

by 

(446) The  focus  in  the  allowances’  differentiation  is  directed  to 
the  higher  types  and  degrees  of  disability.  In  order  to 
ensure  fairness  and  guarantees  for  making  a  decent  and 
independent choice to use the opportunities provided by the 
state  to  support  children  with  permanent  disabilities  and 
their  families,  an  opportunity  is  given  to  their  parents,  at 

308 

available 
for  all  children  with  permanent 
disabilities  to  cover  for  their  basic  and  specific 
needs  due  to  disability.  The  aim  is  to  ensure  the 
provision  of  care  and  support  at  home  and  in 
family environment. 

Furthermore,  according  to  the  Law  on  Family 
Allowances,  if  permanent  disabilities  of  50%  or 
more are established by the time the child reaches 
the age of 2, the mother shall be paid an additional 
one-off benefit upon childbirth to an amount fixed 
annually  with the State Budget of the Republic of 
Bulgaria  Act  for  the  respective  year,  but  not 
smaller than in the previous year. In case the child 
has permanent disabilities, the monthly allowances 
for  raising  a  child  under  one  year  of  age  shall  be 
paid until the child reaches the age of 2, regardless 
of the income of the family.  

Cash  benefits  are  provided  to  pensioners  with 
permanently reduced working capacity and degree 
of  disability  exceeding  90%,  who  constantly  need 
attendance. They can receive a supplement to their 
pension  amounting  at  75%  of  the  social  old-age 
pension (BGN 94.19 in July 2018) as regulated by 
the Social Security Code. They are covered by the 
pensions  fund  and  the  pensions  not  related  to 
labour  activity  fund,  and  in  2015  accounted  for 
27% of all LTC benefits provided in the country. 

The  financial  resources  for  LTC  services  are 
provided  from  the  state  budget,  the  local  budgets, 
by  registered  private  providers  such  as  non-
governmental  organisations,  as  well  as  under 
various  projects  of  national  and  international 
programmes.  In  recent  years,  LTC  social  services 
have  been  considerably  expanded  as  a  result  of 
and 
actions 
providing  more  community-based  and  family-
friendly services. However, there are challenges in 
this  area,  and  a  more  extensive  network  of 
the 
community  services  and  suppliers  across 
country is needed to meet the demand for care. 

at  deinstitutionalisation 

aimed 

Currently,  more  than  90%  of  the  long-term  care 
social  services  are  public.  Institutional  care  is 
almost  entirely  public,  while  non-governmental 
organisations  and  charities  are 
increasingly 
involved in day care for the elderly. Home care is 

their  discretion,  to  manage  these  funds  and  to  choose 
whether to take care personally for their children or to hire 
an assistant. 

 
                                                           
                                                                                   
provided  by  individuals  contracted  by  the  state  or 
municipalities, depending on the type of service. 

Public  spending  on  LTC (447)  was  at  the  level  of 
0.4% of GDP in 2016 in Bulgaria, much below EU 
average  of  1.6%  of  GDP.  According  to  the  2018 
Ageing Report, in 2016 73.4% of this expenditure 
was  spent  on  in-kind  benefits  (EU:  84.4%),  while 
26.6%  was  provided  via  cash-benefits  (EU: 
15.6%). 

The  amount  of  the  fees  for  formal  institutional 
LTC  services  can  be  significant.  For  example,  a 
person  that  is  enrolled  in  a  public  facility  for 
institutionalised elderly care needs to transfer up to 
80%  of  his/her  retirement  income,  but  not  higher 
than the actual monthly expenditure for the service 
provided. 

Social  services  are  provided  in  consideration  of 
fees  paid  by  the  beneficiaries  or  on  a  negotiated 
basis.  Fees  for  social  services  which  are  financed 
by the state budget are fixed by a Tariff of Social 
Services  Fees  endorsed  by 
the  Council  of 
Ministers.  According  to  the  Tariff,  the  amount  of 
the social service fee is determined as a percentage 
of  the  person’s  income,  depending  on  the  type  of 
social  service.  The  fees  should  not  exceed  the 
actual  monthly  income  of  the  recipient  of  care. 
People  with  no  incomes  or  deposits,  persons 
accommodated  in  shelters  and  in  crisis  centers  as 
well as the persons who have transferred real estate 
property  to  the  state  or  to  a  municipality  with  the 
purpose  of  developing 
services  are 
exempted  from  paying  fees  for  social  services. 
Fees  for  social  services  financed  by  municipal 
budgets  are  paid  under  the  Local  Taxes  and  Fees 
Act.  The  payment  for  social  services  provided  by 
private  providers  is  made  on  a  negotiated  basis 
when the social services do not constitute activities 
delegated by the State. 

social 

In  Bulgaria,  similar  to  the  EU  average,  49%  of 
dependents  are  receiving  formal  in-kind  LTC 
services or cash-benefits for LTC. Overall, in 2015 
1.9%  of  the  Bulgarian  population  received  formal 
LTC in-kind and/or cash benefits (EU: 4.6%). On 
the one hand, low shares of coverage may indicate 

(447) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

Long-term care systems 

3.3. Bulgaria 

a situation of under-provision of LTC services. On 
the other hand, higher coverage rates may imply an 
increased  fiscal  pressure  on  government  budgets, 
possibly calling for greater needs of policy reform. 

In 2015, the expenditure for institutional (in-kind) 
services  makes  up  33.3%  of  public 
in-kind 
expenditure  (EU:  66.3%).  Thus,  relative  to  other 
Member States Bulgaria has a less strong focus on 
institutional care. Typically, as institutional care is 
relatively  costly,  Member  States  with  shares  well 
above  the  EU  levels  may  benefit  from  efficiency 
thus 
gains  by  shifting  some  coverage  (and 
expenditure)  from  institutional  to  other  types  of 
care.  

Regarding financial support for provision of social 
services, in 2016 the state provided approximately 
BGN  113.6  million  for  community-based  social 
services  for  children  and  adults,  as  activities 
delegated by the state to the municipalities. These 
are significantly higher than the funds provided for 
specialised  institutions  (BGN  86.9  million).  In 
addition, since January 2016 the sustainability of 9 
for 
centres 
children/youth  with  disabilities  with  constant 
medical  care  has  been  financially  ensured  by  the 
state budget.  

family-type  accommodation 

for 

Types of care 

in 

services  are  provided 

LTC 
specialised 
institutions,  community-based  social  services  of 
residential  type  close  to  family  environment,  and 
also  as  daily  and  consultative  community-based 
social  services,  as  well  as  home-based  social 
services.  Bulgaria 
the  process  of 
deinstitutionalising  the  LTC  system,  aiming  at  a 
higher  provision  of  home  and  community  care 
services.  The  main  target  groups  of  LTC  are 
people  with  impairments  (disability)  and  elderly 
people (65+).  

in 

is 

the 

The number of specialised institutions remains the 
same,  but 
is  showing  significant 
reduction of their capacity. As of December 2017, 
the number of specialised institutions is 161 with a 
capacity of 10 881 places. 

trend 

The transition from traditional institutional care to 
community  and  family-based  services  is  mainly 
realised  through  an  expansion  of  the  range  of 
services (day care centres, social rehabilitation and 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

(personal  assistants, 

integration centres, protected housing, family-type 
accommodation  centres),  as  well  as 
further 
development of the model for services provided at 
social  assistants, 
home 
domestic  assistants,  domestic  social  patronage, 
public  canteens).  By  June  2018,  the  number 
community-based  social  services  for  elderly  and 
people with disabilities was 530 with total capacity 
of  16,206  places.  This  is  a  marked  increase  since 
2012,  when  370  community-based  social  services 
for elderly and disabled people were available with 
a total capacity of 9,205 places.  

term  conditions  and  diseases  are  the  general 
practitioners.  A  significant  part  of  the  funds  for 
rehabilitation  are  provided  by 
the  healthcare 
system.  As  long  as  there  are  medical  indications 
for rehabilitation, it is paid by the National Health 
Insurance Fund (NHIF). Determining the need for 
rehabilitation  is  not  only  the  competence  of 
general practitioners, but also of all other  medical 
specialists  in  the  outpatient  and  inpatient  care. 
There  are  departments  of  physical  medicine  and 
rehabilitation in all major hospitals and in over 20 
specialised  rehabilitation  hospitals,  funded  by  the 
NHIF.  

Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

(adopted  by 

According to the latest amendments to the Law on 
Social  Assistance 
the  National 
Assembly  in  January  2016)  eligibility  for  social 
services  is  based  on  a  needs'  assessment  and  an 
individual  support  plan  developed  by  a  multi-
disciplinary  team  within  the  respective  social 
service.  Assessment  of  LTC  needs  is  individual 
and  normally  based  on  an  application  to  the 
the 
respective  welfare 
minimum  eligibility  criteria  are  defined  in  the 
legislation.  They  are  nation-wide  and  binding  and 
may  include  the  applicant’s  income,  property 
status,  family  status,  potential  care  providers 
(friends  or 
type  and  severity  of 
disability, etc. 

service.  Generally, 

relatives), 

for 

the 

General  practitioners  acting  as  family  doctors  are 
responsible 
initial  examination  and 
monitoring  of  the  health  status  of  the  elderly.  In 
case of impaired health and the need for LTC, the 
elderly  patient  is  referred  to  the  relevant  health 
institutions and medical nursing care is arranged, if 
needed.  The  arrangements 
for  any  medical 
services,  medical  nursing  care  included,  are  made 
by  the  general  practitioner.  Where  necessary,  the 
doctor alerts the social services. Upon receiving an 
application  from  the  elderly  patient  or  his/her 
family  physician,  friends  or  relatives,  the  social 
assistance  directorate  makes  an  initial  assessment 
of the  situation and decides on the  LTC  measures 
and programme to be applied in each specific case.  

Prevention and rehabilitation measures 

and 

prevention 

rehabilitation. 

Another source for prevention and rehabilitation is 
the  National  Social  Security  Institute  (NSSI).  The 
funds  provided  are  defined  in  the  Law  on  State 
Social  Security  Budget  and  in  2017  amounted  to 
BGN 
  20.1  million  (€10.3  million).  It  was 
envisaged for around 47,500 persons to use grants 
The 
for 
rehabilitation programme has a maximum duration 
of  10  days  as  NSSI  assumes 
the  cost  of 
accommodation  and  partial  support  for  food 
expenses  up  to  BGN  7  (€3.58)  per  day-stay.  The 
NSSI signed contracts with 18 entities for a total of 
49 
this  programme. 
implementing 
Entitled to this benefits are the socially insured for 
and 
sickness,  maternity 
occupational disease persons. They must have paid 
contributions  for  a  period  of  six  consecutive 
calendar  months  preceding  the  month  before  the 
start  of  rehabilitation.  The  persons  should  have  a 
specified  diagnosis  by  a  certified  physician, 
indicating  the  need  for  rehabilitation.  Another 
eligible  group  is  recipients  of  personal  disability 
pension.  The  only  condition  for  them  is  that  their 
age  is  below  the  age  of  entitlement  to  old-age 
pension. 

institutions 

accident 

and/or 

Formal/informal caregiving 

Traditionally,  long-term  care  for  the  elderly  is 
provided  as  informal  care  by  family  members. 
There  is  little  information  about  the  number  of 
people  providing  informal  care,  however,  there  is 
little  doubt  that  the  overwhelming  bulk  of  long-
term  care  is  provided  by  informal  carers  in 
families. 

There  are  a  couple  of  mechanisms  for  prevention 
and 
to  be  mentioned.  The 
responsible  partners  for  the  prevention  of  long-

rehabilitation 

As  to  formal  care,  in  line  with  the  national 
legislation,  the  Social  Assistance  Agency  has 
the  private 
established  a  public  register  of 

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providers  of  social  services  who  are  entitled  to 
provide services on the territory of the Republic of 
Bulgaria. The information about all social services 
financed  by  the  state  budget  is  published  on  the 
official web page of the Social Assistance Agency 
and it is regularly updated.  

The provision of LTC is still broadly considered to 
be  a  family  matter.  The  cultural  tradition  in 
Bulgaria  encourages  care  for  elderly  people  to  be 
provided by  family  members,  who  are  not  trained 
professionally, but accept that responsibility out of 
a  sense  of  family  duty.  However,  since  2012 
trainings for professionalisation of care have been 
conducted  under  various  schemes  under 
the 
Operational  Programme 
“Human  Resources 
Development” (OP HRD), co-financed by EU and 
state funds. 

thus 

under 

informal  care 

Though 
is  of  outmost 
importance,  for  a  long  time  it  has  neither  been 
legally  recognised  nor  financially  encouraged. 
Since  2003,  informal  carers  can  be    financially 
supported 
the  National  Programme 
“Assistants  to  people  with  disabilities”  which 
provides  home-based  care  (the  service  “personal 
assistant”)  to  people  with  disabilities  and  lonely 
people  with 
this 
Programme,  managed  by  the  Agency  for  Social 
Assistance,  in 2017 the  funding reached BGN 8.9 
million  and  it  provided  employment  for  2,450 
previously unemployed persons. 

serious  diseases.  Under 

Home-based  services  are  provided  also  by  private 
providers, as well as under EU co-funded projects 
of the Operational Programme "Human Resources 
and  Development"  (OP  HRD).  From  the  start  of 
the  OP  HRD  in  2007  the  amount  of  funding  for 
providing  home-based  social  services  exceeds 
BGN 458 million in total. In this regard, it should 
be  noted  that  the  service  “personal  assistant”  was 
provided  under  the  “New  Opportunities  for  Care” 
project  under  the  “New  Alternatives”  operation. 
The  project  was  implemented  by  the  Agency  for 
Social  Assistance 
in  partnership  with  264 
municipalities  and  its  implementation  ended  in 
February 2016. Project services  were provided to: 
people with disabilities in difficulty or inability to 
self-service;  people  over  65  years  in  difficulty  or 
inability  to  self-service;  families  of  children  with 
disabilities; 
ill  persons.  The 
project  covered  more  than  15,600  service  users 

lonely  seriously 

Long-term care systems 

3.3. Bulgaria 

supported  by  approximately  14,700  personal 
assistants.  

The  Operation  “Independent  living”  supplements 
and  upgrades  measures  financed  under  OP  HRD 
(2007-2013)  and  OP  HRD  (2014-2020),  through 
the  implementation  of  an  all-embracing  approach 
at  municipal  level  to  provide  hourly  services  to 
disabled  people  and 
the  elderly  who  have 
difficulties for self-care. The implementation takes 
place  in  260  municipalities  and  33  districts  (in 
Sofia  Municipality,  Varna  Municipality  and 
Plovdiv  Municipality)  for  nearly  24,800  disabled 
persons,  including  children  and  persons  over  65 
who  are  unable  to  self-service,  from  16,500 
appointed personal assistants, social assistants and 
home helpers by the end of 2016. 

to 

Taking into account the real needs and significant 
contribution  of  social  services 
the  home 
environment  for  the  support  of  disabled  and 
elderly people, the Council of Ministers adopted a 
Decree № 137 of 05.07.2017 approving changes in 
the  2017  budget  programmes  of  the  Ministry  of 
Labour  and  Social  Policies.  The  decree  envisages 
additional  funds  for  the  provision  of  the  social 
services  “Personal  assistant”,  “Social  Assistant” 
and  “Home  Assistant”,  for  more  than  15,000 
disabled  persons  and  persons  over  65  who  are 
unable to self-care.  

Recently 
reforms  

legislated  and/or  planned  policy 

A  comprehensive  reform  in  the  area  of  social 
services sector is underway as part of the efforts to 
provide  entirely  new  model  of  providing 
accessible,  qualitative,  effective  and  integrated 
social services to  meet  more adequately the  needs 
of vulnerable persons. In the context of the current 
reform  in  March  2019  a  Law  on  Social  Services 
(the  Social  Services  Act)  was  adopted  by  the 
National  Assembly. It  will partly enter in force in 
in  2021.  The  relevant  sub-
2020  and  fully 
legislative  acts,  which  are  necessary  for 
its 
implementation  will  also  be  prepared.  The  main 
objective  is  to  improve  the  regulatory  framework 
in  the  field  of  social  services  with  a  view  to 
improve  the  planning,  management,  financing, 
quality, effectiveness and monitoring of the social 
services. 

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the  Implementation  of 

Beginning  of  2014,  the  Council  of  Ministers  has 
adopted a National Strategy on long-term care. The 
current  Plan  for 
the 
National Strategy for Long-term Care refers to the 
period 2018-2021 (448). The  main objective of the 
Strategy  is  to  create  conditions  for  independent 
and  decent  living  of  elderly  and  people  with 
disabilities  by  providing  quality,  accessible  and 
sustainable  long-term  care  services  according  to 
their  individual  needs  and  achieving  a  better 
balance  between  the  quality  of  the  services  and 
their  effective  and  efficient  delivery.  A  strong 
emphasis  in  the  Strategy  is  also  placed  on  the 
deinstitutionalisation  of  care  for  the  disabled  and 
the  elderly, 
the  development  of  home-based 
services and the support of families with increased 
responsibility  for  the  care  of  dependent  family 
members.  The  promotion  of  interaction  between 
social 
the 
development of innovative cross-sectoral services, 
as  well  as  the  implementation  of  an  integrated 
approach  are  also  among  the  priorities  of  the 
Strategy.  

and  health 

including 

services, 

their 

therefore 

In  order  to  address  the  challenge  for  more 
integrated  health  care  and  social  services  (449),  in 
September  2015  the  National  Assembly  adopted 
amendments  to  the  Health  Law  to  regulate  the 
integrated  approach.  However, 
the  regulatory 
framework of these amendments is not yet devised, 
and 
implementation  has  been 
considerably delayed. It is envisaged that the types 
of  services,  the  conditions  and  the  order  for  their 
provision,  the  criteria  and  the  standards  for  the 
quality  of  these  services  and  the  procedures  for 
implementation  of 
their 
the 
compliance  shall  be  regulated  by  an  ordinance 
adopted  by  the  Council  of  Ministers  upon  a 
proposal of the Minister of Health and the Minister 
of Labour and Social Policy.  

control  over 

Key  measures  for  the  realisation  of  the  objectives 
of  the  national  long-term  care  strategy,  to  be 
financed  by  the  state  and  municipal  budgets,  as 
well  as  EU  funds  from  the  European  Social  Fund 
and European Regional Development Fund, are: 

The  strategy  has  the  following  objectives:  1) 
Developing  a  network  for  social  services  in  the 
communities,  tailored  to  the  needs  of  the  elderly 
and  disabled  people.  Provision  of  both  stationary 
and  non-stationary  social  services  close  to  and  in 
home  environment;  2)  Adoption  of  a  regulatory 
framework  for  a  wide  range  of  social  services 
3)  Ensuring 
targeting 
services;  4) 
sustainable 
Improving 
line 
institutions  for  LTC;  5)  Phased  restructuring  of  
the  system  for  inpatient  treatment  and  active 
deinstitutionalisation. 

financing  of  LTC 
coordination 

vulnerable 

between 

groups; 

the 

to 

In  2010,  legislation  for  organising  care  in  homes 
for medical and social care has been adopted. The 
aim  was 
implement  continuous  medical 
monitoring  and  specific  care  for  individuals  with 
chronic  diseases,  disabilities  and  social  problems. 
However,  so  far  there  is  no  budget  for  financing 
these  homes,  such  that  for  now  these  homes  have 
not yet been established. 

(448) Plan  for  the  Implementation  of  the  National  Strategy  for 
Long-term 
(2018-2021), 
Care 
www.mlsp.government.bg/index.php?section=POLICIESI
&lang=&I=280. 

312 

−  Expanding 

access 

services, 
improvement  of  their  quality  and  interaction 
between health, social and educational services.  

social 

to 

−  Deinstitutionalisation of the elderly and people 

with disabilities placed in institutions. 

−  The continued implementation of best practices 
for long-term care for mentally ill patients after 
their active psychiatric treatment and provision 
of adequate living conditions in the community 
through  appropriate  services  and  integrated 
cross-sectorial  reintegration  programs;  The 
development  and  validation  of  a  model  for 
provision of long-term treatment and palliative 
care;  The  provision  of  home  care  for  people 
with  chronic  diseases  resulting  in  damage  to 
critical  functions  (respiratory,  neuromuscular, 
renal failure, etc.). 

(449) Integrated  health and social  services are  activities  through 
which  medical  and  social  service  specialists  provide 
healthcare  and  medical  supervision  and  perform  social 
work, including in home environments, to support children, 
pregnant  women,  people  with  disabilities  and  chronic 
conditions  and  aged  people  who  need  assistance  in  the 
performance  of  their  daily  activities.  The  services  may  be 
provided by municipalities, medical treatment facilities and 
the  persons  under  Article  18(2)  of  the  Law  on  Social 
Assistance. 

 
                                                           
                                                           
−  Provision of adequate training and supervision 
of personnel providing long term care services, 
creating  a  system  of  independent  monitoring;  
for 
developing 
dependent  people;  increase  in  the  number  of 
professionals  providing 
long-term  care  for 
dependent elderly and disabled people at home 
and in the community.  

services 

support 

social 

−  Increase  in  efficiency  mechanisms  for  LTC 

services. 

An  Action  Plan  for  the  period  2018-2021  for  the 
implementation  of  the  National  Long-Term  Care 
Strategy  has  also  been  adopted  by  the  Council  of 
Ministers in January 2018. The Plan addresses the 
deinstitutionalisation of the care for elderly people 
and people with disabilities.  The aim is to improve 
the  conditions  for  independent  and  decent  life  of 
the  elderly  people  and  people  with  disabilities  in 
the  community  by  extending  and  improving  the 
social  services  system,  including  services  for 
social inclusion.  

The  main  groups  of  measures  in  the  Action  Plan 
are  as  follows:  providing  support 
in  home 
environment and in the community for people with 
disabilities  and  elderly  people  dependent  on  care; 
providing quality community-based social services 
for  persons  living  in  specialised  institutions  with 
poor  living  conditions  and  quality  of  care  and 
closing of institutions; enhancing the effectiveness 
the 
of 
necessary  infrastructure  for  providing  social  and 
integrated  health  and  social  services  for  people 
with  disabilities  and  elderly  people  dependent  on 
care.  

long-term  care  system;  building 

the 

in  Growth”  2014-2020  and 

The  financing  of 
the  Action  Plan  will  be 
implemented with funds from the state budget and 
the  Operational  Programme 
EU  funds  from 
the 
“Regions 
Operational  Programme 
“Human  Resources 
Development” 2014-2020. The Plan envisages the 
set  up  of  100  new  community-based  social 
services  for  2,140  users.  Patronage  care  for 
disabled and elderly people dependent on care will 
be  developed.  It  will  provide  mobile  integrated 
health  and  social  services  on  hourly  basis.  The 
provision  of  home-based  social  services  will  also 
continue  with  funds  from  the  state  budget.  Over 

Long-term care systems 

3.3. Bulgaria 

30,000 people will be supported through patronage 
care and assistant services. 

to 
individual 
needs’ 
institutionalisation 

With  regard  to  the  quality  of  long-term  care  in 
January  2016  the  National  Assembly  adopted 
amendments to the Social Assistance Act in order 
to  guarantee  better  access  to  social  services, 
long-term  care  services; 
including  access 
and 
applying 
approach 
an 
prevent 
comprehensive 
permanent 
vulnerable 
persons;  higher  efficiency  of  the  social  services; 
introducing  judicial  control  during  the  process  of 
placement  of  persons  under  full  guardianship  in 
community-based  social  services  of  residential 
type  and  in  specialised  institutions;  facilitate  the 
registration and licensing regimes for the providers 
of social services; and others. 

assessment; 

of 

the 

including  for 

the  project  “New  Standards 

The  social  services’  reform,  including  the  long-
term care, is also supported by the implementation 
of 
for  Social 
Services”.  The  project  aims  at  improving  the 
accessibility, effectiveness and the quality of social 
services as well as the deinstitutionalisation of the 
care  for  children  and  adults,  including  disabled 
people, by developing up-to-date quality standards 
and  financing  in  line  with  the  needs  of  the 
recipients. Within the project financial  models  for 
pricing  the  provision  of  social  services  are  being 
developed, 
long-term  care 
services,  as  well  as  a  model  for  financing  the 
integrated  cross-sectoral  services.  An  important 
activity  is  the  development  of  quality  standards 
with  objective  and  measurable  criteria  and 
indicators and a monitoring and control system of 
the services. Among the activities of the project is 
also the development of a model for planning of a 
minimum  package  of  services  at  regional  and 
municipal level, objective criteria for developing a 
needs’  map  and  a  map  of  services  at  the  national 
level,  as  well  as  the  development  of  the  maps 
themselves.  The  implementation  of  the  project 
activities  will  also  assist  the  overall  reform  in  the 
social  services  sector.  The  project  should  be 
completed by the end of 2019. 

Challenges 

Bulgaria  has  adopted  a  strategy  for  strengthening 
its long-term care system, and the implementation 
of the project has to be duly monitored. The main 
challenges of the system appear to be: 

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through,  respite  care,  cash  benefits  paid  to  the 
care recipients, while ensuring that women are 
not  encouraged  to  withdraw  from  the  labour 
market for caring reasons.  

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
the 
structures  for  care  co-ordination  and 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  LTC;  to  steer  LTC  users  towards 
appropriate settings. 

•  Improving  value  for  money:  to  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

•  Improving the governance framework: to set 
the  public  and  private  financing  mix  and 
organise  formal  workforce  supply  to  face  the 
growing  number  of  dependents,  and  provide  a 
strategy  to  deliver  high-performing  long-term 
care  services  to  face  the  growing  demand  for 
LTC services; to strategically integrate medical 
and social services via such a legal framework; 
To  define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  establish 
good information platforms for LTC users and 
providers;  to  use  care  planning  processes, 
based  on 
individualised  need  assessments, 
involving health and care providers and linking 
need assessment to resource allocation; To deal 
with  cost-shifting  incentives  across  health  and 
care. 

•  Improving  financing  arrangements:  to  face 
the  increased  LTC  costs  in  the  future  e.g.  to 
foster  pre-funding  elements,  which  implies 
setting  aside  some  funds  to  pay  for  future 
obligations;  to  explore  the  potential  of  private 
LTC  insurance  as  a  supplementary  financing 
tool.  

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
coverage  schemes,  and  the  scope  of  coverage, 
that  is,  setting  the  types  of  services  included 
into the coverage. To provide targeted benefits 
to those with highest LTC needs; to reduce the 
risk  of 
impoverishment  of  recipients  and 
informal carers. 

•  Encouraging  independent  living:  to  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

future  needs 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care; to improve recruitment efforts, 
including 
the  migration  of  LTC 
workers and the extension of recruitment pools 
of workers. 

through 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 

314 

 
Table 3.3.1:  Statistical Annex – Bulgaria 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

24
11.6
7.7

0.1
:
0.2

76.2
69.0
:
:
:
:

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

27
11.7
7.6

0.0
:
0.1

76.3
69.2
71.9
66.2
32.1
2.5

32
11.8
7.6

0.0
:
0.1

76.6
69.5
73.9
67.1
29.0
2.5

37
11.7
7.5

:
:
:

77.0
69.8
65.7
62.1
24.4
4.7

37
10.7
7.5

:
:
:

77.4
70.2
65.9
62.1
21.4
4.5

38
11.2
7.4

:
:
:

77.4
70.3
67.1
63.0
19.2
3.8

41
11.2
7.4

:
:
:

77.8
70.7
65.9
62.1
18.2
4.1

42
11.4
7.3

:
:
:

77.9
70.9
65.7
62.1
18.6
3.9

42
11.4
7.3

0.0
0.2
0.0

78.6
71.3
66.6
62.4
19.1
3.8

43
12.0
7.2

0.0
0.2
0.0

78.0
71.1
66.1
62.0
20.5
4.0

45
12.5
7.2

:
0.2
:

78.2
71.2
65.0
61.5
21.6
4.6

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

:
:
:

:
:

15
33
0.6

:
:

24
22
0.6

:
:

33
11
0.6

:
:

42
:
0.6

:
:

43
:
0.6

:
:

43
:
0.6

:
:

15
106
1.7

:
:

15
106
1.7

:
:

15
106
1.7

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

Source: EUROSTAT, OECD and WHO. 

3
1
5

3
.
3
.

l

B
u
g
a

r
i

a

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3
1
6

Table 3.3.2:  Statistical Annex - continued – Bulgaria 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

7.1

0.28

3.9

0.4

0.4

2020

6.9

0.28

4.1

0.4

0.4

12,530

21,689

101,818

12,575

21,733

102,983

1.9

48.6

75.0

25.0

33.3

66.7

56.9

65.8

7.0

2.0

48.9

74.3

25.7

33.7

66.3

56.1

63.9

7.0

2030

6.4

0.29

4.5

0.5

0.5

12,859

20,737

108,431

2.2

49.2

73.6

26.4

35.4

64.6

59.6

67.4

7.2

2040

5.9

0.29

4.9

0.5

0.7

2050

5.5

0.29

5.2

0.5

0.8

2060

5.2

0.29

5.5

0.6

1.1

2070

4.9

0.27

5.6

0.5

1.4

12,836

19,326

109,433

12,791

18,879

110,159

12,787

18,436

111,930

12,072

17,340

107,777

2.4

49.0

73.8

26.2

36.6

63.4

61.8

70.9

7.0

2.6

49.2

74.6

25.4

37.2

62.8

65.6

74.9

7.0

2.7

49.7

74.3

25.7

37.5

62.5

64.6

74.7

6.8

2.8

50.4

73.4

26.6

36.4

63.6

59.0

72.0

6.6

MS Change 2016-
2070

EU Change 2016-
2070

-32%

-3%

43%

37%

244%

-4%

-20%

6%

48%

4%

-2%

6%

9%

-5%

4%

9%

-6%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

r

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.4.  CROATIA 

General 
expenditure, 
sustainability and demographic trends 

context: 

fiscal 

In 2015, GDP per capita was with 16,500 PPS well 
below the EU average of 29,600 PPS. Croatia has 
a  population  of  almost  4.2  million  inhabitants, 
which is roughly 0.8% of the EU population. In the 
absence of any sizeable immigration and a decline 
in  fertility,  the  population  of  Croatia  is  steadily 
decreasing.  In  the  period  from  2016  to  2070  a 
decrease  of  19%  can  be  expected,  based  on  the 
population  forecast  of  Eurostat,  leading  to  a 
population of 3.4 million in 2070. 

Based  on  the  Ageing  Report  2018,  total  public 
expenditure  on  long-term  care  (health  and  social 
part) (450) is with 0.9% of GDP in 2015 under the 
EU average in the same year (1.2%).  

Health status 

Life  expectancy  at  birth  was,  in  2015,  80.5  years 
for women and 74.4years for men and is, although 
having increased during the past decade, below the 
EU  average  (83.3  and  77.9  years  for  women  and 
men  respectively  in  2015).  Similarly,  the  healthy 
life years at birth for both sexes are with 56.8 years 
(women) and 55.3 years (men) lower than the EU-
average (63.3 and 62.6 respectively). On the other 
hand,  the  percentage  of  the  Croatian  population 
having a long-standing illness or health problem is 
at  the  same  level  as  in  the  Union  as  a  whole 
the  population 
(34.2%).  The  percentage  of 
indicating  a  self-perceived  severe  limitation  in  its 
daily  activities  is  at  11.0%  compared  to  the  EU-
average of (8.1%). 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living is projected to increase 
over  the  coming  50  years.  From  310  thousand 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  10%  is 
envisaged until 2070 to around 340 thousand. That 
is less steep an increase than in the EU as a whole 
(25%).  Also  as  a  share  of  the  population,  the 
dependents  are  becoming  a  bigger  group,  from 

(450) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

7.4%  to  10.1%.  This  is  above  the  EU  average 
increase at a projected 35% (EU: 21%). 

Expenditure projections and fiscal sustainability  

in 

reference 

scenario,  public 

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  likely  increasing.  In  the 
AWG 
long-term 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is  a  small  projected  increase  in  spending  of  about 
0.3 pps of GDP (38%) by 2070, well below the EU 
average  of  73%  (451).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 1.1 pps (127%) 
of  GDP  by  2070,  markedly  lower  than  the  EU 
average  of  170%.  Overall,  projected  long-term 
care  expenditure  increase  is  expected  to  add  to 
budgetary  pressure.  Medium  fiscal  sustainability 
risks  appear  over  the  long  run,  mitigated  by  the 
projected  decrease  in  age-related  spending  driven 
by pensions (452). 

System Characteristics  

Long-term  care  is  organised  on  the  principle  of 
social  assistance  and  financed  mainly  from  the 
state  budget  (96%),  while  the  remainder  comes 
from  beneficiaries’  participation  in  payment  of 
costs of care outside one’s own family. Local and 
regional  self-governing  units  participate  in  the 
financing of the system and organisation of social 
welfare  services  within 
their 
competences.  

the  scope  of 

The acting Social Welfare Act (Official Gazette of 
the  Republic  of  Croatia,  157/13,  152/14,  99/15, 
52/16,  16/17,  130/17) 
result  of  a 
comprehensive  social  welfare 
reform,  which 
includes the reform of cash benefits, the system of 
social services, the mode of their financing and the 

the 

is 

(451) The 2018 Ageing Report, 
https://ec.europa.eu/info/sites/info/files/economy-

finance/ip079_en.pdf. 

(452) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

317 

 
                                                           
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

system  of  public  social  welfare  centres.  The 
primary  objective  was  to  simplify  the  system  and 
provide better and more efficient access to services 
and  benefits,  establish  clearer  division  between 
cash benefits and social services and rationalise the 
network  of  social  services  centres.  Previous  15 
cash benefits with different criteria and conditions 
for  obtaining  were  reduced  to  10  better  targeted 
and defined ones (453).  

There  is  no  specific  national-level  data  available 
on  long-term  care  expenses  in  Croatia.  In  2009 
expenses for financing of the social welfare system 
amounted  to  0.89%  of  GDP  (Bodiroga-Vukobrat, 
2012).  The  share  of  beneficiaries  of  permanent 
social assistance in total population in 2010 stood 
at 2.3%, which is an increase of 0.2% as opposed 
to 2009 (2.1%).  

The Ministry of Demographics, Family, Youth and 
Social Policy is in the lead as far as social welfare 
(including  long-term  care)  is  concerned.  Social 
services  are  carried  out  by  public  institutions: 
Social  Welfare  Centres  established  by  the  State, 
institutions  for  elderly  and  disabled  and  people 
who  suffer  from  severe  illnesses,  institutions  for 
those  with  a  physical,  mental  or  sensory 
impairment,  care  homes  for  people  suffer  from 
mental  illness  and  homes  for  children  and  youth 
with  disabilities  and  behavioural  disorders.  Social 
Welfare Centres also decide upon monetary social 
assistance (European Commission 2013). 

Types of care 

Social welfare beneficiaries are entitled to (choose 
freely between) cash benefits, benefits in-kind and 
social services, as established by law. 

There  are  currently  eleven  types  of  cash  benefits 
according  to  the  Social  Welfare  Act  (Article  25), 
some of which are related to LTC: the guaranteed 
minimum benefit, the compensation for the cost of 
housing, the right on firewood costs, the allowance 

(453) Among  ten  cash  benefits  with  different  criteria  and 
conditions  for  obtaining,  which  are  better  targeted  and 
defined  than  previous  ones,  the  most  innovative  is  the 
guaranteed minimum benefit (GMB). GMB consolidates 4 
previous  supplementary  cash  benefits,  ensuring 
that 
persons  have  enough  funds  to  satisfy  their  basic  monthly 
personal needs, while also stimulates the activation of those 
capable  of  working.  Deinstitutionalisation  and  the  role  of 
private providers of social services are emphasised.  

318 

or 

for the personal needs of users of accommodation, 
the  one-off  cash  allowances,  the  fees  related  to 
education,  the  personal  disability  allowance,  the 
allowance  for  assistance  and  care,  the  parent 
caregiver 
the 
caregiver 
unemployment  allowance  and  the  benefit  for 
endangered buyer of energy sources. The personal 
disability  allowance  is  granted  to  persons  with 
grave  disability  or  other  severe  and  permanent 
changes  in  health  status,  for  the  purpose  of 
satisfying necessities of life for involvement in the 
daily life of the community. 

allowance, 

Large  cities  and  cities  which  are  the  seats  of 
counties  are  obliged  to  provide  other  types  of 
material  support  and  assistance,  including  the 
stimulation  of  volunteering  and  work  of  civil 
society organisation. Elderly people mostly rely on 
the guaranteed minimum benefit, the compensation 
for the cost of housing, the right on firewood costs, 
the  allowance  for  the  personal  needs  of  users  of 
accommodation,  the  one-off  cash  allowances,  the 
personal  disability  allowance,  the  allowance  for 
assistance  and  care  and  the  in-home  assistance. 
The in-home assistance is awarded to persons with 
secured  housing  and  other  living  conditions,  but 
who  are,  due  to  old  age,  disability  or  other  grave 
health  conditions  unable  to  take  care  of  their 
personal  needs  alone  or  with  help  from  their 
families.  The  condition  for  receiving  this  means-
tested social service is that the assistance cannot be 
obtained  from  parents,  spouse  or  children,  nor 
based on life maintenance and support agreements 
or other regulations. 

There are nine categories of social services, which 
are  basically  social  benefits  in-kind.  In-home 
assistance  is  an  example  of  a  social  service.  It 
implies  the  provision  of  different  practical  forms 
of  help,  prescribed  in  bylaws  (typically  includes 
delivery  of  meals,  housework,  assistance  with 
personal  hygiene  and  satisfying  other  everyday 
needs). 

The  LTC  users  are  most  often  elderly  and  people 
with disabilities. Long-term care is carried out both 
through institutional and non-institutional forms of 
care.  Long-term  accommodation  is  granted  to 
users  who  need  over  a  long  period  of  time 
intensive  care  and  other  life  needs.  There  also 
exists  a  range  of  institutionalised  forms  of  care, 
e.g.  permanent  or  temporary  accommodation  or 
even daily or shorter stays in care centres. 

 
                                                           
 
there  were  294 

In  2016, 
institutional  LTC 
providers,  governmental  and  non-governmental 
LTC  homes  and  other  legal  providers  (legal 
persons)  for  stay  in  and  accommodation  of  adults 
and  the  elderly  (196  for  the  elderly  and  infirm/ 
seriously sick people, 67 for disabled children and 
adults  with  physical, 
intellectual  or  sensory 
impairments and 31 for mentally ill adults) ( 454). 

Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

Reliance  on  long-term  care  is  certified  by  the 
social  welfare  centres,  established  through  special 
regulations.  Degree  of  physical  and  mental 
impairment, duration of reliance on care, degree of 
(full  or  partial)  incapacity  for  independent  living, 
urgency  and  scope  of  assistance  and  care, 
screening  of  income  and  assets  are  among  the 
indicators being assessed. 

As a rule, the Social Welfare Centre has to verify 
occasionally  or  at  least  once  a  year,  if  the 
conditions  for  social  assistance  are  still  met.  It  is 
also  a  duty  of  the  recipient  to  report  all  relevant 
changes within eight days (455). 

blindness 

and/or 
trained 

There  are  exceptions  when  means  test  does  not 
apply,  such  as  serious  mental  or  physical 
deafness 
impairment, 
(if 
blind/deaf  persons  have 
to  care  for 
themselves,  when determining if persons  have  the 
right  to  receive  the  allowance  for  assistance  and 
care  in  full  amount,  as  well  as  blindness  and/or 
deafness (if blind/deaf persons have trained to care 
for themselves), or the fact that a person is totally 
deprived  of  legal  capacity,  when  determining  if 
persons have the right to receive the allowance for 
assistance and care in reduced amount.  

Means-testing is applied, meaning that a person is 
only  eligible  for  this  kind  of  assistance  if  his/her 

(454) Governmental  and  non-governmental  LTC  homes,  county 
LTC  homes  and  other  legal  providers  (legal  persons)  of 
LTC - total (1.+ 2.+ 3.) includes 294 providers and serves 
30.339  users,  of  which  22.695  are  LTC  users  (i.e.  long-
term accommodation or organised housing users)..  Source: 
Ministry  of  Demographics,  Family,  Youth  and  Social 
Policy, Report for 2016. 

(455) Previous  supplementary  cash  benefits,  ensuring 

that 
persons  have  enough  funds  to  satisfy  their  basic  monthly 
personal needs, while also stimulates the activation of those 
capable  of  working.  Deinstitutionalisation  and  the  role  of 
private providers of social services are emphasised. 

Long-term care systems 

3.4. Croatia 

average income in the three months preceding the 
application  does  not  exceed  200%  of  the  base 
amount (per family  member) or 250% of the base 
amount  (single  persons)  (Article  57  (2)  Social 
Welfare  Act).  The  base  amount  is  defined  by 
Social Welfare Act, Article 27, paragraph 2, and in 
2015 it was 500 HRK (about €66). 

In 2010, the total of HRK 58.1 million (about €7.5 
million)  was  utilised  for  the  implementation  of 
social services of generational solidarity (day care 
services  and  in-home  assistance),  as  well  as  the 
improvement  of  work  quality.  75%  was  financed 
from  the  State  budget  of  the  Republic  of  Croatia, 
while the rest of the financing (25%) was born by 
the local and regional self-government units. 

Role  of  private  sector,  private  insurance  and 
out of pocket co-payments 

In  Croatia,  more  than  two  thirds  of  institutional 
homes  for  the  elderly  are  privately  owned  (see 
footnote 7).  

from 

the  budgets  of 

Long-term  care  is  financed  from  the  state  budget 
and  partly 
regional 
communities  (also  the  city  of  Zagreb)  and  local 
communities. Social services might be co-financed 
by  the  beneficiaries  and  their  family  members 
(European Commission, 2013). 

Prevention and rehabilitation measures 

National  and  county  Centres  for  gerontology 
operate  at  the  county  institutes  of  public  health. 
Apart  from  Centres  of  Gerontology,  there  are 
Gerontology  Centres  as  multifunctional  centres  of 
immediate  and  integral  multidisciplinary  care  for 
elderly  people  in  the  local  community.  A  total  of 
79  Gerontology  Centres  for  community  care  of 
elderly  people  operate  in  Croatia,  12  thereof  in 
Zagreb,  where  most  elderly  people  live  (Ministry 
of Health). 

Formal/informal caregiving 

The  aim  of  the  Foster  Families  Act  (Official 
Gazette, 90/11, 78/12) is deinstitutionalisation and 
increase  of  the  number  of  foster  families,  their 
professionalisation  and  specialisation  for  taking 
care  of  certain  categories  of  beneficiaries.  Foster 
care  is  defined  as  a  non-institutional  type  of  care 
for children and adults out of their families. Types 

319 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

care 

foster 

according 

are  defined 

of 
to 
beneficiaries  (traditional,  specialised,  urgent  and 
temporary)  as  well  as  the  status  of  foster  care 
(kinship,  professional).  Foster  families  for  adults, 
are taking care mainly for elderly and frail persons, 
persons  with  disability  and  mentally  ill  adults. 
Foster care is provided only upon referral from the 
competent Social Welfare Centre.  

The  scale  of  family  care  in  Croatia  is  above  the 
EU27  average.  Around  17%  of  the  respondents 
aged  35-49  report  having  to  care  for  elderly 
relatives  at  least  several  times  a  week.  The  age 
cohort  50-64  apparently  bears  the  greatest  load 
when  it  comes  to  taking  care  of  elderly:  24% 
female  respondents  and  13%  male  respondents  of 
that  age  group  are  involved  in  those  activities, 
which places Croatia among the top three countries 
in  Europe  (after  Italy  and  Estonia)  (Bodiroga-
Vukobrat, 2012). 

the 

In  addition  to  religious  communities  and  non-
governmental  organisations,  the  role  of  the  civil 
sector’s  associations 
long-term  care 
in 
arrangements  is  important  in  Croatia.  There  are 
various  pensioners'  associations  organised  at 
national,  regional  and  local  levels.  For  example, 
one  of  the  oldest  civil  society  organisations  in 
Croatia  is  the  National  Pensioners’  Convention  of 
Croatia (Cro. Matica umirovljenika Hrvatske) with 
around  270,000  members,  300  associations  and 
800  branches  and  clubs  at  the  local  level.  The 
association and its members, organise the purchase 
of winter foodstuffs, meat, fruits and vegetables, as 
well  as  heating  fuel  at  preferential  prices  with 
payment  by  instalments,  while  its  volunteers  visit 
the  sick  and  infirm,  and  socialise  in  clubs, 
branches and associations. 

Recently 
reforms 

legislated  and/or  planned  policy 

transparency, 

During  2013  a  new  Act  on  Social  Welfare  was 
created  and  it  was  put  into  force  on  January  1 
2014.  This  Act  established  prerequisites  for 
IT  and 
enhancing  efficiency, 
expertise base in the system  of social  welfare and 
as  well  raises  the  community  awareness  of  social 
rights.  It  contains  new  criteria  for  social  benefits 
and services in order to promote the integration of 
social  exclusion.  Setting 
those  who 
lays 
standards  for  quality 
and 
foundations 

deinstitutionalisation 

in  social  services 

suffer 

for 

320 

developing  new  extra-institutional  services, 
it 
offers  wider  choice  and  services  improvement 
within the process of social integration; it enables 
creation  of  comprehensive  social  beneficiaries 
base.  As  for  the  cash  benefits,  they  are  better 
defined  in  the  context  of  persons  at  great  risk  of 
poverty  and  social  exclusion.  The  new  Act 
introduced  guaranteed  minimum  benefit,  which  is 
a  new  type  of  cash  benefit  merged  from  four 
previous  social  cash  benefits  which  were  under 
jurisdiction of three different Ministries. The state 
decides  on  the  height  of  this  allowance  on  an 
annual basis. 

The  new  Act  on  Social  Welfare  enabled 
transparent  and  fair  system  of  "social  services 
contracting" which means that all service providers 
within  the  network  will  form  the  service  price  on 
basis of a single calculation methodology and this 
procedure  will  be  prescribed  in  a  separate  bylaw. 
Final service price will also depend on the service 
provider's  harmonisation  with  directives 
for 
service  providing  within  the  network,  taking  into 
account  his/her  professional  resources,  location 
and  harmonisation  with  minimum  quality 
standards. 

Introducing  guaranteed  minimum  benefit 
into 
social  welfare  system  represents  the  beginning  of 
merging various benefits and services and is a step 
forward  to  establishing  a  centre  in  charge  of  all 
cash  benefits,  a  kind  of  „one  stop  shop“.  This 
centre  would  consequently  take  charge  of  all 
existing  cash  benefits,  which  are  currently  under 
jurisdiction  of  various  state  institutes  and  offices. 
Further 
the  social  welfare 
system  and  establishing  network  with  other 
systems with the scope of data exchange will result 
with  lowering  administration  costs  as  well  as 
simplifying the whole process. 

informatisation  of 

Law  on  Unique  Expertise  Body  (Official  Gazette, 
85/14,  95/15)  presumes  founding  of  the  single 
expertise  body  meaning  that  expertise  would  be 
done  in  one  place,  which  would  shorten  the 
existing  administrative  procedures.  According  to 
the past regulations every service claimer has to be 
examined  every  single 
is 
claiming  for  benefits  in  various  systems.  Besides 
generating unnecessary expenses this procedure is 
quite tiring for the benefit claimer. 

time  when  he/she 

 
According  to  the  new  Law  on  Unique  Expertise 
Body,  an  individual  benefit  claimer  can  obtain 
his/her  rights  in  various  systems  based  on  one 
document  and  the  expertise  given  from  the  single 
expertise  body  (pension  insurance,  professional 
rehabilitation  and  employment  of  persons  with 
disability,  various  types  of  maternity  and  parental 
allowances,  allowances  for  civil  and  military  war 
victims).  This  body  should 
function  as  an 
independent  working  unit  within  the  Institute  for 
expertise, 
and 
employment  of  persons  with  disability,  with 
branch  offices  all  around  the  country  (local  and 
regional). The expertise procedure would be based 
on  a  single  methodology  for  determining  the 
disability  level/residual  functional  and  working 
capacity.  Since  January  1,  2015  responsible  for 
this 
for  expert  evaluation, 
professional  rehabilitation  and  employment  of 
disabled people. 

rehabilitation 

professional 

Institute 

the 

is 

by 

the  Family  Law 

Besides  the  above  mentioned  laws,  this  is  partly 
regulated 
(Official 
Gazette,103/15)  according  to  which  parents  have 
obligation  to  maintain  an  adult  child  who  has 
severe  and  permanent  illness  and  disability  and  is 
not able to live/work independently, children have 
obligation  to  maintain  their  disabled  and  without 
living  resources  parents,  and  grandchildren  have 
obligation  to  maintain  their  disabled  and  without 
living  resources  grandparents  (if  grandparents 
maintained grandchildren). 

The  social  welfare  system  provides  assistance  to 
individuals at risk of poverty or social exclusion as 
well  as  those  living  in  non-adequate  personal  or 
family  environment. 
includes  prevention, 
It 
promoting  changes,  assisting  individuals,  families 
or  groups  in  their  everyday  needs  as  well  as 
enhancing  their  social  inclusion.  The  concept  for 
fulfilling 
the 
Ministry of Social Policy and Youth Strategic plan 
2015-2017,  which  sets  three  goals  to  be  achieved 
in the upcoming period: 

these  conditions 

is  defined  by 

Goal  1.  Develop  comprehensive  approach  to 
various  user  groups  by  improving  the  legislative 
frame and upgrading service providers efficiency: 

−  provide  equal  access  to  the  social  services 
network  for  all  users  and  providers  alike,  and 
effective  access  to  cash  benefits  for  disabled 
people; 

Long-term care systems 

3.4. Croatia 

improve and develop a strategic and legislative 
framework  focussed  on  elderly,  people  with 
addiction problems, asylum seekers, victims of 
trafficking and homeless; 

increase  the  efficiency  of  the  social  welfare 
centres; 

legal 

regulations  and 

improve 
implement 
regulations to ensure  more effective protection 
of the individual rights of citizens; 

implement  and  monitor 
the  process  of 
transformation  and  de-institutionalisation  of 
social  welfare homes  founded by  the  Republic 
of Croatia; 

increase  service  quality  by  improving  the 
infrastructure  of  homes 
the 
Republic of Croatia; 

founded  by 

− 

− 

− 

− 

− 

−  as  stated  above,  the  goal  is  to  improve  the 
system through more efficient legislative frame 
and  developing  various  social  programmes 
which  will,  consequently,  guarantee  system 
improvements  especially  in  the  context  of 
groups at social risk. 

Goal 2. Enhance the process of social inclusion for 
various user groups:  

−  develop 

volunteerism 

measurement 
contributions; 

and 

and 
evaluate 

systems 

of 
volunteer 

− 

− 

− 

increase  availability  and  quality  of  social 
services with the regional uniformity; 

improve 
providers; 

quality 

of 

professional  work 

increase level of social inclusion of people with 
disabilities; 

−  develop services that contribute to the inclusion 
of the elderly, people with addiction problems, 
asylum  seekers,  victims  of  trafficking  and  the 
homeless in the community life. 

The idea of volunteering development is present in 
several  national  documents  such  as:  Croatian 
Government programme for the period 2011-2015, 

321 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Law  on  Youth,  Law  on  Youth  Advisory  Boards, 
Law on Agency for Mobility and EU Programmes, 
National  Youth  Programme  2014-2017  and 
Strategy  of  Social  Care  for  Older  People  2014-
2016. Volunteering is presented as an activity to be 
enhanced and promoted with the goal of improving 
life  quality  both  for  service  users  and  volunteers 
and  enhancing  social  inclusion  of  marginalised 
social groups. Promoting  more active engagement 
of  local  and  regional  self-government  in  social 
care system by enhancing the work of NGO's and 
humanitarian  aid  organisations  and  assuring  them 
extra 
financial 
institutional  service  development.  This  type  of 
service  development  is  planned  as  well  in  the 
Transformation  and  deinstitutionalisation  plan  of 
social  care  homes  and  other  legal  entities  who 
practice  social  welfare  activities  in  Republic  of 
Croatia 2011-2016 (2018). 

contributes 

assistance 

to 

Goal  3.  Improve  care  for  vulnerable  groups  by 
setting more efficient coordination in enforcement 
of national and international strategic documents: 

−  ensure conditions for the implementation of EU 
policies,  VE  and  other  international  initiatives 
in accordance with the competence; 

−  ensure conditions for use of EU funds; 

−  strengthen  workforce  and  capacity  of 

the 

respective Croatian social welfare authorities; 

− 

improve care of disabled people by establishing 
more  effective  coordination,  monitoring  and 
the 
evaluation  of 
the 
of 
National  Strategy 
Opportunities  for  Disabled  People  2007  to 
2015  and  the  Convention  on  the  Rights  of 
Disabled People. 

implementation  of 
for  Equalisation 

The Ministry of Social Policy and Youth conducts 
expert  activities  related  to  EU,  Council  of  Europe 
and  UN  membership  obligations  as  well  as  other 
international and regional initiatives in the field of 
social policy and social inclusion and it is obliged 
to  submit  reports  to  these  organisations.  The 
Ministry  also  informs  various  user  groups  on  the 
possibilities  offered  in  EU  funds.  Furthermore,  it 
develops  bilateral  and  multilateral  cooperation 
with organisations/institutions acting in the field of 

322 

social  welfare  by  organising  and  participating  in 
international and regional events. 

Challenges 

Croatia has a relatively fragmented system of LTC, 
a  feature  that  often  leads  to  inefficiencies.  At 
a 
present,  Croatia 
comprehensive  strategy  and  long-term  care  is 
spread across health and social-welfare systems.   

developed 

has 

not 

The main challenges of the system appear to be: 

a 

for 

•  Improving  the  governance  framework  and 
administrative  efficiency: 
to  establish  a 
coherent  and  integrated  legal  and  governance 
clear  delineation  of 
framework 
responsibilities  of  state  authorities  concerning 
the  provision  of  long-term  care  services;  to 
strategically 
integrate  medical  and  social 
services via such a legal framework; to use care 
planning  processes,  based  on  individualised 
need  assessments,  involving  health  and  care 
providers  and  linking  need  assessment  to 
resource allocation.  

•  Improving 

financing  arrangements: 

to 
determine  the  extent  of  user  cost-sharing  on 
LTC  benefits;  to  include  assets  in  the  means-
test  used  to  determine  individual  cost-sharing 
(or  entitlement  to  public  support)  for  B&L 
costs  better 
the  distribution  of 
reflects 
economic welfare among individuals. 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
the  need-level 
coverage  schemes,  setting 
triggering entitlement to coverage; the depth of 
coverage, that is, setting the extent of user cost-
sharing on LTC benefits. 

•  Encouraging  home 

to 

care 

care: 

legislative 

to 
new 

develop 
institutional  care  by  e.g. 
alternatives 
frameworks 
developing 
encouraging  home 
regulation 
controlling  admissions  to  institutional  care  or 
the establishment of additional payments, cash 
benefits  or  financial  incentives  to  encourage 
home care; to monitor and evaluate alternative 
incentives  for  use  of 
including 
services, 
alternative settings. 

and 

 
Long-term care systems 

3.4. Croatia 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons. 

the 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  LTC;  to  steer  LTC  users  towards 
appropriate settings. 

•  Improving value for money: to invest in ICT 
as  an  important  source  of  information,  care 
management and coordination. 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

323 

 
 
3
2
4

Table 3.4.1:  Statistical Annex – Croatia 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

37
15.4
4.3

:
:
:

78.8
71.7
:
:
:
:

40
16.4
4.3

:
:
:

79.3
72.4
:
:
:
:

44
17.4
4.3

:
:
:

79.2
72.2
:
:
:
:

48
17.0
4.3

:
:
:

79.7
72.3
:
:
:
:

45
15.3
4.3

:
:
:

79.7
72.8
:
:
:
:

45
15.1
4.3

:
:
:

79.9
73.4
60.4
57.4
36.5
11.4

45
15.4
4.3

0.0
:
0.1

80.4
73.8
61.7
59.8
36.8
7.7

44
15.5
4.3

0.1
:
0.1

80.6
73.9
64.2
61.9
29.2
5.3

43
15.4
4.3

0.2
24.0
0.3

81.0
74.5
60.4
57.6
31.0
8.0

43
15.6
4.2

0.2
27.8
0.4

81.0
74.7
60.0
58.6
30.9
7.6

44
16.5
4.2

0.2
31.7
0.4

80.5
74.4
56.8
55.3
34.2
11.0

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

:
:
:

:
:

:
:
:

:
:

:
:
:

:
:

:
:
:

:
:

:
:
:

:
:

:
:
:

:
:

16
17
0.8

:
:

16
17
0.8

:
:

16
17
0.8

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.4.2:  Statistical Annex - continued – Croatia 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

4.2

0.31

7.4

0.9

0.9

2020

4.1

0.31

7.7

0.9

0.9

21,020

22,322

112,385

22,079

23,367

113,972

3.7

50.2

50.0

50.0

94.7

5.3

83.1

4.3

16.4

3.9

50.7

50.8

49.2

94.8

5.2

82.7

4.3

16.4

2030

3.9

0.33

8.4

1.0

1.0

22,719

24,056

118,127

4.2

49.5

51.0

49.0

94.8

5.2

84.4

4.4

16.4

2040

3.8

0.35

9.2

1.1

1.2

2050

3.7

0.35

9.5

1.1

1.4

2060

3.5

0.35

9.8

1.2

1.6

2070

3.4

0.34

10.1

1.2

2.0

26,283

27,562

123,342

26,776

27,987

120,980

26,317

27,471

117,447

27,298

28,360

115,265

4.6

50.8

52.8

47.2

94.9

5.1

80.3

4.1

16.1

4.8

50.4

53.9

46.1

95.0

5.0

79.9

4.1

15.9

4.9

49.6

54.8

45.2

95.0

5.0

81.5

4.1

15.9

5.0

50.0

56.9

43.1

95.0

5.0

81.9

4.1

15.5

MS Change 2016-
2070

EU Change 2016-
2070

-19%

10%

35%

38%

127%

30%

27%

3%

35%

0%

14%

-14%

0%

-5%

-1%

-5%

-6%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report  projections (2016-2070). 

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3.5.  CYPRUS 

General 
expenditure, 
sustainability and demographic trends 

context: 

fiscal 

GDP per capita is below EU average based on the 
most recent figures, with 23,820 PPS in 2015(EU: 
29,610). Population was estimated at 0.9 million in 
2016 (456).  According  to  Eurostat  projections,  the 
total  population  is  projected  to  increase  from  that 
level to 1.0 million in 2070, a 20% increase which 
is  well above the average EU value of 2%. Based 
on 
total  public 
expenditure  on  long-term  care  (health  and  social 
part)  (457)  is,  with  0.3  %  of  GDP  in  2015,  below 
above  the  EU  average  in  the  same  year  (1.6%). 
The health component however, with 0.2% in 2015 
is lower than the EU average of 1.2% in the same 
year. 

the  Ageing  Report  2018, 

Health status 

Life expectancy at birth, 83.7 years for women and 
79.9  years  for  men,  was  above  EU  average  levels 
of 83.3 and 77.9years in 2015. However, in terms 
of healthy life years, Cyprus is broadly in line with 
the  average  with  63.4  years  for  women  and  63.1 
years  for  men  (vs.63.3  and  62.6  in  2015  in  the 
EU).  The  percentage  of  the  population  having  a 
long-standing  illness  or  health  problem  is  below 
the  value  for  the  Union  as  a  whole  (32.7%  in 
Cyprus  versus  34.2%  in  the  EU  in  2015).  The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  daily  activities  for 
the  same  year  stands  at  7.9%,  which  is  only 
slightly lower than the EU-average of 8.1%. 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living is projected to increase 
significantly  over  the  coming  50  years.  From  70 
thousand  residents  living  with  strong  limitations 
due  to  health  problems  in  2016,  an  increase  of 
107% is envisaged up to 2070, to slightly less than 
140 thousand. That is a steeper increase than in the 
EU as a whole (25% in the EU). Also as a share of 
the  population  the  dependents  are  projected  to 
become  a  bigger  group,  from  7.8%  to  13.4%,  an 

(456) Based on Eurostat projections. 
(457) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

326 

increase  of  73%,  well  above  the  EU-average 
increase of 21%. 

Expenditure projections and fiscal sustainability  

is 

by 

driven 

expenditure 

is  projected 

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 
to  steadily 
percentage  of  GDP 
increase. In the "AWG reference scenario", public 
long-term 
the 
combination of changes in the population structure 
and  by  a  moderately  positive  evolution  of  the 
health  (non-disability)  status.  The  joint  impact  of 
those factors is a projected increase in spending of 
about 0.3 pps of GDP by 2070(458), an increase of 
84% which stands above the average EU value of 
73%.  The  "AWG  risk  scenario",  which  also 
captures  the  impact  of  additional  cost  drivers  to 
demography  and  health  status,  i.e.  the  possible 
effect of a cost and coverage convergence, projects 
an  increase  in  spending  of  2.9  pps  of  GDP  by 
2070. This reflects the fact that coverage and unit 
costs of care are relatively low in Cyprus, and may 
experience  an  upward  trend  in  future,  driven  by 
demand  side  factors.  Overall,  the  projected  long-
term  care  expenditure  increase  is  expected  to  add 
to  budgetary  pressure,  contributing  to  the  risk  for 
long-term sustainability of public finances (459). 

System Characteristics  

Policies and measures that fall within the spectrum 
of long-term care are administered by the Ministry 
of Health (long-term health care) and the Ministry 
of Labour, Welfare and Social Insurance (MLWSI) 
(long-term social care, sensory, cognitive) through 
the  Welfare  Benefits  Administration  Service,  the, 
Social  Welfare  Services 
the 
Department  for  Social  Inclusion  of  Persons  with 
Disabilities (DSID).   

(SWS) 

and 

In  July  2014,  the  Guaranteed  Minimum  Income 
(GMI) and Social Benefits legislation was adopted 
and the competent Ministry is MLWSI. 

(458) The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(459) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

 
                                                           
 
                                                           
 
Long-term care systems 

3.5. Cyprus 

The  Guaranteed  Minimum  Income  and  in  general 
the  Social  Benefits  (Emergency  Needs  and  Care 
Needs)  Decree  of  2015  N.353/2015,  which  was 
revised  in  2016  (N.  162/2016),  incorporates  the 
“Scheme for the Subsidisation of Care Services” 
which  covers  social  care  needs  of  recipients  of 
guaranteed minimum income and members of their 
family  unit.  The  Scheme  mainly  covers  cash 
benefits  and  in  justified  cases  it  may  provide  for 
in-kind  services  (from  state  home  carers  who  are 
employed under a contract with the government to 
provide  their  services  –  benefits  in  kind–to  the 
beneficiaries).  

Subsidisation  of  care  services  under  the  Decree, 
covers  home  care,  day  care,  respite  care  and 
residential  care  in  approved  and  registered  care 
services  (natural  and/or  legal  persons)  under  the 
relevant legislative framework of the SWS. Long-
term  social  care  services  are  provided  by  the 
government,  local  authorities,  non-governmental 
organisations  (NGOs),  and  the  private  sector 
(private for profit enterprises).  

In  addition,  two  new  Decrees  were  adopted  in 
2017 (365/2017) and 2018 (158/2018), covering in 
particular  the  subsidisation  of  home  care  services 
to  persons  with  disabilities  and  persons  aged  80 
years old and above, respectively.  

[State  Aid  Scheme,  under 

Furthermore,  the  MLWSI  subsidise  social  care 
programmes at local level run by NGO’s and Local 
the 
Authorities 
Regulation  360/2012  for  the  provision  of  services 
of general economic interest (De minimis)]. These 
programmes (day-care, residential care, home care 
and child care) cover the social care needs of older 
people,  people  with  disabilities  and  children  at 
local level.  

The  State  (SWS)  provides  full  time  care  in 
residential  homes  for  older  persons  and  persons 
with  mental  and  physical  disabilities  and 
it 
operates  Houses  in  the  Community  for  persons 
with mental and physical multiple disabilities. 

These  benefits  cover  the  cost  for  the  purchase  of 
care  services  but  also  rehabilitation  services 
(physiotherapy,  occupational 
speech 
therapy  etc).  Due  to  the  absence  of  a  National 
Health  System  and  an  integrated  rehabilitation 
policy,  persons  with  disabilities  often  use  DSID 
cash benefits for purchasing rehabilitation services 
from the private sector. 

therapy, 

Long-term  care  constitutes  a  minor  share  of  total 
government  expenditure.  In  2015,  per  capita 
spending  for  this  item  was  at  the  level  of  38.5 
million  PPS  (EU:  373.6  PPS).  In  terms  of  total 
government  spending,  this  accounted  for  only 
0.4% (EU: 2.5%).  

Public  spending  on  long-term  care  in  Cyprus 
reached 0.2% of GDP in 2013 and remained stable 
at that level until 2015, well below EU average of 
1.2%  of  GDP.  Only  more  than  half  of  this 
spending,  (54%)  was  spent  on  in-kind  benefits, 
which is a much lower share than for the EU as a 
whole  (EU  2016:  84.4%),  while  46%,  far  above 
the  EU  average  of  15.6%  for  2016,  was  provided 
as  cash-benefits.  Based  on  available  figures, 
Cyprus  appears  to  have  a  stronger  focus  on  cash 
benefits,  which  is  a  consequence  of  the  lack  of  a 
formal public long-term care scheme. It is not clear 
which role private co-payments for formal in-kind 
care  play  in  the  financing  of  long-term  care 
services.  

Types of care 

The expenditure for institutional (in-kind) services 
makes  up  12.7%  of  public  expenditure  on  long-
term  care  in-kind  (EU:  66.3%),  87.3%  are  being 
spent for long-term care services provided at home 
(EU:  33.7%).  However,  as  discussed  above, 
Cyprus spends most of its long-term care resources 
via  cash  benefits,  thus  with  a  greater  focus  on 
home care. 

According  to  the  Decree  162/2016  the  following 
types of care (formal care), are covered: 

Moreover,  additional  cash  benefits  are  regulated 
by 
the  DSID  for  persons  with  disabilities, 
irrespective  of  their  income  level,  targeting  to 
cover the cost of disability. In particular, under two 
special laws and two schemes, persons with severe 
motor  disability,  paraplegia,  quadriplegia  or 
blindness  are  entitled  to  monthly  cash  benefits. 

Home  care  may  include  personal  and  household 
care. To cover the needs of home care either by an 
approved  natural  and/or 
legal  person,  or  by 
Domestic Worker the maximum amount granted as 
a  subsidy  is  €400/month  per  family  unit.  For 
extraordinary  and  justified  cases  a  larger  amount 
can  be  covered  for  instance,  when  additional  care 

327 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

attendants  are  required.  According  to  the  Decree 
158/2018, for persons aged 80 years old and above 
the amount of subsidisation for home care services 
is €200 or €400, according to their needs.   

for 

Day  care:  is  offered  during  the  day  at  Day  Care 
Centers 
the  Elderly  and  Persons  with 
Disabilities covering personal care services, meals, 
social and creative activities. The State may pay a 
cash benefit to recipients of long-term care of up to 
€137 per month for day care provided by approved 
physical  and/or  legal  persons.  In  some  cases  the 
transportation/accompanying  costs  especially  for 
persons with disabilities are also covered. 

Residential  care:  provides  for  a  24  hour  care, 
where  the  person  requires  continuous  support  and 
their needs cannot be covered by family  members 
or  other  supportive  services  in  their  environment. 
Residential care is provided by  the public, private 
or non-governmental. In addition to free residential 
care  in  public  institutions,  the  state  may  pay 
monthly  cash  benefit  for  residential  care  provided 
by  approved  natural  and/or  legal  persons.  Cash 
benefits  vary  from  €625  to  €745  per  month 
depending  on  the  care  needs  of  the  beneficiary 
(e.g. bedridden, mobility difficulties or not).  

Respite Care: is for short periods of time in order 
to  give  short  spells  of  rest  to  the  informal  care-
giver and can take the form  of the above types of 
care  (home,  residential  or  day  care).  Informal 
carers  are  supported  in  their  valuable  role  and 
simultaneously  the  person  concerned  is  supported 
for  staying  in  their  home  environment.  Respite 
care  is  arranged  depending  on  the  needs  and 
preferences  of  the  people  themselves  and  of  their 
families as far as possible.  

The  level  of  the  subsidisation  for  the  above  types 
of care is defined by an automated analysis of the 
specific assessment tools used by the SWS.  

In the case of DSID cash benefits can be used by 
the  beneficiaries  at  their  choice  of  care  services 
either formal or informal. 

In addition, as from November 2017 a new Decree 
365/2017  was  issued  according  to  which  home 
care for persons with disabilities in the framework 
of  the  Guarantee  Minimum  Income  Law  has  four 
level subsidy being €100, €200, €300 or €400. The 
needs for care at home and the level of subsidy are 

328 

assessed and certified by the Disability Assessment 
Center  of  the  Department  for  Social  Inclusion  of 
Persons with Disabilities. 

Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

with 

severe 

GMI recipients may be entitled to subsidisation of 
their  long-term  social  care  needs,  except  for 
persons 
disability 
(motor/paraplegia/quadriplegia/blindness), who are 
entitled  to  this  irrespective  of  their  income  level. 
Subsidisation for long-term social care may also be 
provided to persons that are  not eligible  for GMI, 
if  their  income  is  not  sufficient  to  cover  for  their 
long  term  social  care  needs,  provided  that  they 
meet all the other conditions specified in the GMI 
legislation. 

No  qualifying  period  is  defined  for  long-term 
social  care  eligibility.  Entitlement  to  long-term 
social  care  is  based  upon  need,  i.e.  based  on  the 
person’s ability to carry out his/her daily home and 
personal  care  and  his/her  ability  to  meet  his/her 
frequent  activities  outside  of  his/her  home  (i.e. 
shopping,  doctor  visits,  social  activities).  In 
addition, 
the  Decree  (N.162/2016)  does  not 
provide  for  any  element  of  duration/degree  of 
dependency.  Only  in  the  case  of  home  care 
provided by Domestic Worker, the persons should 
be deprived of their ability for self-care.  

GMI  applications  are  evaluated  by  the  Welfare 
Benefits  Administration  Service,  which  informs 
the SWS whether the applicant fits in the category 
of people who can be assessed for the provision of 
care services based on the legislation and whether 
the  applicant  receives  care  benefit  from  any  other 
Service.  Subsequently,  the  SWS  assess  the  social 
care need of applicants and then communicate the 
results of their assessment to the Welfare Benefits 
Administration  Service  for  their  decision  on  the 
application  according 
the 
to 
assessment.  

results  of 

the 

to 

situ  visits 

the 
in 
The  SWS  perform 
accommodation  of  the  applicants/beneficiaries  to 
assess  the  need  for  care  with  the  use  of  specific 
assessment tools. The SWS may ask for additional 
certificates/reports  from  other  Services  (including 
medical  reports).  Subsequently,  the  information 
collected  is  assessed  by  Specialised  Assessment 
Teams of the SWS. In case of a positive evaluation 

 
to 

of  the  care  needs  of  the  applicant/  beneficiary 
which  corresponds 
the  approval  of  care 
provision,  it  includes  the  type,  the  extent  and  the 
duration of the care that will be provided as well as 
the  amount  of 
the 
beneficiary  and  the  approved  service  provider  an 
Agreement  for  the  Provision  of  Social  Care  is 
signed,  which  should  be  notified  to  the  SWS  for 
the  correctness  of  the  content  and  for  the  future 
quality checks of the service provision.  

subsidisation.  Between 

In  case  the  beneficiaries  prefer  a  different  type  of 
care  than  the  one  proposed,  then  they  have  the 
right  to  make  their  own  arrangements,  which  will 
be subsidised up to the approved amount.  

In the case of persons with disabilities, in order to 
become  entitled  of  disability  cash  benefits  by 
DSID  or  the  GMI-Disability  additional  benefit 
they  have  to  follow  a  disability  assessment  and 
the  DSID  Disability 
certification 
Assessment  Centre.  The  disability  assessment 
methodology 
International 
Classification  of  Functioning,  Disability  and 
the  World  Health 
(ICF) 
Health 
Organisation (WHO). 

is  based  on 

issued  by 

through 

the 

According to Decree 365/2017 as from November 
2017,  the  Disability  Assessment  Centers  of  the 
Department  for  Social  Inclusion  of  Persons  with 
Disabilities  also  assess  and  certify,  based  on  the 
ICF  classification,  the  needs  of  persons  with 
disabilities for care at home. 

Prevention and rehabilitation measures 

In  Cyprus  the  health  care  system  for  the  elderly 
people  is  strongly  acute-care  oriented.  Hospital 
and  specialist  care  is  a  priority  over  other  models 
of  care.  Elderly  patients  have  the  opportunity  to 
visit  the  primary  health  care  services  either  at  the 
out  patients  surgeries  or  at  the  health  care  centers 
all  over  the  districts.  The  GPs  do  not  function  as 
gatekeepers  for  medical  care,  as  hospitals  and 
private  specialists  are  directly  accessible 
to 
patients.  Nursing  homes  as  such  do  not  exist,  but 
elderly and very elderly people in need of complex 
care  stay  in  hospitals  or  in  special  care  wards  in 
retirement  homes.  Health  care  provision  is  also 
services, 
in  hospital  physiotherapy 
offered 
according to their needs. 

Long-term care systems 

3.5. Cyprus 

Long-term  care  includes  health,  personal,  and 
support  services,  aiming  at  helping  people  to 
remain  at  home  and  live  as  independently  as 
possible. Long-term care is mainly provided either 
in the home of the person receiving services or at a 
family  member's  home.  In-home  services  may  be 
short-term  -for  someone  who  is  recovering  from 
surgery, for example -or long-term, for people who 
need help continuously. 

Long-term  care  Services  are  provided  mainly  to 
people  with  a  high  level  of  dependency,  often 
elderly  people,  those  with  chronic  diseases  and 
people  with  physical, 
learning  and  mental 
disabilities.  The  Nursing  Services  of  the  Ministry 
of Health facilitate the long-term care provided by 
a network of Community Nurses (General Nursing 
Community Nurses and Mental Health Community 
Nurses) 
ill 
patients,  disabled  people,  artificially  ventilated 
patients at home and elderly people who live alone 
and encounter severe health problems. 

through  home  visits 

to  mentally 

The long-term care provided by the Mental Health 
Services,  is  being  ensured  by  monitoring  chronic 
mental  patients  in  the  community  (at  their  homes 
or at rehabilitation units, such as Day Centers and 
Occupational Rehabilitation Units). These services 
are  provided  by  a  multi-disciplinary  team  of 
mental health professionals – psychiatrists, clinical 
psychologists, ergo therapists, nursing officers.  

Dental  Services  have  a  wide  network  of  clinics 
geographically  distributed  to  provide  access  in 
remote  areas  populated  predominantly  by  elderly 
people.  These  clinics  in  the  rural  and  urban  areas 
offered  primary  and  secondary  oral  care  services. 
large  hospitals  operate 
Alongside 
prosthetic  clinics  for  construction  of  partial  and 
full  dentures.  Beneficiaries  as  third  age  patients, 
have  to  pay  a  small  amount  of  100  euro  per  item 
(denture). 

four 

the 

Formal/informal caregiving 

In the case of DSID cash benefits can be used by 
the  beneficiaries  at  their  choice  of  care  services 
either formal or informal.  

329 

 
European Commission 

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Recently 
reforms 

legislated  and/or  planned  policy 

In  July  2014, 
the  Cyprus  Government  has 
reformed  the  welfare  system  by  introducing  a 
Guaranteed  Minimum  Income  (GMI).  In 
the 
relevant Law (N. 109(I)/2014), article 10 (2) refers 
to  the  care  needs  of  the  GMI  recipients  and  their 
family  members,  where  additional  assistance  can 
be  provided.  In  this  direction,  the  Minister  of 
Labour,  Welfare  and  Social  Insurance,  issued  in 
August  2014  a  Decree  that  incorporates  the 
“Scheme  for  the  Subsidisation  of  Care  Services”, 
which  was  revised  in    2015  (N.353/2015)  and  in 
2016  (162/2016).  The  new  Scheme  subsidises  the 
social care needs of GMI recipients, including the 
members  of  their  family  unit,  as  described  in 
section “LTC System Characteristics”.   

In  addition,  two  new  Decrees  were  adopted  in 
2017 (365/2017) and 2018 (158/2018), covering in 
particular  the  subsidisation  of  home  care  services 
to  persons  with  disabilities  and  persons  aged  80 
years old and above, respectively.  

the 

inspection  of 

In  addition,  the  SWS,  as  the  competent  authority 
for 
the  minimum  quality 
standards  of  care  structures,  have  determined  in 
2016  Terms  and  Conditions  for  the  Provision  of 
Home Care Services, pending the drafting of a new 
law which will regulate home care provision.  

Challenges 

Cyprus  has  recently  reformed  and  clearly  defined 
eligibility  for  long-term  care  benefits,  but  the 
financing  of  the  system  is  relatively  fragmented 
and  overall  governance  seems  improvable.  The 
main challenges of the system appear to be: 

•  Improving the governance framework: to set 
the  public  and  private  financing  mix  and 
organise  formal  workforce  supply  to  face  the 
growing  number  of  dependents,  and  provide  a 
strategy  to  deliver  high-performing  long-term 
care  services  to  face  the  growing  demand  for 
LTC services; to strategically integrate medical 
and social services via such a legal framework; 
to  define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  establish 
good information platforms for LTC users and 

330 

providers;  to  share  data  within  government 
administrations to facilitate the management of 
potential  interactions  between  LTC  financing, 
targeted  personal-income  tax  measures  and 
transfers  (e.g.  pensions),  and  existing  social-
assistance or housing subsidy programmes. 

earned 

•  Improving  financing  arrangements:  to  face 
the  increased  LTC  costs  in  the  future  e.g.  by 
tax-broadening, which means financing beyond 
revenues 
the  working-age 
by 
population;  to  foster  pre-funding  elements, 
which  implies  setting  aside  some  funds  to  pay 
for  future  obligations;  to  explore  the  potential 
of  private  LTC  insurance  as  a  supplementary 
financing tool. 

•  Providing adequate levels of care to those in 
need  of  care: 
risk  of 
to 
impoverishment  of  recipients  and  informal 
carers. 

reduce 

the 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  ,  carer’s 
allowances  replacing  lost  wages  or  covering 
expenses  incurred  due  to  caring,  cash  benefits 
paid to the care recipients,  while ensuring  that 
incentives  for  employment  of  carers  are  not 
diminished  and  women  are  not  encouraged  to 
withdraw  from  the  labour  market  for  caring 
reasons.  

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  coordination  of  care 
pathways  and  along  the  care  continuum,  such 
to 
through  a  single  point  of  access 
as 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
the 
structures  for  care  co-ordination  and 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health and long-term care: to steer LTC users 
towards appropriate settings. 

 
•  Improving value for money: to invest in ICT 
as  an  important  source  of  information,  care 
management and coordination. 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

Long-term care systems 

3.5. Cyprus 

331 

 
 
3
3
2

Table 3.5.1:  Statistical Annex – Cyprus 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

15
27.1
0.7

0.0
:
0.0

80.8
76.5
58.2
59.8
:
:

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

16
27.6
0.7

0.0
:
0.0

82.0
78.1
63.4
64.2
29.1
8.5

18
28.9
0.8

0.0
:
0.0

82.1
77.6
62.8
63.1
28.7
8.2

19
28.1
0.8

0.0
:
0.0

82.9
78.2
64.5
63.9
25.9
6.9

19
26.3
0.8

0.0
:
0.0

83.5
78.5
65.3
64.8
28.4
6.7

19
25.4
0.8

0.1
33.0
0.3

83.9
79.2
64.2
65.1
34.0
7.6

20
24.6
0.8

0.1
34.6
0.3

83.1
79.3
61.0
61.6
32.7
10.3

19
23.2
0.9

0.1
33.5
0.3

83.4
78.9
64.0
63.4
32.6
7.9

18
21.9
0.9

0.2
33.9
0.4

85.0
80.1
65.0
64.3
33.2
8.0

18
22.1
0.9

0.2
35.2
0.3

84.7
80.9
66.3
66.1
32.2
7.3

18
23.8
0.8

0.2
38.5
0.4

83.7
79.9
63.4
63.1
32.7
7.9

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:

2005

Source: EUROSTAT, OECD and WHO. 

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

:
:
:

:
:

3
:
0.4

:
:

3
:
0.4

:
:

4
:
0.5

:
:

4
:
0.5

:
:

4
:
0.5

:
:

5
:
0.5

:
:

3
3
0.7

:
:

3
3
0.8

:
:

3
3
0.8

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.5.2:  Statistical Annex - continued – Cyprus 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

0.9

0.07

7.8

0.3

0.3

8,390

7,798

23,009

4.6

59.3

54.0

46.0

12.7

87.3

2.1

15.5

5.1

2020

0.9

0.07

8.2

0.3

0.3

9,186

8,530

24,654

4.9

59.4

54.2

45.8

12.7

87.3

2.1

15.3

5.1

2030

0.9

0.09

9.3

0.4

0.5

11,530

10,753

29,588

5.6

60.5

53.7

46.3

12.7

87.3

1.9

14.1

5.1

2040

1.0

0.10

10.4

0.4

0.7

13,967

13,066

34,564

6.4

61.9

54.6

45.4

12.7

87.3

1.9

13.7

4.9

2050

1.0

0.11

11.4

0.4

1.1

16,224

15,187

39,108

7.2

62.9

55.6

44.4

12.8

87.2

1.9

13.7

4.9

2060

1.0

0.12

12.3

0.5

1.8

18,538

17,497

44,046

7.9

64.3

57.2

42.8

12.9

87.1

2.0

14.2

4.8

2070

1.0

0.14

13.4

0.6

3.2

21,528

20,603

49,959

9.0

67.2

58.9

41.1

12.9

87.1

2.0

14.1

4.7

MS Change 2016-
2070

EU Change 2016-2070

20%

107%

73%

84%

947%

157%

164%

117%

96%

13%

9%

-11%

1%

0%

-5%

-9%

-9%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

3
3
3

3
.
5
.

C
y
p
u
s

r

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
3.6. CZECH REPUBLIC 

General 
expenditure, 
sustainability and demographic trends 

context: 

fiscal 

GDP per capita in PPS is at 23,700 and below EU 
average  of  29,600  in  2015.  The  Czech  Republic 
had  a  population  of  10.5  million  inhabitants  in 
2016  and  during 
the 
population will slightly decrease to 10.0 million by 
2070. 

the  coming  decennia 

Health status 

Life expectancy at birth for both  women and  men 
is  respectively  81.6  years  and  75.7  years  in  2015 
and is below the EU averages (83.3 and 77.9 years, 
respectively).  Healthy  life  years  at  birth  are  with 
63.7  years  (women)  and  62.4  years  (men)  around 
the EU-averages (63.3 and 62.6, respectively). The 
percentage of the Czech population having a long-
standing illness or health problem is at EU average 
(32.5%  in  the  Czech  Republic  vs.  32.5%  in  the 
EU). The percentage of the population indicating a 
self-perceived  severe 
its  daily 
activities  stands  at  6.5%  in  2015,  which  is  lower 
than the EU-average (8.1%). 

limitation 

in 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living increases significantly 
over  the  coming  50  years.  From  630  thousand 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  37%  is 
envisaged  until  2070  to  870  thousand.  That  is  a 
steeper increase than in the EU as a whole (25%). 
Also  as  a  share  of  the  population,  the  dependents 
are becoming a bigger group, from 6% to 8.7%, an 
increase of 45%. This is more than the EU-average 
increase of 21%. 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
long-term 
"AWG  reference  scenario",  public 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 1.6 pps 

in 

334 

of  GDP  by  2070  (460).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 2.4 pps of GDP 
by 2070. This reflects, that coverage and unit costs 
of  care  are  comparatively  low  in  the  Czech 
Republic, and  may experience an upward trend in 
future, driven by demand-side factors. 

Overall,  the  projected  long-term  care  expenditure 
poses  a  risk  to  the  long-term  sustainability  of 
public finances. Over the long run,  medium  fiscal 
sustainability risks appear for the Czech Republic. 
These  risks  derive  primarily  from  the  projected 
impact  of  age-related  public  spending  (notably 
health care, long-term care and pensions) (461). 

System Characteristics  

Funding and also provision of long-term care is not 
completely  separated  from  health  and  social  care. 
Home  care  services  are  provided  by  special 
insurers  and 
providers  contracted  by  health 
reimbursed by public health insurance system only 
if  indicated  by  a  general  practitioner.  Institutional 
care 
in 
establishments, 
residential 
predominantly  providing  social  care  and  nursing 
care  to  a  limited  extent  only.  Reimbursement  for 
home  and  institutional  care  is  based  on  fee-for-
service.  

in  specific  facilities  or 

is  provided 

social 

care 

Based  on  the  2018  Ageing  Report,  total  public 
spending  on  LTC  (health  and  social  part) (462) 
reached  1.3%  of  GDP  in  2016  in  the  Czech 
Republic, below EU average of 1.6% of GDP. The 
Czech  Republic 
in-kind 
benefits. In fact, 87.3% of public LTC spending is 
done  via  in-kind  benefits,  which  is  slightly  above 
the EU average (EU: 84.4%).  

relies  primarily  on 

(460) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(461) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(462) Long-term care benefits can be disaggregated into health 
       related long-term care (including both nursing care and 
       personal care services) and social long-term care (relating  
       primarily to assistance with IADL tasks). 

 
                                                           
Long-term care systems 

3.6. Czech Republic 

care  allowance.  Any  remaining  costs  have  to  be 
covered  privately,  either  by  the  recipient  or  his 
family. However, in some cases, a top-up from the 
Ministry  of  Labour  and  Social  Affairs  and  the 
municipalities  to  cover  nursing  care  can  be  made 
available. 

Recently 
reforms  

legislated  and/or  planned  policy 

A  new  long-term  attendance  benefit,  covered  by 
the  sickness  insurance,  has  been  effective  as  of 
June  2018  for  people  who  take  care  of  their 
relative  or  household  member  after  a  hospital 
discharge, when all-day care is needed for at least 
one  month.  The  benefit  amounts  to  60%  of  the 
reduced  daily  assessment  base  for  up  to  90 
calendar  days.  During  this  period,  employers  are 
obliged to keep the attending person’s position. 

An  interdepartmental  working  group  has  been  set 
up several years ago to prepare a structural reform 
in  order  to  harmonise  health  and  social  long-term 
care  systems,  which,  although  interconnected,  are 
run  separately  by  the  Ministry  of  Health  and  the 
Ministry of Labour and Social Affairs. The current 
dual  scheme  leads  to  distorted  incentives  and 
ineffective  usage  of  health  and  LTC  facilities. 
However,  so  far  this  cooperation  did  not  deliver 
any concrete results. 

In the EU, 50% of dependents are receiving formal 
in-kind  LTC  services  or  cash-benefits  for  LTC. 
This share is with 90.4% much higher in the Czech 
Republic.  It  means  that  9  out  of  10  individuals 
aged  15  or  more  and  declaring  themselves  as 
severely  dependent,  would  receive  some  kind  of 
formal care (at home or in institution, in-kind or in 
cash). Overall, 5.4% of the population (aged 15+) 
receive  formal  LTC  in-kind  and/or  cash  benefits 
(EU: 4.6%).  

The expenditure for institutional (in-kind) services 
makes  up  77.2%  of  public  in-kind  expenditure 
(EU: 66.3%), 22.8% being spent for LTC services 
provided  at  home  (EU:  33.7%).  Thus,  relative  to 
other  Member  States  the  Czech  Republic  has  a 
focus  on  institutional  care,  which  may  not  always 
be cost-efficient.  As institutional care is relatively 
costly,  Member  States  with  shares  well  above  the 
EU  levels  may  benefit  from  efficiency  gains  by 
shifting  some  coverage  (and  thus  expenditure) 
from institutional to other types of care. However, 
in  the  Czech  Republic  a  significant  part  of  the 
costs  of  institutional  care  is  covered  by  the  care 
from 
recipients 
institutional  long-term  care  to  home  care  may  not 
heavily  decrease  public  costs,  but  may  improve 
quality  of  life  of  recipients  who  receive  care  at 
home rather than in institutions. 

themselves.  Thus, 

shifting 

Types  of  care,  eligibility  criteria  and  user 
choices: dependency, care needs, income 

Challenges 

Recipients of care are differentiated on a four level 
scale according to the recipient's care needs, which 
is  specified  in  the  law.  Care  allowance  is  not 
means-tested  except  for  patients  under  the  age  of 
18  years.  The  highest  care  allowance  amounts  to 
roughly half of the average salary.  

Social  care  services  are  mostly  provided  by 
informal  carers,  but  also  by  professional  social 
services.  Formal  carers  of  social  services  can  be 
registered  or  unregistered.  If  registered,  they  are 
bound  by  administrative  maximum  prices.  If  a 
person is unregistered, then free pricing of services 
applies  to  be  fully  covered  by  private  payments. 
Some  services,  such  as  social  prevention  or 
rehabilitation  are  provided  without  private  co-
payments. For institutional care, recipient's income 
(up to 85%) can be used to cover accommodation 
and food costs for residential care. Reimbursement 
of other social services is limited by the recipient's 

The main challenges of the system appear to be: 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of  responsibilities  of  state  authorities  with 
respect  to  the  provision  of  long-term  care 
services; to set the public and private financing 
mix  and  organise  formal  workforce  supply  to 
face  the  growing  number  of  dependents,  and 
provide  a  strategy  to  deliver  high-performing 
long-term  care  services  to  face  the  growing 
demand  for  LTC  services;  to  strategically 
integrate medical and social services via such a 
legal  framework;  to  define  a  comprehensive 
approach  covering  both  policies  for  informal 
(family and friends) carers, and policies on the 
formal  provision  of  LTC  services  and  its 
financing; 
information 
to  establish  good 
platforms for LTC users and providers; to share 

335 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Improving value for money: to invest in ICT 
as  an  important  source  of  information,  care 
management and coordination. 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

of 

to 
data  within  government  administrations 
facilitate 
potential 
the  management 
interactions  between  LTC  financing,  targeted 
personal-income  tax  measures  and  transfers 
(e.g.  pensions),  and  existing  social-assistance 
or  housing  subsidy  programmes;  to  deal  with 
cost-shifting incentives across health and care. 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage;  the breadth 
of  coverage,  that  is,  setting  the  extent  of  user 
cost-sharing on LTC benefits; and the depth of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage.  

•  Encouraging  home 

to 

care 

care: 

legislative 

to 
new 

develop 
alternatives 
institutional  care  by  e.g. 
developing 
frameworks 
regulation 
encouraging  home 
controlling  admissions  to  institutional  care  or 
the establishment of additional payments, cash 
benefits  or  financial  incentives  to  encourage 
home care; to monitor and evaluate alternative 
services, 
incentives  for  use  of 
including 
alternative settings. 

and 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
labour 
to  withdraw  from 
encouraged 
market for caring reasons.  

the 

•  Facilitating  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  LTC;  to  steer  LTC  users  towards 
appropriate settings. 

336 

 
Table 3.6.1:  Statistical Annex – Czech Republic 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

110
20.0
10.2

0.2
:
0.6

79.2
72.9
60.0
58.0
:
:

124
21.0
10.2

0.2
:
0.6

79.9
73.5
59.9
57.9
29.8
6.8

138
22.2
10.3

0.3
:
0.6

80.2
73.8
63.3
61.4
27.7
5.4

161
22.2
10.3

0.2
:
0.5

80.5
74.1
63.4
61.3
27.8
5.6

149
20.6
10.4

0.3
:
0.6

80.5
74.3
62.7
61.1
29.7
6.2

157
21.1
10.5

0.3
:
0.6

80.9
74.5
64.5
62.2
29.0
6.0

164
21.7
10.5

0.3
:
0.7

81.1
74.8
63.6
62.2
30.7
6.1

161
21.6
10.5

0.3
:
0.7

81.2
75.1
64.1
62.3
30.0
6.2

158
21.8
10.5

0.9
204.3
2.0

81.3
75.2
64.2
62.5
31.5
6.4

157
22.5
10.5

0.9
239.5
2.2

82.0
75.8
65.0
63.4
31.7
6.2

168
23.7
10.5

0.9
254.6
2.2

81.6
75.7
63.7
62.4
34.2
6.5

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
3
7

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

51
120
1.7

:
:

71
112
1.8

257
38

91
104
1.9

276
:

111
96
2.0

281
:

113
99
2.0

:
:

115
101
2.1

:
:

345
94
4.2

:
:

349
96
4.2

:
:

353
98
4.3

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
6
.

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3
3
8

Table 3.6.2:  Statistical Annex - continued – Czech Republic 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

10.6

0.63

6.0

1.3

1.3

2020

10.7

0.66

6.2

1.4

1.4

125,840

99,886

346,008

134,431

109,081

369,567

5.4

90.4

87.3

12.7

77.2

22.8

76.0

28.3

5.2

5.8

92.8

87.1

12.9

76.7

23.3

74.6

28.0

5.2

2030

10.7

0.76

7.1

1.8

1.8

164,088

142,529

455,729

7.1

99.9

87.3

12.7

75.1

24.9

75.6

28.8

5.3

2040

10.5

0.81

7.7

2.1

2.3

192,040

169,421

528,793

8.4

100.0

87.4

12.6

74.6

25.4

76.4

29.6

5.4

2050

10.5

0.83

7.9

2.4

2.7

202,592

183,027

558,488

9.0

100.0

87.9

12.1

73.9

26.1

80.2

31.4

5.4

2060

10.3

0.87

8.5

2.8

3.3

228,340

213,525

637,374

10.5

100.0

87.7

12.3

73.2

26.8

79.7

31.2

5.5

2070

10.0

0.87

8.7

2.9

3.7

243,099

223,704

671,357

11.4

100.0

87.1

12.9

73.4

26.6

75.9

29.9

5.6

MS Change 2016-
2070

EU Change 2016-
2070

-6%

37%

45%

116%

175%

93%

124%

94%

111%

11%

0%

2%

-5%

17%

0%

6%

7%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source:  EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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3.7. DENMARK 

General  context:  expenditure,  sustainability 
and demographic trends 

GDP per capita in PPS is at 34,800 and far above 
EU  average  of  29,600  in  2015.  Denmark  has  a 
population  of  5.7  million  inhabitants.  During  the 
coming decennia the population will steadily grow, 
from 5.7 million inhabitants in 2016 to 6.8 million 
inhabitants  in  2070.  This  19%  increase  is  much 
higher than the EU average of 2%.  

Health status 

Life expectancy at birth for both  women and  men 
is  respectively  82.7  years  and  78.8  years  in  2015 
and  is  slightly  below  the  EU  average  for  women 
and above the EU average for men (83.3 and 77.9 
years, respectively). Healthy life years at birth are 
with  57.6  years  (women)  and  60.4  years  (men) 
below 
(63.3  and  62.6, 
the  EU  averages 
the  Danish 
respectively).  The  percentage  of 
population having a long-standing illness or health 
problem  is  lower  than  in  the  Union  (29.4%  in 
Denmark versus 34.2% in the EU). The percentage 
of the population indicating a self-perceived severe 
limitation  in  its  daily  activities  stands  at  6.6%, 
which is lower than the EU-average (8.1%). 

Dependency trends 

of  GDP  by  2070  (463).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 4.8 pps of GDP 
by 2070.  

Overall,  projected 
long-term  care  expenditure 
increase  is  expected  to  add  to  budgetary  pressure. 
However,  currently  low  fiscal  sustainability  risks 
appear  for  Denmark  over  the  long  run.  This 
initial 
from  a 
derives  primarily 
budgetary  position,  which  fully  mitigates  the 
projected ageing costs increase over the long term 
(464). 

favourable 

System Characteristics  

Denmark  has  a  universal  and  very  extensive 
system  of  LTC.  The  overall  principles  of  the 
system are determined by the central government, 
while  local  authorities  are  responsible  for  the 
allocation  of  resources,  the  delivery  of  LTC 
services,  and  the  design  and  implementation  of 
actual  LTC  policy.  Therefore,  98  municipalities 
are  responsible  for  a  broad  range  of  welfare 
services  which  can  be  provided  as  institutional 
care facilities, special housing, or home care. 

The number of people depending on others to carry 
out activities of daily living increases significantly 
over  the  coming  50  years.  From  390  thousand 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  39%  is 
envisaged  until  2070  to  540  thousand.  That  is  a 
steeper increase than in the EU as a whole (25%). 
Also  as  a  share  of  the  population,  the  dependents 
are becoming a bigger group, from 6.8% to 7.9%, 
an  increase  of  17%.  This  is  slightly  less  than  the 
EU-average increase of 21%. 

Along  with  the  Netherlands  and  other  Nordic 
countries such as Sweden, Denmark has one of the 
highest expenditure on LTC of all EU-28 countries 
in  2016.  Local  authorities  are  responsible  for  the 
allocation  of  resources.  Their  LTC  costs  are 
financed  through  governmental  grants,  local  taxes 
and  equalisation  amounts  (received  from  other 
local  authorities).  The  budget  for  LTC  services  is 
set annually and is global. As a general rule, local 
authorities  can’t  set  charges  for  LTC  help, 
although there are exceptions. 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 
percentage  of  GDP  is  steadily  increasing.  In  the 
"AWG  reference  scenario",  public 
long-term 
expenditure  is  driven  by  the  combination  of 
the  population  structure  and  a 
changes 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 2.2 pps 

in 

Total  public  spending  on  LTC (465)  reached  2.5% 
of GDP in 2016 in Denmark, above EU average of 

(463) The 

2018 

Ageing 

Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(464) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(465) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating  
primarily to assistance with IADL tasks). 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

1.6%  of  GDP.  All  public  expenditure  on  LTC  in 
2016 were spent on in-kind benefits. Most in-kind 
expenditure  is  covered  by  the  public  payer,  as 
92.4%  of  total  LTC  in-kind  expenditure  was 
public,  and  7.6%  private.  Thus,  private  co-
payments for formal in-kind LTC have a marginal 
role in financing.  

rent  for  living  in  a  non-profit  or  conventional 
nursing home. 

As  to  the  provision  of  care,  local  authorities  and 
private  providers  supply  services  in  a  competitive 
framework  defined  by  quality  standards,  and  in 
some cases, price requirement.  

In  Denmark,  41%  of  dependents  are  receiving 
formal  in-kind  LTC  services  (EU:  50%).  Overall, 
2.8%  of  the  population  (aged  15+)  receive  formal 
LTC in-kind and/or cash benefits (EU: 4.6%). On 
the one hand, low shares of coverage may indicate 
a situation of under-provision of LTC services. On 
the other hand, higher coverage rates may imply an 
increased  fiscal  pressure  on  government  budgets, 
possibly calling for greater needs of policy reform. 

The expenditure for institutional (in-kind) services 
makes  up  34.4%  of  public  in-kind  expenditure 
(EU: 66.3%), 65.6% being spent for LTC services 
provided  at  home  (EU:  33.7%).  Thus,  relative  to 
other  Member  States  Denmark  has  a  focus  on 
home  care,  which  may  be  cost-efficient.  As 
institutional  care  is  relatively  costly,  Member 
States  with  shares  well  above  the  EU  levels  may 
benefit  from  efficiency  gains  by  shifting  some 
coverage (and thus expenditure) from institutional 
to other types of care. 

Types of care 

One of the main aims of social services for elderly 
and  disabled  people  is  to  ensure  that  they  can 
manage living in their own homes. In cases where 
elderly or disabled people cannot manage living on 
their own, they can move to residential care homes 
and  sheltered  homes.  Eligibility  is  based  on  a 
needs’  assessment  performed  by 
local 
authority.  Eligible  individuals  may  receive  a  cash 
benefit in order to employ necessary assistance. In 
order  to  qualify  for  this  allowance,  an  individual 
must meet a given level of need. 

the 

Personal  care  (ADL)  and  practical  assistance 
(IADL)  are  available  to  all  dependent  individuals 
without private co-payments.  

Basically, all eligible individuals  have free choice 
of  care  providers. Providers  include  senior  citizen 
residences,  gated  communities,  assisted  living 
units,  nursing  homes  and  day-care  centres  for 
temporary assistance. Individuals generally pay the 

340 

Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

Eligibility is based on a needs' assessment which is 
performed  by  the  local  authority.  There  is  no 
threshold 
requested, 
/  minimum  dependency 
neither for benefits in kind nor for benefits in cash. 

Prevention and rehabilitation measures 

Prevention  and  rehabilitation  are  a  significant 
objective in Danish LTC policies. Local authorities 
are since January 2015 by law under the obligation 
to  evaluate  if  the  person  in  need  of  help  could 
benefit from a rehabilitation scheme i.e. a training 
program  focusing  on  regaining 
independence, 
functionality.  The 
functionality  or  physical 
rehabilitation scheme is therefore offered to elderly 
citizens  that  are  considered  to  be  able  to  profit 
from this initiative.  

Formal/informal caregiving 

Even though most dependents in Denmark receive 
formal  care,  many  family  members  provide 
valuable  support  to  spouses  and  elder  family 
members,  especially  those  family  members  who 
suffer from dementia.  

Recently 
reforms  

legislated  and/or  planned  policy 

A  couple  of  initiatives  have  been  developed 
recently, which are summarised below: 

Agreement  on  “Future  Home  care”.  In  2014,  the 
Danish  Parliament  presented  the  “Agreement  on 
Future  Home  Care”.  Among  other  things  the 
agreement 
the  municipalities’ 
rehabilitation efforts and the services they provide 
to frail, elderly people. 

strengthens 

Transparency  reform  –  greater  focus  on  quality 
and results. The aim is to create greater and more 
systematic  knowledge  about  quality  and  best 

 
practice,  improving  accountability  as  well  as 
achieving  better  management  of  the  health  care 
and long-term care system based on improvements 
in the overall health of the population, a high level 
of  patient  involvement  and  lower  expenditure  per 
capita. The accessible health data should provide a 
platform  for  transparency  and  dissemination  of 
best practice as well as management and priorities 
in the  health care sector on the basis of  key  goals 
and results.  

and 

areas 

action 

Stronger health care agreements. Five health care 
agreements have been completed for 2015-2018 – 
one  for  each  region  –  and  they  include  new 
mandatory  key 
specific 
objectives.  Furthermore,  across  the  boundaries  of 
key action areas, the health care agreements aim to 
ensure  focus  on  inequality  in  health  and  active 
involvement  of  patients  and  their  relatives.  The 
aim  with  the  five  health  care  agreements  is  to 
ensure coherence and coordination of efforts in the 
patient  care  that  goes  on  across  hospitals,  general 
practice and municipalities so that each patient and 
citizen  receives  a  treatment  that  is  consistent  and 
of high quality at the lowest effective cost.  

National  quality  goals.  The  Government,  Danish 
Regions and Local Government Denmark have set 
eight  goals  for  the  quality  of  the  Danish  health 
care.  The  national  goals  set  a  framework  for  the 
continuous  quality  improvement.  The  national 
goals are supported by a number of local goals and 
activities, which leads to local improvements. The 
national goals are part of a national programme to 
improve  the  quality  in  the  health  care  system  in 
Denmark.  Beside  the  national  goals,  the  quality 
programme  consists  of  e.g.  quality  improvement 
leadership  programme  and 
teams,  a  national 
enhanced patient involvement and empowerment.   

Better  usage  of 
telemedicine,  health  IT  and 
digitalisation.  There  is  a  need  for  sweeping 
digitalisation of the health care and long-term care 
system  where  all  procedures  are  supported 
digitally,  where  up-to-date  patient  information  is 
shared by all relevant parties and where IT systems 
underpin  better  resource  utilisation  and  efficient 
care  pathways,  both  at  the  hospitals  and  in  their 
cooperation with the rest of the system. In order to 
meet  this  need,  the  Government  has  presented  a 
new  overall  digitalisation  strategy  for  the  health 
care and long-term care system.  

Long-term care systems 

3.7. Denmark 

Strengthening  of  professionalism  in  municipal 
nursing care. The Government intends to give the 
municipalities  and  municipal  nursing  care  better 
and  more  systematic  possibilities  of  utilising  the 
professional  competencies  in  general  practice  and 
at  hospitals.  In  this  way,  professionalism  will  be 
strengthened  in  municipal  nursing  care  through 
closer  cooperation  across  hospitals,  general 
practitioners and municipalities.  

Ensuring  stronger  involvement  of  patients  and 
their relatives. Active involvement of patients has 
a  positive  effect  on  both  the  results  of  treatment 
and  the  satisfaction  of  patients.  Therefore,  the 
Government  will  strengthen  the  involvement  of 
patients  and  their  relatives  in  the  Danish  health 
care  and  long-term  care  system.  The  Government 
intends to set up partnerships with, e.g., the Danish 
patient  societies  on 
to 
strengthen  the  involvement  of  patients  and  their 
relatives  in  the  Danish  health  care  and  long-term 
care sector.  

the  continued  work 

and 

regions 

Strengthening initiatives aimed at citizens in need 
of  rehabilitation.  It  is  the  Government's  goal  that 
all patients discharged from the hospital and with a 
need  for  rehabilitation  receive  the  necessary  and 
timely  rehabilitation.  This  requires  consistency  in 
the 
the 
between 
initiatives 
municipalities.  The 
communication  between 
hospitals  and  municipalities  must  be  improved, 
e.g. 
the 
municipalities are able to have a better idea of the 
need  of  the  individual  citizen  for  rehabilitation. 
Therefore,  the  Government  intends  to  enhance 
hospital  competencies  in  terms  of  describing  the 
need for rehabilitation of the group of patients with 
for 
a 
rehabilitation.  

the  rehabilitation  plan,  so 

complex  need 

comprehensive 

through 

and 

An  investment  of  the  public  health  care.  An 
ambitious,  long-term  strategy  that  is  targeting  on 
areas where the public health care need to be even 
better. The strategy focuses on five main elements: 
1)  cancer  2)  chronic  diseases  3)  strengthening  of 
general  practitioners  4)  involvement  of  patients 
and relatives 5) better quality in treatments. 

National  Action  Plan 
for  Dementia.  The 
government  and  other  political  parties  has  agreed 
to allocate DKK 470 million (appx. €63 million) to 
the implementation of specific initiatives based on 
a  new  national  action  plan  for  dementia  with  the 

341 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

through  a  single  point  of  access 

to 
as 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

aim of improving conditions for people living with 
dementia.  

Challenges 

Denmark  provides  for  a  comprehensive  and 
structured  LTC  system,  being  at  the  forefront  of 
many EU countries, in what concerns the efforts to 
continuously  improve  system  performance;  yet, 
cost issues are an element to be monitored closely 
in  view  of  the  increasing  LTC  expenditure.  The 
challenges for Denmark appear to be: 

•  Improving  the  governance  framework:  to 
establish  good  information  platforms  for  LTC 
users  and  providers;  to  use  care  planning 
individualised  need 
processes,  based  on 
assessments, 
care 
involving  health 
providers  and  linking  need  assessment  to 
resource allocation. 

and 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage;  the depth of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits;  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage.  

future  needs 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care; To improve recruitment efforts, 
including 
the  migration  of  LTC 
workers and the extension of recruitment pools 
of workers.  

through 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 

342 

 
Table 3.7.1:  Statistical Annex – Denmark 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

213
32.8
5.4

2.0
:
4.0

80.5
76.0
68.4
68.4
:
:

226
34.2
5.4

2.0
:
4.1

80.7
76.1
67.2
67.7
29.6
:

233
34.7
5.4

2.2
:
4.3

80.6
76.2
67.4
67.4
27.8
:

242
33.9
5.5

2.2
:
4.3

81.0
76.5
60.8
62.4
24.7
7.5

231
31.7
5.5

2.5
:
4.4

81.1
76.9
60.4
61.8
29.0
7.7

243
32.9
5.5

2.4
:
4.2

81.4
77.2
61.4
62.3
27.6
7.8

248
33.3
5.6

2.4
714.6
4.2

81.9
77.8
59.4
63.6
29.0
7.7

255
32.9
5.6

2.4
723.1
4.1

82.1
78.1
61.4
60.6
28.7
6.6

259
33.0
5.6

2.3
749.5
4.1

82.4
78.3
59.1
60.4
27.9
6.5

265
33.6
5.6

2.3
773.1
4.2

82.8
78.7
61.4
60.3
28.1
6.1

272
34.8
5.7

2.3
812.2
4.2

82.7
78.8
57.6
60.4
29.4
6.6

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

19
76

16
77

:
:
:

:
:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
4
3

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

123
73
3.6

18
78

106
96
3.7

20
80

89
119
3.8

:
80

72
142
3.9

:
81

73
143
3.9

:
83

74
145
3.9

:
83

44
101
2.6

:
84

45
103
2.6

:
:

46
104
2.6

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
7
.

D
e
n
m
a
r
k

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o
n
g

r

-
t
e
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e
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s

 
 
 
 
 
 
 
 
 
 
 
3
4
4

Table 3.7.2:  Statistical Annex - continued – Denmark 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

5.7

0.39

6.8

2.5

2.5

2020

5.9

0.41

6.9

2.6

2.7

2030

6.3

0.47

7.5

3.3

3.7

2040

6.6

0.50

7.6

3.8

4.6

2050

6.7

0.52

7.8

4.1

5.4

2060

6.8

0.54

7.9

4.4

6.3

2070

6.8

0.54

7.9

4.7

7.3

53,941

106,256

58,185

115,027

77,363

150,164

92,038

171,703

103,443

189,293

114,174

205,204

119,192

215,215

0

2.8

41.2

100.0

0.0

34.4

65.6

92.8

89.7

:

0

2.9

42.7

100.0

0.0

34.4

65.6

92.1

88.9

:

0

3.6

48.2

100.0

0.0

34.6

65.4

92.3

89.8

:

0

4.0

53.1

100.0

0.0

35.5

64.5

95.3

92.7

:

0

4.4

56.2

100.0

0.0

35.9

64.1

94.8

92.6

:

0

4.7

59.7

100.0

0.0

36.3

63.7

95.1

92.9

:

0

4.9

61.9

100.0

0.0

36.2

63.8

98.3

95.7

:

MS Change 2016-
2070

EU Change 2016-
2070

19%

39%

17%

87%

190%

121%

103%

:

75%

50%

0%

:

5%

-3%

6%

7%

:

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source:  EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

r

E
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-

C
o
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D
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m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.8. ESTONIA 

General 
expenditure, 
sustainability and demographic trends 

context: 

fiscal 

Estonia, the most northerly of the Baltic states has 
a GDP of 23.7 thousand PPS per capita, below the 
EU average of 30.0 thousand PPS per capita (466).  

During  the  coming  decennia  the  population  will 
steadily  decrease,  from  1.3  million  inhabitants  in 
2016  to  1.2  million  inhabitants  in  2070.  Thus, 
Estonia  is  facing  a  considerable  decrease  of  its 
population  by  11%,  while 
the  EU  average 
population is estimated to increase by 2%. 

Health status 

than 

Life expectancy at birth for both  men and  women 
was  estimated  at  respectively  73.2  years  and  82.2 
years  in  2015  and  is  below  the  EU  average  (77.9 
and 83.3 years respectively). Similarly, the healthy 
life  years  at  birth  for  both  sexes  are  56.2  years 
(women)  and  53.8  years  (men)  and  substantially 
lower 
the  EU-average  (63.3  and  62.6 
respectively  in  2015).  The  percentage  of  the 
Estonian population having a long-standing illness 
or  health  problem  is  considerably  higher  than  in 
the  Union  (46.2%  in  Estonia  versus  34.2%  in  the 
EU  in  2015).  The  percentage  of  the  population 
indicating  a  self-perceived  severe  limitation  in  its 
daily  activities  decreased  from  2006  to  2009,  but 
has  increased  since  2010  and  is  again  above  the 
EU-average (10.4% against 8.1% in 2015). 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living increases significantly 
over  the  coming  50  years.  From  0.13  million 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  17%  is 
envisaged until 2070 to 0.14 million. That is a less 
steep  increase  than  in  the  EU  as  a  whole  (25%). 
Also  as  a  share  of  the  population,  the  dependents 
are becoming a bigger group, from 9.6% to 12.6%, 
an increase of 31% (EU: 21%). 

Expenditure 
sustainability  

projections 

and 

fiscal 

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 

(466) Eurostat, 2017. 

in 

reference 

scenario,  public 

percentage  of  GDP  is  steadily  increasing.  In  the 
AWG 
long-term 
expenditure  is  driven  by  the  combination  of 
the  population  structure  and  a 
changes 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 0.5 pps 
of  GDP  by  2070  (467).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 3.8 pps of GDP 
by  2070.  However,  no  sustainability  risks  appear 
over the short-term and risks over the medium and 
long run are low ( 468). 

System Characteristics (469) 

The  long-term  care  system  in  Estonia  consists  of 
nursing care and welfare.  

LTC  services  can  be  split  into  community  care 
services  (where  the  recipient  is  supported  while 
continuing  to  live  in  her/his  own  home)  and 
institutional services (care is provided in a welfare 
the 
institution).  Local  governments  determine 
relevant 
basket  of  home  services  and 
them. 
conditions  and  procedures 
Municipalities  also  provide  adequate  housing  for 
those  who  cannot  afford  it.  Where  necessary  they 
also  provide  social  housing  or  assist  persons  who 
need  assistance  with  self-contained  living,  by 
adapting  the  dwelling  or  helping  them  find  more 
suitable housing. 

to  obtain 

the 

Fostering is also provided, care in a suitable family 
that the recipient is not a member of. This service 
is  provided  mainly  for  children  and  needs  to  be 
based  on  a  written  agreement  between 
the 
caregiver (host family) and the local municipality. 

Institutional care is provided in welfare institutions 
that  provide  the  recipients  who  stay  there  with 
appropriate  care  according 
level  of 
dependency  and  age.  Services  are  provided 
according to principles and in the same manner as 

their 

to 

(467) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf . 

(468) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(469) This section draws on OECD (2011b) and ASISP (2014). 

345 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

they  would  be  provided  to  recipients  living  at 
home.  

To  support  informal  care,  a  carer's  allowance  is 
paid  by 
to  guardians  or 
caregivers  of  disabled  persons  aged  18  years  or 
above.  

local  governments 

Public  spending  on  LTC  ( 470)  reached  0.5%  of 
GDP  in  2016  in  Estonia,  below  the  average  EU 
level of 1.6% of GDP. 45.1% of the benefits were 
in-kind,  while  54.9%  were  cash-benefits  (EU:  80 
vs 20%).  

In the EU, 50% of dependents are receiving formal 
in-kind  LTC  services  or  cash-benefits  for  LTC. 
This share is higher in Estonia with 100%. Overall, 
13.1% of the population (aged 15+) receive formal 
LTC in-kind and/or cash benefits (EU: 4.6%). On 
the one hand, high coverage rates couple with low 
overall  expenditure  may  imply  a  lack  of  focus  in 
the  provision  of  long-term  care  services,  possibly 
calling  for  increased  prioritisation.  On  the  other 
hand  low  shares  of  coverage  may  indicate  a 
situation of under-provision of LTC services. 

The expenditure for institutional (in-kind) services 
makes  up  59.2%  of  public  in-kind  expenditure 
(EU: 66.3%), 40.8% being spent for LTC services 
provided at home (EU: 33.7%).  

Types of care 

As  explained  in  the  previous  section,  long-term 
care  is  provided  either  at  home  or  in  institutional 
settings.  The  development  of  home  nursing  care 
(including  home  nurses  and  home  nursing 
services) is still at an early stage and faces a large 
financing gap.  

Care homes are not part of the health care system, 
and  therefore  do  not  in  principle  provide  medical 
care  to  long-term  care  recipients.  The  latter 
therefore are visited by family doctors, and/or use 
private nursing companies. 

accordance 

In 
Tervishoiuteenuste 
with 
korraldamise  seadus  (Act  of  Organisation  of 

(470) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

Health  Services), nursing services  include  nursing 
healthcare  services  and  are  provided  in  home-
based, day care and institutional settings. For more 
demanding  cases  of  nursing  care  for  the  elderly, 
optional geriatric assessment has been available in 
Estonia since 2004.  

The long-term care budget for the first half of 2013 
was 23% higher year-on-year, a three times higher 
increase than  for healthcare as a  whole. The main 
drivers  for  this  budget  increase  were  increased 
investments  into  infrastructure  supported  by  EU 
structural  funds.  Simultaneously,  the  number  of 
long-term  care  cases  financed  by  EHIF,  has 
increased by 12% year-on-year. The availability of 
long-term  care  has  significantly  increased  –  the 
number  of  day  care  nursing  home  visits  and  the 
number  of  persons  serviced  increased  by  8%  and 
11% respectively. 

Eligibility criteria 

Need for care is assessed by a local social worker, 
who  will  take  into  account  the  dependency  needs 
and preferences of the potential recipient and their 
family. The need for nursing care is assessed by a 
doctor (whether a general practitioner or a medical 
specialist).  The  involvement  of  doctors  is  related 
only to the assessment of eligibility and not to the 
provision of long-term care itself.   

An interdisciplinary assessment team performs the 
assessment  of  the  recipient's  level  of  dependency 
and,  based  on  this,  sets  up  a  personalised  nursing 
care  plan.  This 
includes  a  physician 
specialised in geriatrics (geriatrician or an internist 
trained  in  geriatrics)  as  well  as  a  nurse,  a  social 
worker and other relevant specialists. 

team 

Co-payments, out of the pocket expenses and 
private insurance 

LTC  services  are  financed  by  the  municipalities, 
the  budget  of  which  mainly  consists  of  a 
proportion of income taxes distributed to them by 
central  government.  Community  care  services  do 
not  usually  require  co-payment  by  the  individual 
or  his  or  her  family.  In  institutional  care  homes, 
however,  cost-sharing  can  amount  up  to  65%  of 
the  cost  of  provision  (in  general  terms  between 
€400 and €500), which is equivalent to 85% of the 
average  pension.  The  government  is  however 
obliged as part of social assistance to cover the full 

346 

 
                                                           
Long-term care systems 

3.8. Estonia 

cost for recipients and their families when they are 
unable to pay. 

Recently 
reforms  

legislated  and/or  planned  policy 

Geriatric assessment and nursing care are generally 
covered for by the Estonian Health Insurance Fund 
(EHIF),  which  suggests  a  diverse  funding  scheme 
that  goes  beyond  what  is  strictly  healthcare. 
Limited  local  government  and  EHIF  budgets  lead 
to  significant  financial  constraints  for  the  service. 
Similarly,  many  welfare  institutions  and  LTC  are 
faced with a shortage of bed capacity and staff.  

Although  formally  part  of  the  healthcare  sector 
rather  than  the  long-term  care  sector,  for  nursing 
care  a  co-payment  of  15%  (some  €6  per  day)  for 
inpatient  long-term  care  was  introduced  from  1 
January  2010  onwards.  The  aim  was,  in  part,  to 
restrict  the  use  of  hospital  resources  to  those  in 
need of  medical  treatment. This rate is however a 
ceiling,  and  many  hospitals  ask  for  lower  co-
payments,  as  the  bed-day  reimbursement  from 
EHIF  appears  to  be  sufficient  to  cover  more  than 
85% of the cost of provision. 

Formal/informal caregiving 

Informal  care  plays  an  important  role  in  Estonia 
and this is recognised in legal terms. As explained 
above,  local  governments  also  provide  a  carer's 
allowance. The impact of the allowance in helping 
to  reimburse  care  and  alleviating  the  care  burden 
of family members and allowing them to maintain 
their attachment to the labour market.  

eHealth 

The  combination  of  long-term  care  and  ICT  has 
not  been  a  major  priority.  There  have  been  some 
pilot projects in the field of homecare but these are 
still  at  an  early  stage.  Pilot  projects  currently  are 
mostly concerned with either social care (Virtu) or 
secondary/tertiary care (DREAMING and Eliko). 

Prevention 
policies/measures 

and 

rehabilitation 

Neither prevention nor rehabilitation measures are 
defined as (part of) LTC in Estonia; i.e. prevention 
and rehabilitation are part of health care.  

In  the  recent  past,  there  have  been  no  significant 
legislative  reforms  in  the  field  of  long-term  care. 
However, there have been some policy changes in 
this  area.  For  instance,  a  15%  co-insurance  rate 
was introduced in 2010 for inpatient nursing care. 
The aim of the plan was to involve patients in the 
financing  of  the  LTC  system.  However,  the  plan 
met with resistance and was not implemented until 
tough  austerity  measures  were  adopted  as  a 
response to the financial crisis. As a consequence, 
EHIF  expenditure  budgeted  for  inpatient  nursing 
care  in  2011  fell  by  4%  lower  expenditure  in  the 
planned EHIF budget for inpatient nursing care in 
2011.  However,  the  number  of  patients  was  1% 
greater  than  planned.  Additionally,  EU  structural 
funds  aiming  to  strengthen  infrastructure  have 
been granted to LTC hospitals.  

Interdisciplinary  working  groups  are  developing 
strategies  for  better  integration  of  health  care  and 
social 
Successful 
implementation will require consensus between the 
HC  and  LTC  systems,  as  well  as  a  supportive 
legislative framework.  

(including  LTC). 

care 

Challenges 

Estonia  has  taken  significant  steps  to  ensure  the 
fiscal  sustainability  of  LTC  expenditure  and 
increasing  its  availability.  The  main  challenges  of 
the system appear to be:  

•  Improving the governance framework: to set 
the  public  and  private  financing  mix  and 
organise  formal  workforce  supply  to  face  the 
growing  number  of  dependents,  and  provide  a 
strategy  to  deliver  high-performing  long-term 
care  services  to  face  the  growing  demand  for 
LTC services; to strategically integrate medical 
and social services via such a legal framework; 
to  define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  use  care 
planning  processes,  based  on  individualised 
need  assessments,  involving  health  and  care 
providers  and  linking  need  assessment  to 
to  share  data  within 
resource  allocation; 
government  administrations  to  facilitate  the 
management  of  potential  interactions  between 

347 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health and long-term care: to steer LTC users 
towards appropriate settings. 

•  Improving  value  for  money:  to  invest  in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

LTC  financing,  targeted  personal-income  tax 
measures  and  transfers  (e.g.  pensions),  and 
existing  social-assistance  or  housing  subsidy 
cost-shifting 
to  deal  with 
programmes; 
incentives across health and care. 

•  Improving  financing  arrangements:  to  face 
the  increased  LTC  costs  in  the  future;  to 
explore the potential of private LTC insurance 
as a supplementary financing tool; to determine 
the extent of user cost-sharing on LTC benefits.  

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
coverage  schemes,  by  setting  a  need-level 
triggering entitlement to coverage;  the breadth 
of  coverage,  that  is,  by  setting  the  extent  of 
user  cost-sharing  on  LTC  benefits;  and  the 
depth of coverage, that is, by setting the types 
of  services  included  into  the  coverage;  to 
provide  targeted  benefits  to  those  with  highest 
LTC 
of 
impoverishment  of  recipients  and  informal 
carers. 

reduce 

needs; 

risk 

the 

to 

•  Encouraging  home 

to 

care 

care: 

legislative 

to 
new 

develop 
institutional  care  by  e.g. 
alternatives 
frameworks 
developing 
regulation 
encouraging  home 
controlling  admissions  to  institutional  care  or 
the establishment of additional payments, cash 
benefits  or  financial  incentives  to  encourage 
evaluating 
home 
alternative  services,  including  incentives  for 
use of alternative settings. 

care;  monitoring 

and 

and 

•  Encouraging  independent  living:  to  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

future  needs 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term  care;  to  increase  the  retention  of 
recruited  LTC  workers,  by 
successfully 
improving  the  pay  and  working  conditions  of 
the  LTC  workforce,  training  opportunities, 
more 
feedback 
support and supervision.  

responsibilities  on-the-job, 

348 

 
 
 
Table 3.8.1:  Statistical Annex – Estonia 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

11
18.7
1.4

0.1
:
0.4

78.2
67.6
52.4
48.3
:
:

14
19.5
1.4

0.1
:
0.4

78.6
67.6
53.9
49.6
38.6
9.5

16
19.8
1.3

0.2
:
0.5

78.9
67.5
54.9
49.8
40.2
9.3

17
18.3
1.3

0.2
34.4
0.5

79.5
68.9
57.5
53.1
38.1
9.9

14
15.8
1.3

0.2
35.7
0.5

80.3
70.0
59.2
55.0
40.1
7.7

15
16.5
1.3

0.2
35.2
0.5

80.8
70.9
58.2
54.2
42.6
7.9

17
17.6
1.3

0.2
35.7
0.5

81.3
71.4
57.9
54.3
44.7
8.6

18
18.1
1.3

0.2
38.4
0.5

81.5
71.4
57.2
53.1
43.7
9.8

19
17.9
1.3

0.2
43.0
0.5

81.7
72.8
57.1
53.9
44.4
9.3

20
18.4
1.3

0.2
47.4
0.6

81.9
72.4
57.1
53.2
45.9
9.8

20
18.8
1.3

0.2
54.5
0.6

82.2
73.2
56.2
53.8
46.2
10.4

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
4
9

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

4
6
0.7

:
21

5
8
1.0

:
18

6
10
1.2

:
16

8
12
1.5

:
15

8
12
1.5

:
14

8
12
1.5

:
14

15
6
1.6

:
13

16
6
1.7

:
13

16
7
1.7

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
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.

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3
5
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Table 3.8.2:  Statistical Annex - continued – Estonia 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

1.3

0.13

9.6

0.9

0.9

13,235

25,836

132,722

13.1

100.0

45.1

54.9

59.2

40.8

23.9

8.4

4.9

2020

1.3

0.13

9.8

0.9

1.0

14,188

26,791

136,115

13.4

100.0

45.4

54.6

60.1

39.9

23.5

8.3

4.9

2030

1.3

0.14

10.5

1.0

1.3

15,308

28,341

141,791

14.2

100.0

47.5

52.5

60.0

40.0

24.8

8.9

4.9

2040

1.3

0.14

11.2

1.1

1.7

17,217

30,031

147,976

15.2

100.0

50.1

49.9

61.1

38.9

25.7

9.4

4.9

2050

1.3

0.15

11.7

1.2

2.2

18,038

31,500

149,477

15.9

100.0

52.8

47.2

60.8

39.2

27.2

10.0

4.8

2060

1.2

0.15

12.1

1.3

2.9

18,965

32,292

148,575

16.4

100.0

55.3

44.7

61.1

38.9

28.2

10.5

4.8

2070

1.2

0.15

12.6

1.4

3.8

20,386

33,098

148,390

17.2

100.0

57.0

43.0

62.0

38.0

27.9

10.6

4.7

MS Change 2016-
2070

EU Change 2016-
2070

-11%

17%

31%

52%

321%

54%

28%

12%

31%

:

26%

-22%

5%

-7%

17%

25%

-4%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
3.9. FINLAND 

General  context  of  long-term  care  system: 
expenditure, 
and 
demographic trends 

sustainability 

fiscal 

Finland,  member  of  the  European  Union  since 
1995,  has  a  population  of  around  5.5  million 
inhabitants, which is slightly above 1% of the EU 
population in 2016 (471). It is expected to reach 5.6 
million  in  2070,  a  demographic  expansion  of  2%. 
With a GDP of around 28,300 PPS per capita it is 
slightly  below  the  EU  average  GDP  per  capita  of 
29,600 for the most recent year of 2015.  

Health status 

Life expectancy at birth for both  men and  women 
was,  in  2015,  respectively  78.7  years  and  84.4 
years and is above the EU average (77.9 and 83.3 
years respectively). However, the healthy life years 
at birth for both sexes are 56.3 years (women) and 
59.4  years  (men)  are  below  the  EU-average  (63.3 
and 62.6 respectively), as measured in 2015. At the 
same 
the  Finnish 
the  percentage  of 
population having a long-standing illness or health 
problem is far higher than in the Union as a whole 
(46.6%  and  34.2%  respectively  in  2015).  The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  its  daily  activities 
has decreased since 2004, and  was lower than the 
EU-average in 2015 (7.6% against 8.1%). 

time, 

Dependency trends 

In  terms  of  dependency,  the  number  of  people 
depending  on  others  to  perform  daily  activities  is 
projected  to  grow  from  0.40  in  2016  to  0.51 
million in 2070, marking a 29% increase above the 
EU  average  increase  of  25%  for  these  years.  The 
proportion  of  the  dependents  as  a  group  in  the 
whole population is also foreseen to increase from 
7.2% to 9.0% in 2070, a change of 93% above the 
EU average increase of 73%. 

Expenditure projections and fiscal sustainability  

Long-term public spending on LTC is expected to 
rise over the course of the next 60 years (472). The 
AWG  reference  scenario  displays  an  93%  rise  in 

(471) This is according to the 2015  Eurostat projections. 
(472) The 

Ageing 

2018 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf . 

expenditure from 2.2 in 2016 to 4.2 in 2070, with 
the  EU  averaging  a  73%  rise  for  those  years. 
However 
the  AWG  risk  scenario  reveals  a 
comparably  flatter  increase  for  Finland  as  the 
corresponding  growth  rate 
the  EU 
average this time (131% vs. 171%). Expenditure is 
still expected to grow in this  scenario  from 2.2 in 
2016 to 5.1 in 2070. 

is  below 

Finland does not appear to face fiscal sustainability 
risks  in  the  short  run.  There  are  low  fiscal 
sustainability  risks  in  the  medium  term,  but 
medium risks in the long term, primarily related to 
the projected ageing costs (473). 

System Characteristics (474) 

Public  spending  on  LTC  ( 475)  reached  2.2%  of 
GDP in 2016 in Finland, above the EU average of 
1.6% of GDP.  

In  Finland,  100%  of  dependents  are  receiving 
formal  in-kind  LTC  services  or  cash  benefits  for 
LTC,  far  above  the  EU  average  of  50%.  Overall, 
10%  of  the  population  (aged  15+)  receive  formal 
LTC in-kind and/or cash benefits (EU: 4.6%). On 
the one hand, low shares of coverage may indicate 
a situation of under-provision of LTC services. On 
the other hand, higher coverage rates may imply an 
increased  fiscal  pressure  on  government  budgets, 
possibly calling for greater needs of policy reform.  

The expenditure for institutional (in-kind) services 
(including 
sheltered  housing  with  24-hour 
assistance)  makes  up  21.1%  of  public  LTC 
expenditure (EU: 66%), 79% being spent for LTC 
services provided at home (EU: 34%).  

LTC  policy  is  implemented  both  at  local  and 
national  level.  The  main  responsibility  for  the 
provision  of  LTC  to  elderly  and  disabled  people, 
including  rehabilitation,  lies  with  the  municipal 
authorities, their social welfare, health care service 
and  service  organisations.  In  contrast,  at  national 
level, 
the 
general conditions for the provision of services. 

legislative  framework  contains 

the 

(473) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(474) This section draws on OECD (2011b) and ASISP (2014). 
(475) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

351 

 
                                                           
                                                           
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The  303  municipalities  have  the  responsibility  to 
provide  health  and  LTC  services  for  residents. 
They  may  exercise  this  power  on  their  own  or  in 
cooperation  with  other  municipalities.  As  well  as 
directly providing services, municipalities can also 
commission  them  from  private  or  public  service 
providers,  or  provide  LTC  recipients  with  service 
vouchers  that  can  be  used  to  directly  purchase 
services from private providers.  

and  service  centres,  sheltered  housing  and  family 
care.  The  Social  Security  Institution  (KELA) 
provides  cash  benefits.  In  long-term  care,  most 
important is the Care Allowance for Pensioners, a 
cash benefit that aims to support pension recipients 
with  an  illness  or  disability  to  continue  living  at 
home, as well as to help meet extra costs caused by 
illness  or  disability.  The  allowance  is  around 
EUR70/153/324 per month. 

Long-term  care  can  be  provided  as  home  care,  in 
the  recipients'  own  homes  or  in  sheltered  housing 
units, as well as, as institutional care in residential 
institutions for and in the inpatient wards of health 
centres or hospitals. 

Administrative organisation 

these  services 

Residence  is  the  basis  for  entitlement  to  LTC 
services  in  Finland.  Services  and  income  security 
are provided as part of health and social care. It is 
the  responsibility  of  municipalities  to  arrange  the 
delivery  of 
to  recipients.  An 
individual  needs  assessment  is  performed  by  the 
municipality  to  decide  whether  to  grant  services.  
As  explained  above,  municipalities  may  provide 
the services directly or alternatively purchase them 
from  other  municipalities  or  private  service 
providers. 

Since  2011,  recipients  of  LTC  that  have  received 
care  for  more  than  a  year  have  been  granted  the 
right to change the municipality that provides them 
LTC. The original  municipality has to pay  for the 
services arranged in the new municipality. 

The municipality grants services on the basis of an 
individual assessment of needs. The needs must be 
assessed  in  a  flexible  manner,  using  reliable 
evaluation  methods,  and 
in  cooperation  with 
various  actors.  Based  on  the  identified  needs,  a 
service  plan  is  drawn  up  together  with  the  person 
and,  if  necessary,  a  family  member  or  a  friend. 
After that, an administrative decision is made by a 
public  servant  concerning  the  services  that  the 
municipality is responsible for providing. 

Types of care 

Long-term  care  benefits  are  benefits  in  kind, 
except  informal  care  support,  which  is  a  cash 
benefit. Benefits in kind include institutional care, 
home  help,  informal  care  support,  day  care,  day 

Home service and home nursing care support older 
people  with  their  activities  of  daily  living  when 
to  reduced  functional 
they  require  help  due 
capacity  or  illness.  They  are  combined  in  many 
municipalities  as  home  care  and 
is 
this 
supplemented by additional support services.  

If  the  older  person  is  not  able  to  live  in  his/hers 
own  home  or 
in  sheltered  accommodation 
(sheltered  accommodation,  service  homes),  care 
can  be  provided  in  an  institutional  care  setting. 
Institutional  care  can  be  provided  both 
in 
specialised  nursing  homes  as  well  as  in  the 
inpatient  departments  of  health  care  centres (476). 
LTC  can  only  be  provided  in  an  institutional 
setting if there is a medical justification or if there 
are  other  reasons  why  safe  care  for  the  recipient 
needs to be provided in an institution.  

Informal  care  support  is  aimed  at  relatives  with  a 
caring responsibility for LTC recipients. Decisions 
on whether to grant informal care support are made 
by local authorities. 

Eligibility criteria 

The sections above have shown that Finland offers 
a very broad coverage to its citizens. For defining 
eligibility  criteria,  the  country  does  not  seem  to 
have a general means-tested criterion (for either in-
kind  or  cash  benefit),  with  some  discretion  given 
to  municipalities  over  fees  and  charges  (see  co-
payments  section  below).  In  addition,  users  do 
have a discretionary use of cash benefits.  

The  health  care  system  covers  all  residents  of  the 
country  according  to  Section  19  of  the  Finnish 
Constitution. There is no single long-term scheme. 
Long-term care is provided through general social 
welfare  and  health  care  legislation  which  is 
supplemented  by  special  legislation  (for  example 

(476) Usually reported as hospital beds in international statistics. 

352 

 
                                                           
Long-term care systems 

3.9. Finland 

on  services  for  older  people  and  on  services  for 
people  with  disabilities).  Municipalities  are 
responsible for arranging social and health services 
that  their  population  requires  and  as  stipulated  by 
legislation.  Severely  disabled  persons  have  a 
subjective  right  to  certain  services  under  the 
Services and Assistance for the Disabled Act. .  

As explained above, municipal authorities arrange 
social services for older people on the basis of an 
assessment  of  their  individual  needs  by  experts. 
Citizens  above  75  years  of  age  and  pensioners  on 
the highest rate of care allowance have the right to 
have their needs assessed within a specified period 
of  time.  The  Social  Welfare  Act  was  amended  in 
2006  to  include  provisions  on  the  municipalities’ 
responsibility  and  expected  delays  for  the  needs 
assessment  (in  general  within  seven  days  or 
immediately  for  urgent  cases).  Once  the  need  has 
been  established,  the  municipal  authorities  in 
collaboration  with  the  recipient  and,  if  necessary 
their  next  of  kin,  draw  up  a  personal  care  and 
service  plan  that  details  the  services  and  support 
measures to be provided..  

The  Social  Insurance  Institution  also  grants  care 
allowances for pensioners (around EUR70/153/324 
per  month)  and  disability  allowances  for  children 
and  adults  (EUR92/215/416  per  month).  These 
allowances  are  not  subject  to  means  testing,  but 
granted  based  on  eligibility  criteria  according  to 
the  Disability  Benefits  Act.  Recipients  can  also 
benefit  from  tax  deductions  for  the  purchase  of 
home  care.  Conversion  of  homes  to  improve  the 
ability  of  the  recipient  to  perform  daily  tasks  is 
also  available  from  the  public  social  welfare 
authorities in line with the Services and Assistance 
for the Disabled Act. Finally, repair of housing for 
the elderly and the disabled can also be supported 
due to social reasons by the housing authorities. 

Co-payments, out of the pocket expenses and 
private insurance 

Public  LTC  services  are  financed  by  municipal 
taxation as well as by central government subsidies 
and  user  fees  (cost-sharing).  While  some  services 
are  provided  free  of  charge  (some  services  for 
people with disabilities), other services have a flat 
fee (some home care services) or are means-tested 
and  determined  according  to  income  and  family 
composition  (for  example  for  institutional  care, 
which  tends  to  be  the  costliest).  However,  the 

current  legislation  also  allows  each  municipality 
some degree of freedom to make their own choices 
in this field.  

Role of the private sector  

Private companies and non-profit organisations are 
important  service  providers  in  publicly  funded 
LTC.  With  respect  to  housing  services  (service 
accommodation  and  institutional  care),  private 
organisations  accounted  for  around  30  %  of  all 
clients  in  2012,  up  from  around  20  %  in  2000. 
Private  organisations  primarily  focus  on  serviced 
accommodation  with  almost  all  institutional  care 
provided by municipalities. Finally, the role of the 
private  sector  in  home  help  services  is  relatively 
minor. 

Most  of  the  private  sector  LTC  services  are 
commissioned  by  municipalities,  i.e.  selling  of 
services  to  households  directly  plays  a  smaller 
is  home  help  services, 
role.  The  exception 
although 
these  services  by 
households is subsidised. 

the  purchase  of 

Formal/informal caregiving 

Informal  care  support  is  targeted  towards  family 
members  caring  for  a  dependent  relative  (an  aged 
spouse or parent,  for example). Decisions on  who 
receives  informal  care  support  are  made  by  the 
municipalities.  

Support  for  informal  care  includes  caregiver’s 
allowance, statutory leave for the caregiver (if the 
care  is  binding),  necessary  services  to  support  the 
care-giver, and pension and accident insurance for 
the  caregiver.  The  amount  of  the  caregiver’s 
allowance  depends  on  the  municipality,  minimum 
EUR384.67  (in  2016)  per  month.  Support  from 
municipality  requires  an  agreement  between  the 
informal  caregiver  and  the  municipality  based  on 
an individual service plan. 

Prevention  and 
measures 

rehabilitation  policies  and 

Municipalities  are  in  charge  of  health  promotion 
and LTC prevention policies for the elderly. These 
include  the  provision  of  information  on  healthy 
lifestyles,  the  prevention  of  accidents  and  illness 
to 
and  early  detection  of  reduced  capacity 

353 

 
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function(477).  Many  municipalities  also  provide  a 
visiting  service  for  elderly  living  at  home,  which 
includes  a  discussion  on  the  challenges  faced  by 
the  person  and  information  on  the  public  help 
available.  Separately,  each  person  over  the  age  of 
75 is entitled to a social-service needs assessment. 

financed  by 

Counties  will  be 
the  central 
government  and  the  current  multisource  financing 
will  be  simplified  in  later  phases  of  the  reform. 
The  relevant  perspectives  of  European  Union  law 
and  the  realisation  of  fundamental  rights  will  be 
taken into account in the legislative drafting. 

Rehabilitation  of  the  elderly  is  carried  out  by  the 
municipalities  in  co-operation  with  the  Social 
Security Institution (Kela). 

Recently 
reforms  

legislated  and/or  planned  policy 

On  April  5  2016 
the  Finnish  Government 
published  it’s  detailed  position,  which  will  guide 
the  drafting  of  legislation  on  three  interconnected 
reforms:  (1)  the  reform  of  the  organisation  of 
health  and  social  services,  (2)  the  reform  relating 
to  freedom  of  choice  and  multisource  financing, 
and  (3)  the  regional  government  reform,  i.e.  the 
establishment of 18 independent counties governed 
by elected county councils.  

The  goals  of  these  reforms  are  to  (1)  reduce  the 
currently  forecasted  public  finance  sustainability 
gap  by  €3  billion  by  2030,  (2)  guarantee  equal 
access  to  high  quality  services  everywhere  in  the 
country and (3) reduce health inequities.  

The health and social reform  is based on a client-
centred integration of health and social services as 
the  key  measure  for  narrowing  health  and 
wellbeing  disparities,  improving  the  effectiveness 
of  the  services  in  an  equal  manner  and  bringing 
cost  savings.  A  single  strong  organiser,  county, 
will  be  responsible  for  services,  steering,  official 
activities,  evaluation  of  regional  impact,  cost-
effectiveness  and  quality  services  as  well  as 
supporting the  users’  freedom of choice. Freedom 
in  the  choice  of  choice  of  services,  will  enable 
users  themselves  to  make  choices  between  the 
providers. 

The county will have a single budget and a single 
financial  management  and  it  will  produce  the 
necessary  health  and  social  services  itself  or 
together  with  other  counties,  or  it  may  rely  on 
private or third sector in the provision of services. 

(477) http://www.thl.fi/fi/tutkimus-ja-

asiantuntijatyo/tyokalut/iakkaiden-neuvontapalvelut-ja-
hyvinvointia-edistavat-kotikaynnit. 

Counties  will  ensure  that  the  organisation  and 
provision  of  services  are  genuinely  separated  and 
performed  by  different  organisations 
(legal 
persons).  Freedom  of  choice  will  significantly 
promote  competition  in  the  provision  of  services. 
Integration  of  information  systems  will  increase 
information  flows  between  different  providers. 
Consequently,  the  integration  of  service  chains 
will  improve.  Essential  public  health  functions, 
including health promotion and disease prevention, 
will be ensured.  

The decision entails a major shift of paradigm and 
will  require  additional  planning  to  that  already 
carried  out  at  earlier  phases  of 
the  reform 
preparations.  

The draft laws will be voted in the parliament in by 
the end of 2018 after the constitutional assessment. 
The new  legislation is planned to come into force 
at  the  beginning  of  2019.  The  new  health  and 
social care system itself, is due to commence on 1 
January 2021. In preparation, the Government has 
introduced Bills to the parliament ranging from the 
Counties Act to the Freedom of Choice legislation. 
The  latter  is  planned  to  come  into  force  in  stages 
during  2021-2023.  An  election  of  the  county 
councils will follow in spring 2019. The voting in 
the  Parliament  is  expected  to  be  tight.  If  the  laws 
are not accepted in the Parliament, the preparation 
of  the  reform  continues  during  the  next  electoral 
period. 

Successful and skilful change management will be 
a  prerequisite  for  achieving  the  targets  and  thus 
will  receive  particular  attention  during  the  reform 
implementation. 

Challenges 

Finland  has  a  comprehensive 
long-term  care 
system  that,  in  the  last  few  years  has  been 
successful in increasing the proportion of care that 
is  administered  at  home  rather  than  in  more 
expensive institutional settings. However, the high 
level of expenditure, the lack of means-testing and 

354 

 
                                                           
Long-term care systems 

3.9. Finland 

the  inequality  in  quality  and  access  of  services 
across  municipal  authorities  mean  there  are  still 
many challenges: 

•  Improving  the  governance  framework:  To 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of  responsibilities  of  state  authorities  wrt.  the 
provision of long-term care services; To set the 
public  and  private  financing  mix  and  organise 
formal  workforce  supply  to  face  the  growing 
number  of  dependents,  and  provide  a  strategy 
long-term  care 
to  deliver  high-performing 
services  to  face  the  growing  demand  for  LTC 
services; To strategically integrate medical and 
social services via such a legal framework; To 
define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  To  use  care 
planning  processes,  based  on  individualised 
need  assessments,  involving  health  and  care 
providers  and  linking  need  assessment  to 
resource  allocation;  To  deal  with  cost-shifting 
incentives across health and care. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use for LTC; To create better rules, improving 
(and 
safe  care  pathways  and 
information  delivered  to  chronically-ill  people 
or circulated through the system; To steer LTC 
users towards appropriate settings. 

securing) 

•  Changing payment incentives for providers: 
To  adapt  provider  payments  for  LTC  away 
from  the  basis  of  salary;  To  consider  fee-for-
service  to  pay  LTC  workers  in  home-care 
settings  and  capitation  payments;  To  consider  
a focused use of budgets negotiated ex-ante or 
based on a pre-fixed share of high-need users.  

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people  with  chronic  care;  To  employ 
prevention  and  health-promotion  policies  and 
identify  risk  groups  and  detect  morbidity 
patterns earlier. 

•  Improving 

financing  arrangements:  To 
explore the potential of private LTC insurance 
tool;  To 
as  a 
determine  the  extent  of  user  cost-sharing  on 
LTC benefits. 

supplementary 

financing 

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering  entitlement  to  coverage;  the  breadth 
of  coverage,  that  is,  setting  the  extent  of  user 
cost-sharing on LTC benefits; and the depth of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage; To provide targeted 
benefits to those with highest LTC needs. 

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
to 
through  a  single  point  of  access 
as 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
the 
structures  for  care  co-ordination  and 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

355 

 
3
5
6

Table 3.9.1:  Statistical Annex – Finland 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

164
29.7
5.2

1.1
290.2
2.3

82.5
75.6
52.5
51.7
:
:

173
30.8
5.3

1.1
310.8
2.3

83.1
75.9
52.8
53.2
43.3
12.0

187
32.7
5.3

1.2
355.9
2.5

83.1
76.0
58.0
56.8
41.7
8.8

194
32.3
5.3

1.2
369.5
2.5

83.3
76.5
59.5
58.6
40.6
7.8

181
28.9
5.3

1.4
377.9
2.5

83.5
76.6
58.6
58.2
42.8
8.0

187
29.6
5.4

1.3
378.9
2.4

83.5
76.9
57.9
58.5
44.0
7.9

197
29.9
5.4

1.4
416.3
2.6

83.8
77.3
58.3
57.7
45.4
7.7

200
29.1
5.4

1.5
445.2
2.6

83.7
77.7
56.2
57.3
46.7
7.1

203
28.0
5.4

1.5
436.0
2.5

84.1
78.0
:
:
47.5
:

205
27.7
5.5

1.4
431.5
2.4

84.1
78.4
57.5
58.7
46.1
7.5

210
28.3
5.5

1.3
419.6
2.3

84.4
78.7
56.3
59.4
46.6
7.6

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

50
56
2.0

:
:

69
60
2.4

:
:

88
63
2.8

:
:

107
67
3.2

:
:

109
68
3.3

:
:

112
70
3.4

:
:

51
159
3.9

:
:

52
162
3.9

:
:

54
165
4.0

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.9.2:  Statistical Annex - continued – Finland 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

5.5

0.40

7.2

2.2

2.2

41,702

182,750

324,184

10.0

100.0

86.4

13.6

21.1

78.9

52.7

45.1

5.1

2020

5.6

0.41

7.4

2.3

2.4

45,479

196,666

340,913

10.5

100.0

86.9

13.1

20.9

79.1

52.1

45.6

5.0

2030

5.7

0.46

8.1

3.0

3.2

58,131

246,044

393,827

12.2

100.0

88.5

11.5

20.6

79.4

54.0

49.3

5.0

2040

5.7

0.49

8.6

3.6

3.9

72,091

297,865

441,039

14.2

100.0

89.3

10.7

20.5

79.5

53.0

49.6

5.0

2050

5.7

0.49

8.6

3.8

4.2

75,551

309,747

449,102

14.7

100.0

89.5

10.5

20.5

79.5

52.2

49.2

5.0

2060

5.7

0.49

8.7

3.9

4.5

78,156

316,836

454,090

15.0

100.0

89.7

10.3

20.5

79.5

51.6

49.3

5.0

2070

5.6

0.51

9.0

4.2

5.1

85,612

344,914

479,035

16.2

100.0

90.0

10.0

20.4

79.6

51.4

49.6

5.0

MS Change 2016-
2070

EU Change 2016-
2070

2%

29%

26%

93%

131%

105%

89%

48%

62%

:

4%

-26%

-3%

1%

-3%

10%

-1%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

3
.
9
.

l

i

F
n
a
n
d

3
5
7

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
3.10. FRANCE 

General 
sustainability and demographic trends   

Expenditure, 

context: 

fiscal 

France,  had  in  2016  a  population  of  almost  66.8 
million  inhabitants,  which  is  expected  to  grow  by 
15%  up  to  77  million  by  2070,  above  the  EU 
overall  growth  of  2%.  With  a  GDP  of  more  than 
€2,194 bn in 2015, or 29,200 PPS per capita, it is 
slightly  below  the  EU  average  GDP  per  capita  of 
€29,600 PPS.  

Health status 

Life expectancy at birth for both  women and  men 
was,  in  2015,  respectively  85.5  years  and  79.2 
years and is above the EU average (77.9 and 83.3 
years respectively). In 2015, the healthy life years 
at  birth  for  both  sexes  were  64.6  years  (women) 
and  62.6  years  (men)  significantly  above  the  EU-
averages (63.3 and 62.6 respectively). At the same 
time,  the  percentage  of  the  French  population 
having a long-standing illness or health problem is 
higher than in the Union as a whole (37.5% versus 
34.2% in 2015). The percentage of the population 
indicating  a  self-perceived  severe  limitation  in  its 
daily  activities  was  in  2015  8.8%,  slightly  above 
the EU-average (8.1%). 

Dependency trends 

The  share  of  dependents  is  set  to  increase  in  this 
period,  from  9%  in  2016  to  10.6%  of  the  total 
population  in  2070,  an  increase  of  17%.  This  is 
lower than the EU-average increase of 21%. From 
6  million  residents  living  with  strong  limitations 
due to health problems in 2016, an increase of 35% 
is  envisaged  until  2070  to  8.2  million.  That  is  a 
steeper increase than in the EU as a whole (25%).  

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
"AWG  reference  scenario",  public 
long-term 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 0.8 pps 

in 

358 

of  GDP  by  2070  (478).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 1.1 pps of GDP 
long-term  care 
by  2070.  Overall,  projected 
to 
to  add 
expenditure 
budgetary pressure.  

is  expected 

increase 

France  faces  low  fiscal  sustainability  risks  in  the 
short run. There are high risks for the country from 
debt  sustainability  analysis  in  the  medium  term, 
but  the  contribution  of  health  care  and  long-term 
care  is  relatively  small.  Finally,  according  to  the 
new  risk  classification  assessment  of  the  2018 
Fiscal  Sustainability  Report,  long-term  risks  are 
medium ( 479). 

System Characteristics (480) 

is 

state 

subdivided 

(departments). 

a  unitary 
areas 

in 
France 
administrative 
Public 
provision of long-term care is organised as a two-
pronged system. On the one hand, the public health 
insurance scheme – providing universal population 
coverage – covers the cost of health care provided 
in  institutions  to  the  recipients  of  care  (including 
the dependent elderly or disabled patients). It also 
funds  LTC  units  in  hospitals,  as  well  as  nursing 
care provided directly in the patient’s home. These 
health  care  costs  are  paid  for  by  the  health 
insurance  scheme and patients do not need to pay 
for these services themselves. 

On the other hand, there are two schemes, that are 
mainly  financed  by  local  authorities  and  that 
provide social benefits to the dependents (whether 
elderly or disabled) in order to help them meet part 
of the cost of care not covered by health insurance, 
whether that care is provided in an institutional or 
de 
domiciliary 
compensation  du  handicap"  (PCH  -  Disability 
compensation  benefit)  and  the  "  L'Allocation 
personnalisée  d'autonomie  "  (APA  -  Personalised 
Autonomy Benefit), briefly described below. 

"Prestation 

setting: 

the 

(478) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf . 

(479) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(480) This section draws on OECD (2011b) and ASISP (2014). 

 
                                                           
Public  spending  on  LTC  ( 481)  reached  1.7%  of 
GDP in 2016 in France, close to the EU average of 
1.6%  of  GDP.  93.8%  of  public  LTC  expenditure 
was  spent  on  in-kind  benefits  (EU:  84.4%),  while 
6.2%  were  provided  via  cash-benefits  (EU: 
15.6%).  

In France, 50% of dependents are receiving formal 
in-kind LTC services or cash-benefits for LTC, in-
line with the EU average of 50%. Overall, 3.6% of 
the population (aged 15+) receive formal  LTC in-
kind and/or cash benefits (EU: 4.6%). On the one 
hand,  low  shares  of  coverage  may  indicate  a 
situation  of  under-provision  of  LTC  services.  On 
the other hand, higher coverage rates may imply an 
increased  fiscal  pressure  on  government  budgets, 
possibly calling for greater needs of policy reform. 

The expenditure for institutional (in-kind) services 
makes up 94% of public in-kind expenditure (EU: 
66%),  6%  being  spent  for  LTC  services  provided 
at  home  (EU:  34%).  Thus,  relative  to  other 
Member States France has a focus on institutional 
care, which may be inefficient, as institutional care 
is  relatively  costly  with  respect  to  other  types  of 
care. 

Administrative organisation 

As  explained  above,  the  public  provision  of  long-
term care relies on a two-pronged system. The cost 
of  health  care  is  financed  by  the  public  health 
insurance  scheme,  while  social  benefits  provided 
by  two  schemes  (PCH  and  APA)  are  essentially 
financed by the State and by local authorities. The 
PCH  and  the  APA  are  provided  by  departments 
(local authorities).  

Types of care 

The range of types of care available is very large. 
It  comprises  help  with  daily  activities  (cooking, 
cleaning  and  laundry,  etc.),  help  with  personal 
activities (bathing, getting dressed, etc.). 

A dependant or disabled person can also receive a 
benefit  specifically  aimed  to  adapt  their  home  to 
their level of need (stair lift, walk-in bathtub, etc.) 

(481) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

Long-term care systems 

3.10. France 

activities:  mobility, 

and any charge due to their situation in relation to 
four 
care, 
communication and capacity to protect themselves 
and to control their environment.  

personal 

All  of  these  can  be  provided  either  at  home  or  in 
institution. 

Eligibility criteria 

reducing 

reimbursement, 

In  general,  in  the  basic  health  care  insurance 
system  cost-sharing  applies  to  most  goods  and 
services,  especially  primary  care  and  specialist 
consultations.  Some 
specific  categories  are 
exempted from cost-sharing. The private voluntary 
complementary health insurance increases the rate 
the  discrepancy 
of 
between the actual amount paid by patients and the 
amount  they  are  reimbursed  by  their  social  health 
insurance fund. In doing so, complementary health 
insurance  reduces  the  ability  of  cost-sharing  to 
control  overconsumption,  as  it  renders  users  less 
cost-aware.  As 
authorities 
implemented  a  ticket,  and  a  “deductible”  that  are 
not  covered  by  complementary  health  insurance. 
According  to  the  ticket  system  implemented  in 
2005  the  patient  has  to  pay  €1  for  each  physician 
visit  and  each  biomedical  analysis.  The  so-called 
medical  deductible  has  been  implemented  since 
2008.  The  patient  has  to  pay  €0.50  per  drug  box, 
€0.50  on  each  paramedical  procedure  and  €2  for 
each medical transport.  

result, 

the 

a 

As most EU countries, France does allow for users 
to  have  a  discretionary  use  of  cash  benefits. 
Discretionary  use  may  not  necessarily  lead  to  the 
most  cost-effective  use  of  cash 
resources, 
especially  if  the  use  of  cash  benefits  is  not 
monitored,  although  it  does  allow  flexibility  to 
compensate informal carers.  

The  PCH  is  available  for  the  disabled  under  60. 
The dependent above 60 receive the APA, which is 
based  on  an  assessment  of  a  person's  needs.  As 
mentioned  above,  the  APA  benefit  amount  varies 
both according to the person’s level of dependency 
(established  by  a  socio-medical  team,  using  a 
nation-wide  unified  grid  –  the  AGGIR  grid  – 
which identifies 6 levels of dependency, with only 
the  first  4  levels  being  taken  into  account  for  the 
granting of the APA benefit) and according to the 
elderly’s financial resources. 

359 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Co-payments, out of the pocket expenses and 
private insurance 

fees in exchange for a determined future stream of 
income in case they become dependent. 

For the disabled under 60, a new benefit is in place 
from January 2006, the PCH. It is intended to help 
cover  the  needs  of  the  disabled  person  regardless 
of  whether  those  needs  have  to  do  with  labour 
market  attachment,  home  adaptation,  human  and 
technical aids, etc. Average  monthly  spending per 
recipient is €800. 

From  age  60  onwards,  the  dependent  elderly  –  at 
home or in an institution – can receive the APA, a 
universal  benefit  for  people  over  60  that  was 
established  in  2002.  This  benefit  is  calculated  on 
the  basis  of  a  "help  plan"  designed  for  each 
individual  according  to  an  assessment  of  their 
needs.  The  APA  benefit  is  intended  to  cover  part 
of  the  cost  of  the  "help  plan",  with  the  rest  (on 
average  about  one  quarter  of  the  total  amount) 
being  paid  by  the  beneficiary  through  user  fees 
which  increase  in  proportion  to  their  income. 
Recipients  with  an  income  below  €800.53  per 
month  do  not  pay  these  fees.  The  benefit  amount 
thus  depends  on  both  the  person’s  level  of 
dependency as  well as on the recipient’s  financial 
resources.  The  level  of  dependency  is  established 
by a socio-medical team, using the unified AGGIR 
grid.  

The  APA  is  administered  by  the  relevant  local 
departments,  which  cover  around  two  third  of  its 
cost,  with  the  rest  being  financed  by  the  National 
Solidarity  Fund  for  Autonomy  (CNSA).  The 
average  amount  of  the  "Help  plan"  granted  to 
home  care  recipients  care  is  around  €482  per 
month, of  which about a fifth (€94 on average) is 
covered  by  cost-sharing.  The  amount  provided 
through  the  "Help  plan"  varies  depending  on  the 
level of dependency from €342 to €991 per month. 

France is one of the leading markets in terms of the 
proportion  of  its  population  that  is  covered  by 
private  LTC  insurance.  In  2012,  18%  of  the 
population  aged  over  40  years  had  private  LTC 
coverage ( 482).  Indemnity  policies  are  the  most 
frequent  type  of  private  coverage  arrangement. 
Under this model the insured typically pay annual 

(482) Private  insurances  in  France  often  include  long-term  care 
coverage  as  part  of  a  larger  package.  In  2016,  private 
expenditure  on  LTC  accounted  for  17%  of  overall 
expenditure on LTC. 

Role of the private sector  

Care  for  disabled  people  is  provided  almost 
exclusively  by  the  public  sector,  although  the 
private  sector  plays  an  increasing  role  in  old-age 
LTC: a third of health expenditure for older people 
(including,  home  care  and  hospitals)  is  for  care 
provided  in  a  private  institution  (profit  making: 
14%  of  the  total;  non-profit  making:  19%  of  the 
total).  Among  all  institution  for  older  people,  A 
quarter  of  all  institutions  providing  care  for  older 
people are private profit-making institutions. 

Formal/informal caregiving 

In  2003,  about  75%  of  APA  recipients  received 
care  from  a  family  member.  The  majority  of 
informal carers were women (62%, average age of 
58  years  old).  Only  about  10%  of  informal 
(family) carers are paid through APA. 

In terms of the balance of care and work activities, 
informal  carers  who  are  in  employment  have  the 
right to take 3 months of unpaid leave (up to 1 year 
over  their  career)  to  care  for  a  dependent.  There 
are also specific tax reductions available for carers. 

Prevention 
policies/measures 

and 

rehabilitation 

Prevention  and  rehabilitation  are  managed  by  the 
public health system. 

Recently 
reforms  

legislated  and/or  planned  policy 

A reform for “the adaptation of society to ageing” 
was adopted by the Parliament by the end of 2015 
and came into force in 2016. 

This  reform  (€645  million)  was  financed  by  the 
Additional  Solidarity  Contribution  for  Autonomy 
(CASA) introduced in 2013. 

375  million  euros  were  spent  on  the  APA  benefit 
in  order  to  help  the  elderly  remain  longer  in  their 
own  homes.  The  amount  of  the  APA  benefit  was 
thus  raised  by  €400  for  the  most  dependent 
patients,  and  by  €150  for  the  least  dependent 
patients.  Furthermore,  the  amount  of  co-payment 

360 

 
                                                           
(ticket  modérateur)  was  reduced  by  up  to  80%  in 
some cases. 

to 
25  million  euros  were  also  be  devoted 
improving the wages of the low-waged domiciliary 
care providers. 

Informal care is supported by the 2015 bill, thanks 
to  new  financing  and  the  creation  of  a  “trusted 
person” accompanying the dependent person. 

Finally, the bill also supports carers: 

−  It  creates  a  new  status  and  training  for  people 

helping a dependent relative; 

−  It  gives  them  a  “respite  assistance”,  i.e.  a 
replacement while they take a “break” or in the 
case of an hospitalisation. 

sharing  amongst  public 
To  promote  data 
administrations, the “loi de modernisation de notre 
système  de  santé”,  promulgated  in  January  2016, 
creates  a  new  database  called  «  système  national 
des données de santé » (article 193). It will contain 
data on the disabled and the elderly. 

140  million  euros  were  spent  on  subsidising 
technical  aids  to  help  the  elderly,  and  especially 
those with most modest incomes, to remain longer 
at home. 

80  million  euros  were  devoted  to  adapt  private 
housing  to  the  needs  of  dependent  people  and  to 
renovate  intermediary  forms  of  homes  –  named 
“autonomy residences” - for the elderly, who need 
help but not to the extent that they need to be in a 
nursing home. 

Regulations  on  private  dependency  insurances 
were  also  introduced,  as  well  as  special  help  for 
informal carers (up to 500 euros per year in order 
to cover the cost of some time off). 

In May 2018, a roadmap on elderly LTC has been 
announced by the government: 

−  On prevention: a universal free health check at 
the  time  of  retirement  as  well  as  financing 
prevention in institutions; 

Long-term care systems 

3.10. France 

−  In order to improve the care pathway of elderly 
people,  funding  will  be  granted  to  institutions 
to improve general access to telemedicine; 

−  Promote  home  care:  €100  M  granted  to  home 
care  to  businesses  in  the  sector  to  deploy 
themselves between 2019 and 2020; 

−  Upgrade care quality in institutional care: €500 
M  plan  to  insure  care  is  delivered  properly  in 
care institutions and €100 M a year starting in 
in 
to  boost 
in  order 
2019 
institutional care. 

investment 

−  A  broad 

consultation 

"Grand  Âge 

et 
Autonomie"  (Ageing  and  Autonomy)  was 
carried  out  and  a  summary  of  the  results  were 
published  in  a  report  ("Rapport  Libault"), 
proposing  a  set  of  reforms  to  improve  LTC 
policies.  The  French  government  will  draw 
upon  theses  propositions  in  order  to  present  a 
reform  of  LTC  policies  in  autumn  2019.  This 
reform will address a number of the challenges 
listed below. 

Challenges 

The main challenges of the system appear to be: 

•  Improving  the  governance  framework:  To 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of responsibilities of state authorities wrt. to the 
provision of long-term care services; To set the 
public  and  private  financing  mix  and  organise 
formal  workforce  supply  to  face  the  growing 
number  of  dependents,  and  provide  a  strategy 
to  deliver  high-performing 
long-term  care 
services  to  face  the  growing  demand  for  LTC 
services; To strategically integrate medical and 
social services via such a legal framework; To 
define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  To  deal  with 
cost-shifting incentives across health and care. 

•  Improving  financing  arrangements:  To  face 
increased  LTC  costs,  choices  will  be  made  to 
define  the  balance  between  public  and  private 
financing and between generations”. 

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European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage;  the breadth 
of  coverage,  that  is,  setting  the  extent  of  user 
cost-sharing on LTC benefits; and the depth of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage; To provide targeted 
benefits  to  those  with  highest  LTC  needs;  To 
reduce the risk of impoverishment of recipients 
and informal carers. 

•  Ensuring  availability  of  formal  carers:  To 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
to 
through  a  single  point  of  access 
as 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
the 
structures  for  care  co-ordination  and 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  steer  LTC 
users towards appropriate settings. 

•  Changing payment incentives for providers: 
To  consider  a 
focused  use  of  budgets 
negotiated  ex-ante  or  based  on  a  pre-fixed 
share of high-need users.  

•  Improving  value  for  money:  To  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; To 
invest  in  ICT  as  an  important  source  of  care 
management and coordination. 

centeredness, 

and 

362 

 
Table 3.10.1:  Statistical Annex – France 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

1,772
28.2
62.8

1.0
:
1.8

83.8
76.7
64.6
62.3
:
:

1,853
28.6
63.2

0.9
242.7
1.8

84.5
77.3
64.4
62.8
34.4
6.3

1,946
29.2
63.6

1.0
259.0
1.8

84.8
77.6
64.4
62.8
33.7
6.1

1,996
28.1
64.0

1.0
274.2
1.9

84.8
77.8
64.5
62.8
36.7
8.6

1,939
26.7
64.4

1.2
293.0
2.0

85.0
78.0
63.5
62.8
37.0
9.0

1,998
27.5
64.7

1.2
309.4
2.1

85.3
78.2
63.4
61.8
36.9
9.6

2,059
28.0
65.0

1.2
321.2
2.2

85.7
78.7
63.6
62.7
36.5
9.3

2,087
27.9
65.3

1.2
334.7
2.2

85.4
78.7
63.8
62.6
36.6
8.8

2,115
28.2
65.6

1.3
350.4
2.2

85.6
79.0
64.4
63.0
36.5
9.1

2,148
28.6
65.9

1.3
360.2
2.3

86.0
79.5
64.2
63.4
37.0
9.2

2,194
29.2
66.5

1.2
374.3
2.1

85.5
79.2
64.6
62.6
37.5
8.8

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

2,102
:

:
:
:

:
:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
6
3

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

552
521
1.7

:
:

532
657
1.9

:
:

511
792
2.0

:
:

491
928
2.2

:
:

507
947
2.2

:
:

523
966
2.3

:
:

854
1,089
3.0

868
1,103
3.0

881
1,118
3.0

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

:
:

:
:

:
:

3
.
1
0
.

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3
6
4

Table 3.10.2:  Statistical Annex - continued – France 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

66.8

6.04

9.0

1.7

1.7

2020

68.0

6.28

9.2

1.8

1.9

2030

70.7

6.96

9.9

1.9

2.2

2040

73.0

7.65

10.5

2.3

3.0

2050

74.4

7.97

10.7

2.4

3.5

2060

75.6

8.12

10.7

2.4

4.0

2070

77.0

8.18

10.6

2.4

4.5

1,099,785

1,207,470

711,232

1,147,950

1,261,995

706,575

1,265,516

1,446,938

720,262

1,541,487

1,713,034

711,268

1,689,683

1,846,969

711,653

1,764,289

1,903,213

718,154

1,766,791

1,909,968

722,835

4.5

50.0

93.8

6.2

66.9

33.1

66.3

29.9

10.1

4.6

49.6

94.3

5.7

66.7

33.3

66.3

30.1

9.7

4.9

49.3

95.4

4.6

65.6

34.4

67.6

31.0

8.7

5.4

51.9

96.7

3.3

64.4

35.6

67.3

33.6

7.8

5.7

53.3

97.4

2.6

63.8

36.2

65.9

34.1

6.7

5.8

54.0

97.8

2.2

63.7

36.3

64.7

34.2

5.7

5.7

53.8

98.1

1.9

63.7

36.3

65.0

34.2

4.8

MS Change 2016-
2070

EU Change 2016-
2070

15%

35%

17%

37%

160%

61%

58%

2%

26%

8%

5%

-69%

-5%

9%

-2%

14%

-52%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
3.11. GERMANY 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

GDP per capita in PPS is at €33,200 and above EU 
average  of  €29,600  in  2015.  Germany  has  a 
population of 82.7  million inhabitants. During  the 
coming  decennia  the  population  will  steadily 
decrease, from 82.1 million inhabitants in 2016 to 
79.3 million inhabitants in 2070 depending on the 
migration rate. Thus, Germany is facing a decrease 
of  its  population  by  3%,  while  the  EU  average 
population is estimated to increase by 2%.  

Health status 

Life expectancy at birth for both  women and  men 
is  respectively  83.1  years  and  78.3  years  in  2015 
and is around the EU average for women and men 
(83.3  and  77.9  years  respectively).  Healthy  life 
years at birth in 2015 are with 67.5 years (women) 
and 65.3 years (men) above the EU-averages (63.3 
and  62.6  respectively).  The  percentage  of  the 
German  population  having  a  long-standing  illness 
or  health  problem  is  higher  than  in  the  Union 
(42.5% in Germany versus 34.2% in the EU). The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  its  daily  activities 
stands  at  7.1%,  which  is  lower  than  the  EU-
average (8.1%); however, it should be noticed that 
these  figures  are  based  on  self-reported  indicators 
and  therefore  can  be  influenced  among  others  by 
cultural factors.   

Dependency trends 

living  with 

(self-assessed) 

The number of people depending on others to carry 
out activities of daily living increases significantly 
over  the  coming  50  years.  From  7.0  million 
residents 
strong 
limitations due to health problems in 2016 (483), an 
increase of 8% is estimated until 2070 with nearly 
7.6 million (484). That is a less steep increase than 
in the EU as a whole (25%). Also as a share of the 
population,  the  dependents  are  becoming  a  bigger 
group,  from  10.0%  to  11.7%,  an  increase  of  17% 
(EU: 21%). 

(483) The number of dependent population is estimated for those 

(484) According 

to 

the  AWG 

insured under social health insurance only. 
the 

robustness  of 
dependency  rates  calculated  on  the  basis  of  the  EU-SILC 
survey  has  been  improved,  by  using  a  5-year  average 
(where  available)  of  the  dependency  rates  for  each  of  the 
age-gender groups.  

report 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing  in  most 
scenarios. In the "AWG reference scenario", public 
long-term  expenditure (485) 
the 
combination of changes in the population structure 
and  a  moderately  positive  evolution  of  the  health 
(non-disability)  status.  The  joint  impact  of  those 
factors is a projected increase in spending of about 
1.9 pps of GDP by 2070 (486).  

is  driven  by 

The "AWG risk scenario", which in comparison to 
the "AWG reference scenario" captures the impact 
of  additional  cost  drivers  to  demography  and 
health  status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  the  latter  being  dependent 
on  self-assessed  measure  people  experiencing 
severe  limitations  in  daily  activities,  projects  an 
increase  in  spending  of  3.4  pps  of  GDP  by  2070. 
Overall,  projected 
long-term  care  expenditure 
increase for these two scenarios is expected to add 
to  budgetary  pressure.  However,  no 
fiscal 
sustainability risks appear over the long run as the 
initial  budgetary  position  would 
favourable 
mitigate  the  projected  increase  in  age-related 
expenditure (487).  

In  Germany,  currently  long-term  care  benefits  are 
indexed  to  prices.  To  account  for  this  legislation 
and 
the  financial  precaution  principle  while 
preserving  the  realism  of  the  projections,  in  the 
displayed  scenarios  2/3  of  the  public  expenditure 
on  in-kind  benefits  are  indexed  to  GDP per  hours 
worked  and  1/3  of  the  cash  benefits  to  GDP  per 
capita.  

System Characteristics  

Social long-term care insurance (LTC) insurance is 
compulsory.  All  members  of  the  social  health 
insurance  are  covered  by  the  public  and  members 
of  the  private  health  insurance  (PHI)  are  covered 
by  the  private  LTC  insurance.  Both  parties  are 
entitled  to  the  same  benefits,  which  is  basically 

(485) Public  expenditure  on  LTC  in  Germany  refers  to  the 

Statutory Health Insurance Funds only. 
Ageing 
2018 

(486) The 

Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(487) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

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European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

covering a portion of long-term nursing care costs. 
If costs of care exceed benefits, the person in need 
of  care  has  to  bear  the  difference,  also  including 
support  from  their  children  or  near  relatives,  or 
ultimately social assistance.  

Premiums for social LTC insurance are calculated 
as a fixed proportion of the labour income (2.55% 
for  insured  with  and  2.80%  for  insured  without 
children  in  2017).  Employers  bear  one  half  of  it 
and  children  and  spouses  with  no  substantial 
individual  labour  income  are  co-insured  without 
extra  costs.  Private  LTC  insurance  premiums  are 
related to (income independent) premiums of PHI. 

Since  2012,  employees  with  a  family  member  in 
need  of  home  care  are  entitled  to  reduce  their 
weekly  working  time  to  15  hours  for  up  to  two 
years.  Their  employers  can  top  up  the  reduced 
salary  by  half  of  the  difference  between  old  and 
new  salary  with  an  interest  free  credit  from  the 
Kreditanstalt  für  Wiederaufbau.  Afterwards,  the 
employee  has  to  work  full-time  until  the  credit  is 
paid back. The uptake of this policy was very low 
so far.  

For informal carers getting sick or taking holidays, 
LTC insurance pays benefits for up to six weeks of 
respite  care  or  eight  weeks  short-term  residential 
care,  but  not  more  than  €1,612  each  once  a  year. 
This  is  conditional  on  the  informal  carer  having 
taken  care  of  the  recipient  for  at  least  six  months 
prior to application. Also, benefits for people with 
dementia  have  been  increased.  An  additional 
optional  private  LTC  insurance  is  now  subsidised 
with a maximum of €60 per year.  

Public  spending  on  LTC  (488),  encompassing 
expenditure  of  statutory  health  insurances  only, 
reached 1.3% of GDP in 2016 in Germany, below 
the  average  EU  level  of  1.6%  of  GDP  (489).  The 
share  of  the  in-kind  benefits  was  67.7%,  while 
32.3%  were  cash-benefits  (EU:  84.4%  vs  15.6%). 
Private  co-financing  of  formal  LTC  services  is 
important in Germany. According to 2016 Eurostat 

(488) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily to assistance with IADL tasks). 

(489) This  is  according  to  the  Ageing  Report  2018.  Due  to 
agreements taken with the Member States delegates in the 
AWG-EPC,  definition  of  LTC  expenditure  may  deviate 
from expenditure levels as reported in other publications.  

366 

data, 29% of expenditure on LTC services are co-
financed  privately,  either  through  a  voluntary 
insurance scheme or out-of-pocket payments. 

In  the  EU,  50%  of  self-perceived  dependents  are 
receiving  formal  in-kind  LTC  services  or  cash-
benefits for LTC. This share is with 54.7% higher 
in  Germany.  Overall,  6.4%  (including  disabled 
persons)  of  the  population  (aged  15+)  receive 
formal  LTC  in-kind  and/or  cash  benefits  (EU: 
4.6%).  On  the  one  hand,  low  shares  of  coverage 
may indicate a situation of under-provision of LTC 
services. On the other hand, higher coverage rates 
may 
increased  fiscal  pressure  on 
government  budgets,  possibly  calling  for  greater 
needs of policy reform. 

imply  an 

The expenditure for institutional services makes up 
70.7%  of  public  LTC  expenditure  on  in-kind 
services (EU: 66.3%), 29.3% being spent for LTC 
services  provided  at  home  (EU:  33.7%).  Thus, 
relative to other Member States Germany seems to 
might have some potential to focus more on home 
care,  which  may  be  more  cost-efficient.  As 
institutional  care  is  relatively  costly,  Member 
States  with  shares  well  above  the  EU  levels  may 
benefit  from  efficiency  gains  by  shifting  some 
coverage (and thus expenditure) from institutional 
to other types of care. 

Types of care 

care 

home 

benefits, 

(in-kind), 

Recipients  of  LTC  services  can  choose  between 
cash 
and 
institutional care. Cash benefits allow recipients to 
live at home and be taken care of typically by their 
relatives.  Home  care  (in-kind)  allows  for  a 
professional care, paid directly by the recipients to 
the  providers.  Institutional  care  refers  to  either 
short-term or long-term stay in a nursing home.  

Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

The  LTC  insurance  has  defined  five  degrees  of 
care based on the assessment of independence and 
abilities.  Factors  included  in  the  assessment  are 
mobility,  cognitive  and  communicative  abilities, 
self-supply,  illness  or  therapy  related  activities, 
daily life and social contacts. Recipients in need of 
care should/must be insured for at least six months 
prior 
the  application  of  care  allowance. 
Eligibility and the level of care are assessed by an 

to 

 
                                                           
Long-term care systems 

3.11. Germany 

independent  Medical  Review  Board  of 
the 
Statutory  Health  Insurance  Funds  (MDK)  for  the 
social LTC insurance or an equivalent body for the 
private LTC insurance. 

In  order  to  make  the  job  of  formal  carers  more 
attractive  and  to  increase  the  quality  of  care,  the 
government  has  passed  the  carer  education  law 
(Pflegeberufsgesetz) (491).  

Prevention and rehabilitation measures 

Since 2016 social LTC insurance contributes to the 
prevention  efforts  in  institutions  of  the  health 
insurance  with  estimated  €21  million  each  year; 
the  amounts  in  the  following  years  depend  on  the 
reference  figure  and  the  number  of  recipients  of 
formal care in institutions. Rehabilitation measures 
are  not  defined  as  (part  of)  LTC  in  Germany;  i.e. 
rehabilitation is part of health care.  

Recently 
reforms  

legislated  and/or  planned  policy 

The  Ministry  of  Health  has  improved  LTC  with 
three interlaced laws  strengthening long-term care 
(Pflegestärkungsgesetz  [PSG]  I-III).  PSG  I  has 
significantly  increased  services  for  dependants 
from January 2015 onwards and has increased the 
number  of  caregivers  in  institutional  care;  besides 
that  a  LTC  provident  fund  for  demographic 
sustainable financing has been introduced.   

As  described  in  the  preceding  sections,  new 
measures  have  also  been 
to 
strengthen prevention.   

taken  recently 

Challenges 

financing  mix,  ensure 

Germany has taken significant steps to establish a 
fiscal 
coherent 
sustainability  of  LTC  expenditure  and  provide 
adequate  coverage  to  the  population.  The  main 
challenges  of  the  publicly  funded  LTC  system 
appear to be:  

the 

•  Improving  the  governance  framework:  to 
establish  good  information  platforms  for  LTC 
users and providers.  

•  Encouraging  independent  living:  to  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

PSG I-III increased LTC premiums in two steps by 
0.5 pps starting from 2015 (0.3 pps in 2015 and 0.2 
pps  in  2017).  From  the  additional  revenues,  €1.3 
billion  will  be  transferred  yearly  to  the  LTC 
provident  fund  until  2034.  The  remaining  €3.7 
billion  per  year  will  be  spent  on  additional  and 
improved  services  for  dependents  (services  will 
increase by 20%) (490). As of 2019, LTC premiums 
to  strengthen 
will  be 
law 
measures 
(Pflegepersonal-Stärkungsgesetz). 

increased  by  0.5  pps 

personnel 

care 

the 

of 

introduced  within 

PSG  II  and  III  were 
the 
legislature  period  2013-2017.  PSG  II  redefines 
care levels and care assessment methods based on 
individual  care  demands;  especially  dementia  is 
now  part  of  the  assessment.  PSG  III  strengthens 
the  local  coordination  and  provision  of  care  and 
focuses on counselling.  

(490) Source: 

https://www.bundesgesundheitsministerium.de/service/ges
etze-und-verordnungen/guv-18-lp.html. 

future  needs 

•  Ensuring  availability  of  formal  carers:  to 
for 
determine  current  and 
qualified  human  resources  and  facilities  for 
long-term care; to improve recruitment efforts, 
including 
the  migration  of  LTC 
workers and the extension of recruitment pools 
of workers.  

through 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  create  better 
improving  (and  securing)  safe  care 
rules, 

(491) Source: 

http://www.bmg.bund.de/ministerium/meldungen/2016/160
113-pflegeberufsgesetz.html. 

367 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

and 

pathways 
to 
chronically-ill people or circulated through the 
system. 

information  delivered 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

368 

 
Table 3.11.1:  Statistical Annex – Germany: 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2,301
29.1
82.5

1.0
281.6
2.2

82.0
76.7
54.8
54.5
:
:

2006

2,393
30.2
82.4

1.0
286.7
2.2

82.4
77.2
58.3
58.7
38.2
8.3

2007

2,513
31.5
82.3

1.0
298.7
2.3

82.7
77.4
58.6
59.0
37.9
8.2

2008

2,562
31.3
82.2

1.0
305.8
2.3

82.7
77.6
57.7
56.4
35.3
10.6

2009

2,460
28.9
82.0

1.1
318.6
2.3

82.8
77.8
58.1
57.1
35.2
10.1

2010

2,580
30.5
81.8

1.1
343.0
2.4

83.0
78.0
58.7
57.9
35.2
10.2

2011

2,703
31.9
80.2

1.1
365.0
2.5

83.1
77.9
58.7
57.9
35.4
10.0

2012

2,758
32.1
80.3

1.1
387.7
2.6

83.1
78.1
57.9
57.4
35.7
10.9

2013

2,826
31.7
80.5

1.2
405.8
2.7

83.1
78.4
57.0
57.8
36.8
10.4

2014

2,932
32.6
80.8

1.2
428.0
2.7

83.6
78.7
56.5
56.4
37.2
10.7

2015

EU 2009

EU 2011

EU 2013

EU 2015

3,044
33.2
81.2

1.3
464.9
2.9

83.1
78.3
67.5
65.3
42.5
7.1

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

3,256
628

:
:
:

:
:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
6
9

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

561
1,028
1.9

:
:

610
1,188
2.2

:
695

658
1,349
2.4

:
:

707
1,509
2.7

:
746

726
1,537
2.8

:
:

743
1,565
2.9

:
792

740
348
1.4

:
:

751
352
1.4

:
864

764
358
1.4

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
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.

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3
7
0

Table 3.11.2:  Statistical Annex - continued – Germany 

PROJECTIONS

Population
Population projection in millions*
*Note: The LTC projections are based on the SHI insured part of the population
Dependency
Number of dependents in millions
Share of dependents, in %
Projected public expenditure on LTC as % of GDP
AWG reference scenario
AWG risk scenario

Coverage
Number of people receiving care in an institution
Number of people receiving care at home
Number of people receiving cash benefits
% of pop. receiving formal LTC in-kind and/or cash benefits
% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs
Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)
Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)
Public spending on institutional care ( % of tot. publ. spending LTC in-kind)
Public spending on home care ( % of tot. publ. spending LTC in-kind)
Unit costs of institutional care per recipient, as % of GDP per capita
Unit costs of home care per recipient, as % of GDP per capita
Unit costs of cash benefits per recipient, as % of GDP per capita

2016

82.1

7.04
10.0

1.3
1.3

775,005
379,049
1,595,152
3.9
39.0

67.7
32.3
68.2
31.8
53.9
51.5
18.3

2020

83.8

7.31
10.2

1.5
1.6

833,929
404,324
1,701,518
4.1
40.2

68.1
31.9
68.3
31.7
59.2
56.8
19.9

2030

84.6

7.61
10.7

1.7
1.9

979,597
453,139
1,906,949
4.7
43.9

69.8
30.2
69.1
30.9
58.4
56.4
18.8

2040

84.1

7.76
11.1

1.8
2.3

1,060,364
493,629
2,077,347
5.2
46.8

71.0
29.0
69.1
30.9
57.8
55.7
17.4

2050

82.7

8.11
11.9

2.0
2.8

1,278,885
557,253
2,345,098
6.1
51.5

72.5
27.5
70.1
29.9
54.2
53.0
16.0

2060

80.8

7.72
11.7

2.0
3.1

1,313,781
545,339
2,294,958
6.3
53.8

73.9
26.1
71.1
28.9
52.0
51.1
14.8

2070

79.3

7.61
11.7

1.9
3.4

1,300,496
549,287
2,311,576
6.4
54.7

74.8
25.2
70.7
29.3
50.3
49.4
13.5

MS Change 2016-
2070

EU Change 2016-
2070

-3%

8%
17%

48%
164%

68%
45%
45%
64%
40%

10%
-22%
4%
-8%
-7%
-4%
-26%

2%

25%
21%

73%
170%

72%
86%
52%
61%
33%

5%
-27%
0%
-1%
10%
1%
-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.12. GREECE 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

Greece  has  a  population  of  around  10.9  million, 
projected to decrease by 29% by 2070 and to reach 
7.7 million. With a GDP of around €180 billion or 
21,158 PPS per capita, it is below the EU average 
GDP  per  capita  of  29,610  PPS,  slowly  increasing 
after  the  significant  contraction  recorded  in  the 
post-crisis  years.  Based  on  the  Ageing  Report 
2018,  total  public  expenditure  on  long-term  care 
(health and social part) (1) is, with 0.1 % of GDP 
in  2016,  below  the  EU  average  in  the  same  year 
(1.6%). 

Health Status 

Life expectancy at birth for women and men was, 
in 2015, respectively 83.7 and 78.5 years, close to 
the EU average (83.3 and 77.9 years respectively). 
In  2015,  the  healthy  life  years  at  birth  were  64.1 
years  for  women  and  63.9  years  for  men,  slightly 
and 
above 
62.6 
(63.3 
the  EU-average 
respectively).  The  percentage  of 
the  Greek 
population having a long-standing illness or health 
problem  was  lower  than  in  the  Union  as  a  whole 
(23.6% and 34.2% respectively in 2015). However, 
in the same year, the percentage of the population 
indicating  a  self-perceived  severe  limitation  in  its 
daily  activities  was  10.8%,  above  the  EU-average 
(8.1% in 2015). 

Dependency Trends 

The number of people depending on others to carry 
out  activities  of  daily  living  is  projected  to  rise 
over  the  next  decades  up  to 2070. The  number  of 
people living with strong limitations due to health 
problems  in  2016  were  estimated  at  1.12  million 
and  an  increase  by  3%  is  expected  by  2070, 
bringing 
to  approximately  1.16 
million  (492).  The  corresponding  EU  change  for 
that period is 25%. Moreover, dependents are also 
projected to increase as a share of the population, 
from  10.4%  to  15.1%,  a  rise  of  45%,  more  than 
double the EU growth over the same period (21%). 

this  number 

(492) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

Expenditure projections and fiscal sustainability  

Based  on  the  "AWG  reference  scenario",  the 
current  value  of  public  expenditure  on  long-term 
care  (health)  as  a  percentage  of  GDP  is  projected 
to  grow  from  0.1  in  2016  to  0.2  in  2070,  a 
difference of 76%  which is  slightly above  the EU 
for  the  same  period  (73%).  According  to  the 
"AWG  risk  scenario",  which  also  captures  non-
demographic  cost  drivers,  expenditure  is  foreseen 
to  increase  from  0.1  in  2016  to  4.9  in  2070.  This 
corresponds  to  a  bigger  projected  change,  3.8  pps 
of  GDP,  corresponding  to  an  increase  of  4834%, 
well above the EU average of 170% over the same 
period (493)(494). 

System Characteristics 

In  Greece,  there  is  no  universal  statutory  scheme 
for long-term care and there is a  mixed landscape 
of services provided by public entities, private for-
profit and non-profit entities and families.  

Traditionally,  long-term  care  was  provided  by  the 
family,  and  only  when  the  family  was  not  able  to 
care for the dependent or to afford alternatives, the 
solution would be institutionalisation. In the 1980s 
the  state  began  the  process  of  recognition  of  the 
specificities  of  long-term  care  as  a  separate  item 
from primary care or secondary care, with the aim 
of allowing for the non –institutionalisation of the 
elderly  who  were  in  general  good  health  but  still 
required some sort of regular assistance or support. 
This  was  implemented  through  KAPIs  ('Open 
Protection  Centres  for  the  Elderly').  During  the 
decade,  local  authorities  worked  towards 
the 
expansion  of  this  network  relying  on  public 
funding,  reaching  the  1000  centres  over  the 
territory,  a  number  that  fell  since  2016  and 
currently stands at 750 centres. However, coverage 
was not even and there was a substantial degree of 
inequality  in  access  to  services  over  the  territory 
and  lack  of  quality  assessment  based  on  the 

(493) The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(494) Greece has just completed the third adjustment programme 
monitored by the EU, the IMF and the ECB. The medium-  
and  long-term  fiscal  sustainability  indicators  S1  and  S2 
point  to  remaining  challenges  to  ensure  future  fiscal 
(2018),  Fiscal 
(European  Commission 
sustainability 
Sustainability 
(2018) 
https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_1.pdf). 

Report 

371 

 
                                                           
                                                           
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

intended  goals.  In  the  1990s,  a  project  to  deliver 
community and home care through the network of 
KAPIs was initiated under the programme Help at 
Home  and  was  run  by  the  local  authorities  across 
Greece.  This  programme,  though  very  popular, 
never  managed  to  achieve  the  necessary  coverage 
due to funding issues. 

The result is that of a currently highly fragmented 
system with uneven coverage across users and low 
coverage overall. Due to the great fragmentation of 
the  system  and  limited  coverage,  a  large  share  of 
service  provision  is  left  to  informal  care,  with 
primary 
financial  and 
practical  support  of  dependants  resting  firmly  on 
the family. 

responsibility 

the 

for 

Administrative organisation  

According to official statistics, long-term care beds 
in  nursing  and  residential  care  facilities  for  every 
100,000 inhabitants were amongst the lowest in the 
EU  in  2015  (495).  This  issue  is  paired  with  an 
uneven  distribution  of  available  services,  mostly 
and 
areas 
the 
located 
Thessaloniki (496). 

of  Athens 

in 

The state provides both direct and indirect support, 
the  former  through  social  services,  the  latter 
through social security funds and allowances or tax 
reductions.  Public 
is 
formal 
financed by the Ministry of Health, the Ministry of 
Labour  Social  Security  and  Social  Solidarity 
(MoLSSSS),  and  also  by  EFKA,  the  unified 
agency  for  social 
insurance.  Formal  services 
mainly  consist  of  institutional/residential  care  and 
community-based services ( 497). 

long-term  care 

The delivery of community and home care, in the 
form  of  help  with  activities  of  daily  living,  is 
currently  provided  by  local  authorities,  based  on 
directives  and  legal  framework  provided  by  the 
MoLSSSS.  and,  informally,  is  left  to  the  patient's 
network 
(non-
contributory)  disability  benefits  (in  cash  and  in 

family).  Other 

(mostly 

the 

(495) See  Eurostat  [hlth_rs_bdsns].  However,  these  are  not 
comparable  with  other  Member  States  as  Greece  does  not 
report figures for the majority of NUTS2 regions, only two 
being covered in the dataset. 

(496) Ziomas D., Konstantinidou D., Vezyrgianni K., Capella A. 
(2018),  ESPN  Thematic  Report  on  Challenges  in    long-
term care – Greece 2018, European Social Policy Network. 

(497) Ibid. 

372 

kind) are provided by the social welfare system to 
persons  who  are  in  need  of  care  because  of  a 
specific chronic illness or incapacity. 

Available formal long-term care services (Help-at-
Home,  Day  Care  Centres,  Care  units  for  the 
chronic  sick  and  limited  public  Residential  Care 
Homes - MFI) are financed through the competent 
local  authorities,  the  state  budget,  frequently  co-
financed  through  European  Funds  (currently  the 
ESF)  and  are  free  to  the  user.  Public  nursing 
homes  for  the  chronically  ill  are  financed  by  the 
state  budget  through  13  regional  Social  Welfare 
Centers  (public  entities  operating  under 
the 
supervision  of  MoLSSSS)  and  by  per  diem  fees 
paid by EFKA and EOPYY (498).  

Dependent  on  the  level  of  invalidity,  the  state, 
through  these  Social  Welfare  Centres,  provides 
residential care to the indigent and the elderly who 
are  alone  and  in  need  of  care  through  chronic 
illness  nursing  homes  plus  nursing  homes  for 
disabled persons, with a capacity of approximately 
1.800 beds. These, however, are not targeted at the 
elderly as only three centres have a proper geriatric 
section.  On  top  of  those  within  public  nursing 
homes, 
is  an  additional  capacity  of 
approximately  3000  long-term  beds  within  other 
settings,  namely  acute  and  psychiatric  hospitals 
(1000  and  2000  beds  respectively).  Additional 
beds are available within private structures. 

there 

In  general,  public  residential  and  semi-residential 
care  for  disabled  adults  and  children  and  for 
indigent  people  above  65  who  lack  a  social 
network  to  rely  on  for  their  care  is  provided 
through  the  above  mentioned  regional  Social 
Welfare  Centres,  financed  by  the  state  budget, 
supervised by the MoLSSSS and by per diem fees 
paid  by  EOPYY.  These  13    regional  Centres  plus 
one  dedicated  to  the  children  protection  ran  51 
‘social care units in 2018 . Overall, the social care 
units include 22 chronic illness nursing homes for 
disabled  adults  and  old  people,  23 
  social 
protection  centres  for  children,  6  rehabilitation 
centres  for  disabled  persons  and  there  are  4  other 
relevant structures (all legal entities of public law).  

(498) Ziomas D., Konstantinidou D., Vezyrgianni K., Capella A. 
(2018),  ESPN  Thematic  Report  on  Challenges  in    long-
term care – Greece 2018, European Social Policy Network. 

 
                                                           
                                                           
is 

through 

currently 

MoLSSSS 
running 
deinstitutionalisation  (DI)  projects  for  disabled 
persons 
the  regional  Social  Welfare 
Centers.    The  two  first  projects  of  this  kind  are 
running  in  Western  Greece  (aiming  to  the  closure 
of the nursing home in Lechaina), and in the region 
of  Attica.  DI  projects  include  a  broad  range  of 
special 
actions 
housing, 
supported 
training  programmes,  hiring 
educational  and 
expertise 
to  move 
specialised  carers  etc.), 
beneficiaries  from  closed  care  institutions  to  their 
place  of  residence  as  well  as  to  establish  a 
community-based  services  network  for  supporting 
living 
and  preventing 
community 
in 
institutionalisation.   

(e.g. 

the 

A  broader  DI  National  Strategy  for  the  Welfare 
sector, including children and the elderly, has been 
also  under  construction  by  the  MoLSSSS.  The 
strategy  includes  a  2019-2023  Action  Plan  for 
and 
providing 
preventing institutionalisation. 

community 

services 

based 

Several  private  clinics  operate  under  a  contract 
with  EOPYY  to  provide  long-term  care,  indeed, 
based  on  data  from  the  Eurofound (499),  it  seems 
that  more  than  95%  of  the  care  homes  are  of 
private  ownership,  with  slightly  more  than  half 
being  non-profit  and  the  rest  for-profit.  All  the 
long-term  care  units  (public  and,  for-profit  and 
non-profit  private  ones  amount  to  approximately 
250 and account for a total of approximately 12000 
to  15000  long-term  care  beds.  Non-profit  care 
homes  tend  to  provide  nursing  care  services  and 
are  partly  subsidised  by  the  state,  and  partly 
funded by donations (and per diem fees paid by the 
social  insurance  organisation  for  those  entitled  to 
social  insurance).  For-profits  are  financed  by  the 
beneficiaries and seem to have put a greater focus 
on 
such  a  dementia  and 
rehabilitative services.  

specific 

issues 

Day-care to the elderly is provided by the 62 Day 
Care  Centres  for  the  Elderly  (KIFI).  Since  their 
establishment 
they  have  been  funded  mostly 
the 
through  EU 
strengthening  of  services  of  semi-residential  care, 

resources, 

dedicated 

to 

(499) Eurofound  (2017),  Care  homes  for  Older  Europeans: 
Public,  for-profit  and  non-profit  providers,  Publications 
the  European  Union,  Luxembourg, 
Office 
https://www.eurofound.europa.eu/printpdf/publications/rep
ort/2017/care-homes-for-older-europeans-public-private-
and-not-for-profit-providers. 

of 

Long-term care systems 

3.12. Greece 

both  for  the  elderly  and  for  the  disabled,  and  of 
home  care.  Currently  KIFIs  are  funded  by  the 
European  Social  Fund,  through  the  Operational 
Programmes of the 13 regions of Greece.  

As with the centres of day care, the Help at Home 
programme  (introduced  in  1998),  operated  by 
municipal enterprises, has been initially funded by 
EU  resources  (European  Social  Fund  until  2015), 
but has been since then administrated by the local 
authorities  funded  for  this  purpose  by  the  state 
budget.  In  the  past,  the  insufficient  criteria  to 
contain  expenditure  undermined  the  viability  of 
service provision, especially in the case of Help-at-
Home. 
adopted 
In  December  2018,  new 
legislation (500)  secured  the  permanent  nature  of 
local 
the  programme  Help-at-Home 
authorities  and  subsequently  its  funding  by  the 
state  budget.    The  necessary  procedures  to  hire 
carers  under  open-end  contracts  are  currently 
running  according  to  the  rules  of  the  Supreme 
Council for Civil Personnel Selection (ASEP). 

the 

in 

At present, there are 860 ‘Help at Home’ schemes 
in  operation,  run  by  282  agencies  (municipalities, 
municipal  enterprises,  non-profit  organisations, 
etc.)  and  providing  services  to  about  71,563 
beneficiaries (501). Lastly, some outpatient services 
are provided by rehabilitation centres. 

Types of care 

Public  services  include  Help-at-Home,  KAPIs 
(ΚΑΠΗ-Open  Care  Centres  for  Older  People,  i.e. 
local  community  day  centres),  public  residential 
care homes for older people, Day-Care Centres for 
Older  People  (ΚΗΦΗ,  providing  day  care  for 
dependent  older  people  with  no  family  or  while 
their  family  carers  are  at  work),  Centres  for 
chronic diseases and rehabilitation.  

started 

setting  up  a  new 
The  MoLSSSS 
administrative  scheme,  named  OFILI  (Integrated 
Care for the Elderly) in order to link, monitor and 
coordinate the three existing  forms of care for the 
(KAPIs,  KIFIs,  Help-at-Home).  This 
elderly 
scheme  has  been  designed  to    be  part  of  the 
Community  Centres’  platform  and  thus  extending 

(500) Article 91 of Law 4583/2018 (Gov.Gaz.A’212). 
(501) Ziomas D., Konstantinidou D., Vezyrgianni K., Capella A. 
(2018),  ESPN  Thematic  Report  on  Challenges  in    long-
term care – Greece 2018, European Social Policy Network. 

373 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

possibilities  for  better  targeting  and  adequate 
coverage of those in need (502).   

based on the kind of chronic illness, recipients are 
entitled  to  different  levels  of  care  provision.  The 
invalidity levels are set at 50%, 67% or 80%. 

Private for-profit sector’s services in the long-term 
care system include: residential care homes (MFI), 
care  workers  at  home  (often  migrants),  medical 
care (private medical care).  

include 

non-profit 

services 
charity 

and 
Private 
programmes 
and 
run  by  NGO’s, 
philanthropic  organisations,  churches  and  their 
branches  and  privately  funded  foundations  These 
include: NGO's for special groups, NGO's of older 
people,  NGO's  as  service  providers  and  NGO's 
combating social exclusion (503) (504). 

Eligibility criteria 

Admissions  to  state  operated  care  centres  for  the 
chronically  ill,  which,  however,  hardly  cover  the 
needs  among  deprived  elderly  people,  and  to 
contracted  non-profit  and  for-profit  clinics  are 
subject  to  referral  by  the  social  services  of  local 
authorities, of “regional units” (ex-prefecture level 
social  welfare  directorates),  of  the  NHS  hospitals 
and quite often by the local state prosecutors acting 
in  defence  of    the  best  interest  of  those  people. 
Existing  legislation  does  not  define  a  specific 
income  threshold.  It  rather  stresses  that  economic 
hardship  is  a  crucial  criterion,  but  other  factors 
defining the severity of need  should be taken  into 
account too in the evaluation of each specific case. 

Dependent  on  invalidity  levels  as  assessed  by  the 
Centres  for  Certifying  Incapacity  (KEPA),  and 

(502) Community  Centres  are  structures  designed  by 

the 
MoLSSSS as both “one-stop-shop” and “on the field” spots 
of  the  National  Mechanism  for  Monitoring,  Coordinating 
and  Evaluating  All  Social  Inclusion  and  Social  Cohesion 
Policies. Their purpose is to inform citizens about services 
and  programmes  they  are  entitled  to  and  assist  them  in 
getting  access  to  them.  Community  Centres  are  operating 
as part of the social services of the local Municipalities and 
will  be  funded  by  ESF  through  Regional  Operational 
Programmes  up  to  2023  (then  anticipated  to  be  fully 
integrated to municipalities’ social services). 

(503) Mastroyiannakis,  T.,  Kagialaris,  G., Triantafillou,  J.:  "The 
role  of  informal  care  in  long-term  care",  Greek  National 
Report 
(2010), 
http://interlinks.euro.centre.org/sites/default/files/WP6_EL
_NRP_final.pdf. 

(504) Due to the uncharted constellation of these entities, the law 
4455/2017 
a 
(art.7,  Gov.Gaz.  A’22) 
compulsory  procedure  for  registering  in  an  electronically 
run  National  Registry.  Approximately  6.000  entries  have 
been recorded until December 2018.           

established 

374 

Co-payments, out of the pocket expenses and 
private insurance 

to 

There are no comprehensive formal long-term care 
services  guaranteeing  universal  coverage  nor  any 
specific  budget  allocated 
long-term  care 
services.  Existing  services  are  addressed  to  the 
neediest, indigent people. Care for the chronically 
ill  (either  in  state  residential  units  or  contracted 
non-profit and for-profit care centres and clinics) is 
limited.  This  means  that  in  many  circumstances 
care must be financed privately. 

it, 

Private  insurance  for  long-term  care  is  negligible 
and  the  cost  of  private  residential  care,  by  those 
who  can  afford 
is  met  by  out-of-pocket 
payments.  In  semi-private  clinics,  services  of 
rehabilitation  and  nursing  for  older  people  may 
benefit from partial coverage by the social security 
funds,  but  this  is  a  time  limited  (up  to  6  months) 
and  small  share  of  the  total  expenditure  which 
mainly  burdens  the  beneficiary.  Consequently, 
over  the  last  few  years  occupancy  of  private  for 
profit  care  homes  has  significantly  fallen  from 
100% to about 80%.  

In  addition,  due  to  the  crisis  and  economic 
hardship  families  opt  to  look  after  the  elderly  at 
home  as  pension  benefits  are  a  major  source  of 
income  particularly  among  households  with  low 
work intensity. 

Formal/informal care giving 

Although  some  formal  care  is  provided,  informal 
care  giving  is  still  an  important  part  of  the  Greek 
long-term  care  system.  Due  to  the  traditional 
central  role  of  the  family  as  a  provider  of  elderly 
care,  and  to  the  financial  hardship  and  lack  of 
supporting 
are 
increasingly resorting to the use of migrant carers. 
These  are  typically  hired  to  look-after  the  elderly 
and  often  live  with  them,  providing  24-hour  care, 
and they are entirely financed by the patient or his 
network. 

provision, 

families 

private 

 
                                                           
Long-term care systems 

3.12. Greece 

Prevention 
measures 

and 

rehabilitation 

policies/ 

Three  types  of  rehabilitation  centres,  recently 
transferred under the responsibility of the Ministry 
of Health and managed by ESY hospitals, provide 
outpatient  long-term  care  services  (Centres  for 
Further  Therapy  and  Rehabilitation  of 
the 
Disabled,  Centres  for  Physical  and  Medical 
Rehabilitation; and the so-called KEKYKAMEA - 
Centres 
for  Education,  Training  and  Social 
Support  to  Disabled  Persons).  Prevention  is  a 
rather neglected policy area. 

Recently 
reforms  

legislated  and/or  planned  policy 

redesigned 

territory 
the 

the 
stipulated 

In 2010, the Kallikratis plan transferred social care 
to local authorities, which have so far been unable 
to integrate services into a comprehensive package 
ensuring  coverage  to  the  citizens.  In  2011,  Law 
the  map  of  welfare 
4025  has 
through  a 
organisations  over 
consolidation  and 
systematic 
registration of recipients of service benefits into a 
unified  electronic  database.  The  following  year, 
Law  4052  has  explicitly  linked  AKAGE's(505) 
resources  to  the  additional  purpose  to  support  the 
Help at Home programme, on top of its mandate to 
cover future pension deficit. AKAGE has covered 
the  cost  of  the  programme  up  to  end  2018.  An 
element of novelty within this version of the Help 
at Home is that the criteria of eligibility are clearly 
defined based mainly on means testing.  

among 

Another  important  feature  was  the  introduction  of 
competition 
providers.  Alongside 
municipal schemes, non-profit as well as for-profit 
Help-at-Home  units  would  be  able  to  submit  bids 
for  being  included  in  the  registry  of  certified 
providers  in  the  schemes  administered  by  EFKA 
from  which beneficiaries  would be able to choose 
a  provider.  Those  working  in  municipal  schemes 
would  be  able  to  form  “social  cooperatives”  and 
bid  for  becoming  accredited  providers  under  the 
new,  competitive  system.  However,  due  to  strong 
stakeholder  opposition,  the  implementation  of 
these  changes  is  weak  and  progresses  with  slow 
pace. 

(505) AKAGE: Security Fund for Intergenerational Solidarity.   

4583 

In  December 
enabled 
2018,  Law 
Municipalities  having  participated  so  far  in  the 
programme  Help-at-Home 
these 
services in their social structures’ regular activities 
and  hire  staff.  Necessary  procedures  are  already 
applied so that municipalities hire permanent staff 
upon open-end contract and include their payroll in 
their annual budget.  

include 

to 

Recent  policy  measures  adopted  by  Law 
4445/2016  and  Law  4455/2017  provide  for  the 
creation  of  an  official  registry  of  all  agencies 
(public and private) that provide long-term care (as 
part  of  the  broader  range  of  social  and  welfare 
services),  the  establishment  of  a  national  registry 
of  private  non-profit  providers  of  social  care 
services. 

In  addition,  Law  4520/2018  establishes    a  single 
welfare  benefits 
authority,  named  OPEKA 
(Organisation  for  Welfare  Benefits  and  Social 
Solidarity)  which  is  in  charge  of  achieving  better 
coordination,  improving  transparency,  removing 
the  red  tape  and  developing  more  effective, 
efficient  and  coherent  policies  for  vulnerable 
groups. OPEKA  is currently fully operational and 
has  undertaken  the  payment  of  disability  welfare 
benefits,  family  benefits,  school  meals,  special 
allowance for the uninsured elderly and special aid 
to  victims  of  fires  in  Attica  and  soon  it  will 
manage  the  Social  Solidarity  Income  (a  GMI 
scheme) programme too.  

Further, the National Observatory for Alzheimer’s 
and Dementia was created in 2014 and paired with 
the  adoption  of  an  action  plan  in  2016  to  also 
strengthen  support  to  this  part  of  the  population 
with the creation of special care units, such as day-
care  centres,  for  persons  suffering  from  such 
diseases,  and  by  envisaging  measures  to  support 
their  carers.  Another  important  step  could  be 
an 
represented  by 
institutional setting for the provision of ‘Integrated 
Care  for 
to  recent 
the  Elderly’.  According 
announcements  by 
the  Minister  of  Social 
Solidarity,  this  would  currently  be  in  the  pipeline 
and the outcome could reduce the fragmentation of 
the  existing  care  services  for  the  elderly  (open 
protection centres for the elderly (KAPI), KIFI and 

establishment  of 

the, 

375 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

the  ‘Help  at  Home’  programme)  by  increasing 
their coordination (506).  

to 

the  national 
the  MoLSSSS 
According 
deinstitutionalisation strategy,  including the 2019-
2023  Action  Plan  for 
  deinstitutionalisation 
projects  and  the  provision  of  community  based 
services preventing institutionalisation is due to be 
filed by first semester of  2019. 

coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage; the depth of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage; to reduce the risk of 
impoverishment  of  recipients  and  informal 
carers. 

A  legislative  framework  related  to  the  general 
rules  of  social  protection  provision 
the 
the 
populations  as  well  as  a 
management,  functioning  and  financing  of  social 
care  institutions  are  also  going  to  be  filed  in  the 
Parliament in the near future. 

to 
ruling 

law 

Challenges 

Greece,  despite  recent  efforts,  has  a  highly 
fragmented  and  unstructured  system  of  long-term 
care,  with  relatively  low  coverage  and  high 
reliance on informal care. The  main challenges of 
the system appear to be: 

long-term  care  services; 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of  responsibilities  of  state  authorities  wrt.  the 
provision  of 
to 
integrate  medical  and  social 
strategically 
services via such a legal framework; To define 
a  comprehensive  approach  covering  both 
policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  establish 
good information platforms for LTC users and 
providers;  to  share  data  within  government 
administrations to facilitate the management of 
potential  interactions  between  LTC  financing, 
targeted  personal-income  tax  measures  and 
transfers  and  existing  social-assistance  or 
housing  subsidy  programmes;  to  deal  with 
cost-shifting incentives across health and care. 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 

(506) Ziomas D., Konstantinidou D., Vezyrgianni K., Capella A. 
(2018),  ESPN  Thematic  Report  on  Challenges  in    long-
term care – Greece 2018, European Social Policy Network. 

376 

•  Improving 

financing  arrangements:  To 
determine  the  extent  of  user  cost-sharing  on 
LTC benefits; following the interconnection of 
programmes  platforms (507),  to    continue  the 
centralised  means-testing 
determine 
individual cost-sharing (or entitlement to public 
support)  so  that,  while  accounting  for  the 
economic  context,  it  guarantees  a  uniform  and 
equal  treatment  to  all  citizens,  it  captures 
different 
including 
benefits, and it also captures wealth in the form 
of assets. 

components, 

income 

to 

•  Encouraging  independent  living:  to  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

•  Ensuring  availability  of  formal  carers:  to 
for 
determine  current  and 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons. 

the 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals, while at the same time ensure that the 
payment  systems  and  financial 
incentives 
discourage acute care use for LTC. 

(507) Cf  the  programmes’  platforms  of  the  Social  Solidarity 
Income,  the  Social  Divident  2017  and  2018,  the  Child 
Benefit, the Housing Benefit.   

 
 
                                                           
                                                           
•  Improving  value  for  money:  to  encourage 
competition across  LTC providers to stimulate 
productivity  enhancements.  To 
in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
and 
information, 
coordination. 

centeredness, 

management 

invest 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and  health-promotion  policies    and    identify 
risk  groups  and  detect  morbidity  patterns 
earlier. 

•  Improving administrative efficiency. 

•  Ensuring good budgeting practices. 

Long-term care systems 

3.12. Greece 

377 

 
3
7
8

Table 3.12.1:  Statistical Annex – Greece 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

273
:

:
:
:

:
:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

199
25.1
11.0

:
:
:

82.5
76.8
67.4
65.9
:
:

218
26.3
11.0

:
:
:

82.7
77.1
68.1
66.5
20.3
6.1

233
26.0
11.0

:
:
:

82.5
76.9
67.6
66.0
21.7
6.8

242
25.2
11.1

:
:
:

83.0
77.5
66.2
65.6
22.2
8.2

238
23.2
11.1

0.0
8.3
0.1

83.3
77.5
66.8
66.1
22.1
8.0

226
21.5
11.1

0.1
11.0
0.1

83.3
78.0
67.7
66.1
22.8
8.1

207
19.6
11.1

0.0
6.3
0.1

83.6
78.0
66.9
66.2
23.4
8.6

191
19.0
11.1

0.0
7.8
0.1

83.4
78.0
64.9
64.8
23.8
10.1

181
19.5
11.0

0.1
8.8
0.1

84.0
78.7
65.1
64.7
23.9
10.8

179
20.5
10.9

0.0
5.5
0.1

84.1
78.8
64.8
64.1
24.1
11.4

176
21.2
10.9

0.0
7.0
0.1

83.7
78.5
64.1
63.9
23.6
10.8

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

66
148
1.9

:
:

83
177
2.3

:
:

100
205
2.8

:
:

117
234
3.2

:
:

121
239
3.2

:
:

125
244
3.3

:
:

4
10
0.1

:
:

5
11
0.1

:
:

5
11
0.1

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.12.2:  Statistical Annex - continued – Greece 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

199
25.1
11.0

:
:
:

82.5
76.8
67.4
65.9
:
:

218
26.3
11.0

:
:
:

82.7
77.1
68.1
66.5
20.3
6.1

233
26.0
11.0

:
:
:

82.5
76.9
67.6
66.0
21.7
6.8

242
25.2
11.1

:
:
:

83.0
77.5
66.2
65.6
22.2
8.2

238
23.2
11.1

0.0
8.3
0.1

83.3
77.5
66.8
66.1
22.1
8.0

226
21.5
11.1

0.1
11.0
0.1

83.3
78.0
67.7
66.1
22.8
8.1

207
19.6
11.1

0.0
6.3
0.1

83.6
78.0
66.9
66.2
23.4
8.6

191
19.0
11.1

0.0
7.8
0.1

83.4
78.0
64.9
64.8
23.8
10.1

181
19.5
11.0

0.1
8.8
0.1

84.0
78.7
65.1
64.7
23.9
10.8

179
20.5
10.9

0.0
5.5
0.1

84.1
78.8
64.8
64.1
24.1
11.4

176
21.2
10.9

0.0
7.0
0.1

83.7
78.5
64.1
63.9
23.6
10.8

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

273
:

:
:
:

:
:
:

:
:

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

66
148
1.9

:
:

83
177
2.3

:
:

100
205
2.8

:
:

117
234
3.2

:
:

121
239
3.2

:
:

125
244
3.3

:
:

4
10
0.1

:
:

5
11
0.1

:
:

5
11
0.1

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

3
7
9

3
.
1
2
.

r

G
e
e
c
e

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
3.13. HUNGARY 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

Hungary  has a population estimated at around 9.8 
million  inhabitants  in  2016,  and  it  is  projected  to 
fall  down  to  8.9  by  2070.  With  a  GDP  of  around 
€111 bn, or 17,200 PPS per capita, it is below the 
EU average GDP PPS per capita of 29,600.  

Health status 

Life expectancy at birth for both  men and  women 
was,  in  2015,  respectively  72.3  years  and  79.0 
years and is below the EU average (77.9 and 83.3 
years  respectively).  The  healthy  life  years  at  birth 
for  both  sexes  are  60.1  years  (women)  and  58.2 
years  (men)  are  also  below  the  EU-average  (63.3 
and  62.6  respectively).  At  the  same  time,  the 
percentage  of  the  Hungarian  population  having  a 
long-standing  illness  or  health  problem  is  far 
higher  than  in  the  Union  as  a  whole  (39.4%  and 
34.2% respectively in 2015). The percentage of the 
population 
indicating  a  self-perceived  severe 
limitation in its daily activities has decreased since 
2004,  and  is  similar  to  the  EU-average  (8.1% 
against 8.1% in 2015). 

Dependency trends 

The share of dependents is expected to increase in 
this period, from 9% in 2016 to 11.5% of the total 
population  in  2070,  an  increase  of  28%,  which  is 
above  the  EU  average  increase  of  21%.  From 
around  0.89  million  residents  living  with  strong 
limitations  due  to  health  problems  in  2016,  an 
increase  of  15%  is  envisaged  until  2070  to  1.02 
million. That is below the increase in the EU as a 
whole (25%).  

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on  long-term  care  (LTC)  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
"AWG  reference  scenario",  public 
long-term 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is  a  projected  increase  in  spending  of  about  0.4  p 

in 

of  GDP  by  2070.  (508)  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 4.1 pps of GDP 
by 2070.  

Hungary faces low fiscal sustainability risks in the 
short  run.  In  the  medium  and  long  term  the  fiscal 
sustainability risks are high, but the contribution of 
health  care  and  long-term  care  is  relatively  low 
(509).  

System Characteristics (510) 

Public  spending  on  LTC  ( 511)  reached  0.7%  of 
GDP in 2016 in Hungary, below the EU average of 
1.6% of GDP. 100% of the benefits  were in-kind, 
with  no  expenditure  on  cash  benefits  (EU:  84  vs 
16%). 

35.5%  of  dependents  are  receiving  formal  in-kind 
LTC services or cash benefits for LTC, below the 
the 
EU  average  of  50%.  Overall,  4.3%  of 
population (aged 15+) receive formal LTC in-kind 
and/or cash benefits (EU: 4.6%). On the one hand, 
low shares of coverage may indicate a situation of 
under-provision  of  LTC  services.  On  the  other 
hand,  higher  coverage  rates  may 
imply  an 
increased  fiscal  pressure  on  government  budgets, 
possibly calling for greater needs of policy reform. 

The expenditure for institutional (in-kind) services 
makes up 68% of public in-kind expenditure (EU: 
66.3%),  32%  being  spent  for  LTC  services 
provided at home (EU: 39%).  

Long-term  care  is  generally  seen  as  a  relatively 
small  section  of  the  social  protection  system  in 
Hungary. However, over the last five years a rapid 
shift  to  publicly-financed  home  based  care  has 
taken place. 

(508) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf . 

(509) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(510) This section draws on OECD (2011b) and ASISP (2014). 
(511) Long-term  care  benefits  can  be  disaggregated  into  health-
related  long-term  care  (including  both  nursing  care  and  
personal  care  services)  and  social  long-term  care  (relating 
primarily to assistance with IADL tasks). 

380 

 
                                                           
Hungary  has  no stand-alone  LTC system. Instead, 
LTC services are provided either by the health care 
system  or  by  the  social  care  system.  The  two 
systems  have  a  different  legislation,  financing 
mechanisms and services. They each have parallel 
institutional networks that include institutional and 
home  care.  There  is  only  weak  coordination 
recent 
between 
improvements  due  to  the  merging  of  the  health 
care  and  social  affairs  portfolios  under 
the 
supervision the Ministry of Human Resources. 

them  despite 

some  minor 

Until recently the LTC system was still shaped by 
the  organisational 
logic  of  central  planning: 
centralisation  (as  fewer  institutions  are  easier  to 
control),  a  preference  for  institutionalised  care 
versus  home-based  care  and  a  lack  of  awareness 
beyond its immediate operational sphere. The main 
consequence  was  a  dual  structure  consisting  of  a 
centralised  institutional  supplemented  through  the 
informal  behaviour  of  individual  and  households. 
However,  this  has  recently  changed  with  a  shift 
towards more home care.  

Health  care  system  provides  nursing  care  in 
nursing departments of hospitals and home nursing 
care.  Hospitals  have  nursing 
/  chronic  beds 
(determined  by  law)  for  those  who  are  in  need  of 
long-term  nursing.  Tasks  of  these  department  or 
services:  help  in  stabilising  and  improving  health 
conditions,  alleviation  of  pain,  and  supporting 
relatives for participation in home care. The social 
care system provides three main types of services: 
home care (including “meals-on-wheels” services), 
day care and residential care. 

The  LTC-system  does  not  offer  cash  benefits  for 
recipients to improve access to care. There is only 
one  type  of  social  allowance,  the  nursing  fee,  for 
those  relatives  with  caring  responsibility  for  a 
disabled family member. 

Beyond  this,  the  bulk  of  LTC  provision  is  left  to 
private households or the informal market.  

Administrative organisation 

Home care is organised at a local level, whether by 
social  work  centres,  homes  for  elderly  or  special 
institutions.    In  general,  the  financial  system  of 
public  LTC  functions  as  a  direct  subsidy  to 
suppliers of care. Services include help with daily 
social  assistance  and 
activities 

supervision, 

Long-term care systems 

3.13. Hungary 

medical services. Home health care is organised by 
community  nurses.  Additionally,  there  also  some 
day-centres and transitional accommodation. 

Types of care 

Long-term  care  in  Hungary  includes  benefits  in 
kind  (institutional  or  home  care)  as  well  as  one  
cash benefit (nursing fee, as explained above). The 
provision  of  LTC  is  regulated  by  legislation  on 
social  security,  such  as  health  care  and  health 
insurance,  pension  and  disability  insurance  and 
social assistance. As shown in the statistical annex, 
most  services  are  currently  provided 
in  an 
institutional setting. 

Eligibility  criteria,  co-payments,  out  of  the 
pocket expenses and private insurance 

As  explained  above,  the  nursing  fee  is  a  social 
allowance provided to carers. Applications need to 
be  based  on  the  expert opinion  of  the  GP  treating 
the dependent person. Since January 2013 they can 
be submitted directly to the district office. The fee 
is  paid  to  carers  who  provide  LTC  for  severely 
disabled  family  members  (including  both  the 
elderly  as  well  as 
severely  disabled 
permanently  ill  young  (minor)  family  members). 
In this way, the nursing fee is not only targeted to 
LTC  of  the  elderly.  Additionally,  the  social 
legislation  allows 
to  give 
financial  help  to  those  caring  for  permanently  ill 
family members aged over 18 but under 65. 

local  governments 

the 

Apart from these cash benefits services are funded 
directly.  Private 
insurance  schemes  are  not 
involved  in  the  funding  of  LTC.  The  operational 
costs  of  providing  LTC  are  financed  by  the 
"Health  Insurance  Fund"  for  health  care  and  the 
central  government  budget  for  the  social  care 
component of  LTC.  

In  addition,  care  providers  are  allowed  to  charge 
user  fees.  The  exact  amount  charged  differs 
depending on the service. The regulations stipulate 
algorithms  that  take  into  account  the  personal 
income and real state assets of the recipient but do 
neither  include  other  assets  nor  the  availability  of 
informal family carers. The fee can go up to 80% 
of monthly income for institutional care and 50 % 
for  group  homes  for  rehabilitation.    Besides  these 
according  to  the  different  providers  the  maximum 
fees are the  following: for day care:  max. 15% of 

381 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

monthly  income;  for  day  care  +  meals:  max  30% 
of monthly income; for temporary care: max. 60%- 
of monthly income). 

Recently 
reforms 

legislated  and/or  planned  policy 

Unit  costs  of  both  residential  and  home  care  are 
low in comparison with the rest of the EU. In 2012 
the financial support for residential care for a year 
was  HUF  635,650,  about  €2,200,  around  22%  of 
per  capita  annual  GDP.  In  2013  the  method  of 
calculation  has  changed.  In  contrast  to  the  "per 
resident  quota"  in  effect  till  2012,  since  then  the 
average  wage  of  carers  in  residential  homes  is 
regulated  by  the  government.  The  normative 
support per resident can be calculated according to 
further  rules  on  residents  per  carer,  with  special 
multipliers  for  care  intensity  (1.0  for  regular 
elderly homes, 1.18 for dementia care and 0.19 for 
special elderly care). As a consequence, the quota 
for  regular  care  has  increased  slightly  up  to  HUF 
651,510,  (about  €2,255  per  annum).  For  home 
care,  the  corresponding  figure  was  HUF  166,080, 
around  €575  or  about  6%  of  per  capita  GDP,  in 
2012,  cut  back  to  HUF  145,000  (around  €490)  in 
2013. 

Formal/informal caregiving 

There  is  empirical  evidence  showing  that  family 
relations  play  a  relatively  important  role  in  LTC 
for  the  elderly  in  Hungary.  The  4th  wave  of 
SHARE (Survey of Health, Ageing and Retirement 
in  Europe),  for  the  first  time  including  Hungary, 
found  that  the  elderly  in  Hungary  are  by  far  the 
most  likely  to  name  their  offspring  among  the 
confidants  they  can  rely  on  and  the  second  most 
likely  to  name  their  spouses  (Stoeckel  and  Litwin 
2013).  Additionally,  the  majority  are  women  (the 
highest proportion within the OECD). 

Prevention 
policies/measures 

and 

rehabilitation 

Prevention and rehabilitation are provided through 
the health care system.  

382 

Modification  of  the  responsibility  of  institutions 
providing  permanent  accommodation  and 
care  

In the "Act III. of 1993. on Social Administration 
and  Social  Benefits"  (regulates  the  responsibility 
of operate of social services. Before the enactment 
of  the  act,  the  responsibility  for  ensuring  services 
providing LTC belonged to county authorities and 
local  authorities  of  cities  with  county  rights.  The 
state  took  over  the  social  institutions  of  county 
authorities  in  2012  during  a  process  of  its  debt 
consolidation. 
legislative 
responsibility  of  operating  institution  providing 
long  term  care  became  the  responsibility  of  the 
state.  

parallel 

the 

In 

residential 

takeover  process  of 

social 
The 
institutions  took  place  in  2013,  as  the  legislative 
responsibility  of  maintaining  of 
residential 
institutions  to  people  with  disabilities,  psychiatric 
patients  and  people  with  addictions  became  the 
responsibility  of  the  state  from  1  January  2013. 
Simultaneously  therefore  all  institutions  which 
earlier  were  maintained  by  local  authorities  were 
taken  over  by  the  state.  The  takeover  gives 
opportunity for reforming of these institutions and 
for  rationalising  the  available  capacities  and  for 
ensuring an efficient and qualitative service.  

to  organise 
Local  authorities  may  continue 
residential care service for elderly at a local level. 
For towns with county rights, and for the capital it 
is still a binding duty. 

Replacement  of  social  institutional  capacities 
providing  nursing  and  care  for  people  with 
disabilities and supported living 

In  July  2011,  the  Hungarian  Government  adopted 
the  Government  Decree  No.  1257/2011.  (VII.21.) 
on  the  strategy  for  the  replacement  of  social 
institutional  capacities  providing  nursing  and  care 
for people with disabilities 2011-2041 (hereinafter: 
DI 
of 
the 
strategy) 
the 
governmental 
deinstitutionalisation 
full 
is 
enjoyment of human rights, to increase the quality 
of life of persons with disabilities and at the same 

implementation 
tasks.  The  main  goal  of 
the 

to  ensure 

and 

 
Long-term care systems 

3.13. Hungary 

time to develop and modernise the structure of the 
provision of social services.  

giving 
organisations.  

preparatory 

support 

for 

inquiring 

the 

Social 

institutions  – 

For  the  purpose  of  implementing  the  targeted 
developments  and  conversions  in  the  first  three-
year  period  of  the  30-year-long  strategy,  a  tender 
of 
Infrastructure  Operational 
Programme  (TIOP  3.4.1.  A-11  ‘Replacement  of 
residential 
institutions 
component’) was launched with the overall amount 
of  HUF  7  billion.  In  the  first  two  phases  of  the 
tender,  six  projects  were  submitted.  Four  of  them 
were  related  to  care  homes  for  disabled  persons 
and two of them to psycho-social care homes. The 
total amount of support received by the applicants 
is almost HUF 6 billion (€19,344,327). 

social 

The  operators  who  applied  for  subsidies  for 
deinstitutionalisation  had  to  clearly  blueprint  the 
implementation  of  the  transformation  of  their 
institutions  and  services  before  its  beginning; 
demands and needs of every service user had to be 
measured;  the  process  of  their  preparation  for 
changes  and  the  structures  of  the  tailor  made 
services had to be designed.  

The  "National  Body  for  Deinstitutionalisation" 
(hereinafter  called:  the  Body)  was  established  to 
overview and approve the feasibility studies on the 
basis  of  the  principles  and  objectives  of  the 
deinstitutionalisation  (DI)  strategy.  The  Body 
outlines  preliminary  professional 
evaluation 
criteria by submitting professional proposals on the 
feasibility  studies. The Body  determines the order 
of  the  implementation  and  takes  part  in  the 
monitoring  of  the  development.  Furthermore,  the 
Body  makes  comments  on 
the  concept  of 
utilisation of the infrastructure remaining after the 
deinstitutionalisation  process 
the 
proposals  and  outlines 
the  Action  Plan  for 
restructuring  the  institutions  in  every  three  years. 
The  Body  ensures  the  full  transparency  of  the 
implementation  of  the  strategy.  Persons  with 
disabilities,  civil  services,  advocacy  groups, 
representatives  of  social  and  higher  education, 
institutions of special education, other background 
institutions,  service  providers  and  senior  civil 
servants take part in the activity of the Body. 

indicated 

in 

The  DI  strategy  is  also  promoted  by  the  Social 
Renewal  Operational  Programme 
(TÁMOP 
5.4.1/12  ‘Modernisation  of  social  services’)  by 
giving  communicational  support  for  a  more 
effective social inclusion.  

In order to establish  the legislative background of 
the strategy, supported living was introduced from 
1 January 2013 as a new form of social services in 
the  Act  III  of  1993  on  Social  Administration  and 
Social Benefits. 

Supported  living  is  a  flexible  combination  of 
various  forms  of  housing  and  supportive  services, 
where  the  housing  and  supportive  services  are 
separated  from  each  other.  The  supported  living 
service provides appropriate conditions  for people 
with disabilities, psychiatric patients, persons with 
addictions  and  homeless  people  concerning 
housing and social services in accordance with the 
beneficiaries’  age,  health  condition  and  self-care 
skills.  The  provided  service  is  based  on  complex 
needs  assessments 
the 
(taking 
necessary intensity of support, the existing abilities 
and  the  users’  will)  and  it  is  modified  in  parallel 
with the possible changing circumstances.  

into  account 

The  service  provides:  housing/living  service;  care 
management;  support  for  follow  up  the  persons’ 
living  conditions  based  on  personal  needs 
assessments;  meals; 
care; 
development/rehabilitation,  and  services  to  help 
participation in social life. 

nursing 

and 

After  1  January  2013,  new  institutional  places 
providing  nursing  and  care  for  people  with 
disabilities,  psychiatric  patients  or  people  with 
addictions can be established: a) 
In  the  case  of 
large  institutions  only  by  providing  supported 
housing; b) 
in  the  case  of  creating  new 
institutions  which  can  only  be  set  up  in  houses 
described  by  legislative  regulations  on  supported 
housing  (flat  for  maximum  6  people  or  house  for 
maximum 7-12 people). 

The  network  of  mentors  set  up  by  the  support  of 
the  European  funds  is  also  important  for  the 
success  of 
implementation  by  ensuring 
counselling on the questions of replacement and by 

the 

383 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Supporting 

family  carers:  To  establish 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  create  better 
improving  (and  securing)  safe  care 
rules, 
pathways 
to 
chronically-ill people or circulated through the 
system;  To 
towards 
appropriate settings. 

information  delivered 

steer  LTC  users 

and 

•  Improving  value  for  money:  To  invest  in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services; To 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people  with  chronic  care;  To  employ 
prevention  and  health-promotion  policies  and  
identify  risk  groups  and  detect  morbidity 
patterns earlier. 

Challenges 

The main challenges of the system appear to be:  

•  Improving  the  governance  framework:  To 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of responsibilities of state authorities wrt. to the 
long-term  care  services;  To 
provision  of 
strategically 
integrate  medical  and  social 
services via such a legal framework; To define 
a  comprehensive  approach  covering  both 
policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and 
its  financing;  To  set 
guidelines  to  steer  decision-making  at  local 
level  or  by  practising  providers;  To  use  care 
planning  processes,  based  on  individualised 
need  assessments,  involving  health  and  care 
providers  and  linking  need  assessment  to 
resource  allocation;  To  share  data  within 
government  administrations  to  facilitate  the 
management  of  potential  interactions  between 
LTC  financing,  targeted  personal-income  tax 
measures  and  transfers  (e.g.  pensions),  and 
existing  social-assistance  or  housing  subsidy 
programmes;  To  deal  with  cost-shifting 
incentives across health and care. 

•  Improving 

financing  arrangements:  To 
foster  pre-funding  elements,  which  implies 
setting  aside  some  funds  to  pay  for  future 
obligations; To explore the potential of private 
LTC  insurance  as  a  supplementary  financing 
tool;  To  determine  the  extent  of  user  cost-
sharing on LTC benefits. 

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  LTC 
coverage schemes, by setting: (i) the need-level 
triggering  entitlement  to  coverage;  (ii)  the 
breadth  of  coverage,  that  is,  setting  the  extent 
of  user  cost-sharing  on  LTC  benefits;  and  (iii) 
the depth of coverage, that is, setting the types 
of  services  included  into  the  coverage;  To 
reduce the risk of impoverishment of recipients 
and informal carers. 

•  Ensuring  availability  of  formal  carers:  To 
for 
determine  current  and 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

384 

 
 
Table 3.13.1:  Statistical Annex – Hungary 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

91
17.7
10.1

0.3
:
0.5

77.2
68.7
54.3
52.2
:
:

92
17.8
10.1

0.2
35.3
0.4

77.8
69.2
57.2
54.4
35.8
13.5

102
17.5
10.1

0.3
40.5
0.5

77.8
69.4
57.8
55.1
37.0
12.8

108
17.4
10.0

0.3
42.6
0.5

78.3
70.0
58.2
54.8
38.2
10.3

94
16.1
10.0

0.3
40.9
0.5

78.4
70.3
58.2
55.9
36.2
8.5

99
16.5
10.0

0.3
44.3
0.5

78.6
70.7
58.6
56.3
36.0
8.6

101
16.8
10.0

0.2
42.9
0.5

78.7
71.2
59.1
57.6
36.0
8.0

100
16.5
9.9

0.2
41.2
0.5

78.7
71.6
60.5
59.2
36.4
8.0

102
16.5
9.9

0.3
46.4
0.5

79.1
72.2
60.1
59.1
37.8
7.8

106
16.7
9.9

0.3
52.0
0.5

79.4
72.3
60.8
58.9
37.4
7.5

111
17.2
9.9

0.2
51.2
0.5

79.0
72.3
60.1
58.2
39.4
8.1

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
33

:
34

:
:
:

:
:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
8
5

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

45
41
0.9

:
34

60
46
1.1

:
37

75
52
1.3

:
38

89
57
1.5

:
39

92
58
1.5

:
44

94
60
1.6

:
40

95
61
1.6

:
43

96
62
1.6

:
42

97
62
1.6

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
1
3
.

H
u
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g
a
r
y

L
o
n
g

r

-
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a
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s
y
s
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s

 
 
 
 
 
 
 
 
 
 
3
8
6

Table 3.13.2:  Statistical Annex - continued – Hungary 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

9.8

0.89

9.1

0.7

0.7

255,362

59,896

0

3.2

35.5

2020

9.8

0.91

9.3

0.7

0.8

262,142

62,444

0

3.3

35.7

2030

9.7

0.98

10.1

0.8

1.1

281,893

69,636

0

3.6

36.0

2040

9.5

1.01

10.7

0.9

1.6

295,682

75,877

0

3.9

36.6

2050

9.3

1.03

11.1

1.0

2.3

302,531

79,978

0

4.1

37.2

2060

9.1

1.05

11.6

1.1

3.4

308,220

84,892

0

4.3

37.3

2070

8.9

1.02

11.5

1.1

4.8

300,668

84,690

0

4.3

37.6

100.0

100.0

100.0

100.0

100.0

100.0

100.0

0.0

71.6

28.4

19.3

32.6

:

0.0

71.3

28.7

18.8

31.8

:

0.0

70.6

29.4

18.9

32.0

:

0.0

69.9

30.1

20.3

34.1

:

0.0

69.2

30.8

21.5

36.3

:

0.0

68.5

31.5

22.6

37.8

:

0.0

68.1

31.9

22.9

38.1

:

MS Change 2016-
2070

EU Change 2016-
2070

-10%

15%

28%

63%

591%

18%

41%

:

35%

6%

:

:

-5%

12%

19%

17%

:

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
3.14. IRELAND 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

GDP per capita in PPS thousand is at €47,800  and 
far above EU average of €29,600 in 2015. Ireland 
has a population of 4.7 million inhabitants ( 512). It 
should  be  noted  that  in  2015  the  GDP  of  Ireland 
grew  by  25.1%  from  its  2014  level,  which  has  a 
strong effect on some of the variables presented as 
a ratio of GDP in this country profile (513). 

During  the  coming  decades  the  population  will 
steadily  increase  to  6  million  inhabitants  in  2070. 
Thus,  Ireland  is  facing  a  considerable  increase  of 
its  population  by  29%,  while  the  EU  average 
population is estimated to increase by 2%.  

Health status 

Life expectancy at birth for both  women and  men 
was,  in  2015,  respectively  83.4  years  and  79.6 
years  and  is  slightly  above  the  EU  average  (83.3 
and 77.9 years respectively). However, the healthy 
life  years  at  birth  for  both  sexes  are  67.9  years 
(women) and 66.6 years (men) significantly above 
the  EU-average  (63.3  and  62.6  respectively).  At 
the  same 
the  Irish 
population having a long-standing illness or health 
problem  is  lower  than  in  the  Union  as  a  whole 
(26.8%  and  34.2%  respectively  in  2015).  The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  its  daily  activities 
has  decreased  since  2005,  and  is  significantly 
lower than the EU-average (5.4% against 8.1%). 

the  percentage  of 

time, 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living increases significantly 
over  the  coming  50  years.  From  0.25  million 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  88%  is 
envisaged  until  2070  to  slightly  more  than  0.46 
million.  That  is  a  far  steeper  increase  than  in  the 
EU  as  a  whole  (25%).  Also  as  a  share  of  the 
population,  the  dependents  are  becoming  a  bigger 
group,  from  5.3%  to  7.7%,  an  increase  of  46% 
(EU: 21%). 

(512) This is according to Eurostat projections.  
(513) Real GDP based on 2017 National Income and Expenditure 

Accounts. Nominal growth in 2015 was 34.4%. 

Expenditure projections and fiscal sustainability  

in 

reference 

scenario,  public 

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
AWG 
long-term 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 1.9 pps 
of  GDP  by  2070  (514).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 3.4 pps of GDP 
by  2070.  Ireland  faces  low  fiscal  sustainability 
risks  in  the  short  run  and  medium  term,  but  risks 
are  medium  in  the  long  term,  risks,  due  to  the 
significant  projected  increase  in  ageing  costs 
including health care and long-term care (515).  

System Characteristics (516) 

The  National  Positive  Ageing  Strategy  (NPAS) 
was  published  in  2013.  It  is  the  first  policy 
document focused on the care of older people since 
the  publication  of  "The  Years  Ahead"  in  1998.  It 
the  over-arching  blueprint  for  age 
represents 
service  delivery  across 
related  policy  and 
Government  and  society 
the  years  ahead 
in 
(Department of Health, 2013).  

A Framework for Improved Health and Wellbeing 
2013-2025  (Department  of  Health,  2013)  is  a 
reform  within  Ireland's  ongoing  health  reform 
programme  that  is  of  key  importance  to  the 
implementation of the NPAS. 

The  Nursing  Homes  Support  Scheme  (NHSS), 
introduced  in  2009,  had  the  aim  of  ensuring 
consistency in the funding of nursing home care by 
the  State  and  individuals.  Its  aim  was  to  ‘make 
long term nursing home care accessible, affordable 
and  anxiety  free’  (Department  of  Health  and 
Children,  2009).  It  replaced  the  previous  Nursing 

(514) The 

2018 

Ageing 

Report 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(515) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(516) This section draws on OECD (2011b) and ASISP (2014). 

387 

 
                                                           
                                                           
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Home  Subvention  Scheme  which 
hugely 
subsidised  care  for  some  recipients,  but  meant  a 
great  number  of  recipients  having  to  pay  for  the 
majority of the extremely high care costs. 

In  line  with  government  policy,  home  support 
services are provided to assist older people to live 
as  independently  as  possible  in  their  own  homes 
and  communities.  In  addition  to  the  mainstream 
Home  Help  (HH)  service,  enhanced  home  care  is 
provided  through  Home  Care  Packages  (HCP), 
introduced  in  2005  and,  since  2014,  Intensive 
Home Care Packages for people with complex care 
needs  In  2018,  the  funding  streams  for  HH  and 
standard HCPs were combined and a single Home 
Support Service came into operation, streamlining 
the  application  process  and  facilitating  service 
users to move to changed levels of service as their 
assessed  needs  change.  The  target  for  this  year  is 
to provide 17.09 HSS hours to 50,500 people. This 
compares  with  16.34  hours  (HH  &  HCPs)  to 
50,000  people  in  2017.  In  addition,  235  Intensive 
HCPs  will  provide  360,000  hours  to  people  with 
complex needs.  

The  provision  of  short-stay  residential  beds  is  a 
key  component  of  the  integrated  model  of  care 
planned  for  the  delivery  of  services  to  older 
people.  Short stay beds are allocated across ‘step 
up/step  down’  care,  intermediate  care,  rehab  and 
respite  care  depending  on  current  demands.  In 
2018,  approximately  2,000  short-stay  residential 
care  beds  will  be  provided.    In  addition,  to 
facilitate discharge from acute hospitals, there is a 
targeted 
850 
of 
transitional care beds at any one time. 

approximately 

provision 

Services  are  provided  on  the  basis  of  assessed 
health-care  need  and  there  is  no  means-testing.  
Other  services  include  day  care  which  provides 
about  28,000 places  per  week  in  299  centres,  and 
meals-on-wheels provided by 345 centres.  

In contrast to  most other EU  countries, the public 
expenditure  long-term  care  takes  exclusively  the 
shape  of  in-kind  benefits,  with  no  role  for  cash 
benefits, beyond those provided to carers.   

Administrative organisation 

of State  with responsibility  for Mental Health and 
Older  People    at  the  Department  of    Health.  The 
Minister  for  State  for  Older  People  is  also 
responsible  for  the  coordination  of  policy  beyond 
the Department of Health. 

The Health Service Executive (HSE) of Ireland is 
responsible  for  providing  and/or  supervising  a 
wide  range  of  residential,  community  and  home 
services  designed  to  support  people  to  live  at 
home. 

Types of care 

In Ireland, long-term care can be taken to include 
both  home  care  and  residential  care.  This  gives  a 
four-fold  classification  of  long-term  care:  older 
people/people 
(under  65)  with  disabilities, 
residential care/domiciliary care. 

Several  schemes/benefits  provide  support  for 
people who require long-term care. 

The  Nursing  Homes  Support  Scheme  provides 
financial  support  towards  the  cost  of  long-term 
nursing  home  care.  A  care  needs  assessment  is 
carried  out  by 
appropriate  healthcare 
professional to identify whether an applicant to the 
Scheme requires long-term care 

an 

Home care is an increasingly important component 
of  the  supports  offered  to  older  people.  These 
services are critical to support older people to stay 
in their own homes and communities, and maintain 
their  independence  for  as  long  as  possible.  They 
also  facilitate  the  discharge  of  older  people  from 
hospital  when  the  acute  phase  of  their  care  has 
been completed. 

Home  Support  Services  are  provided  on  the  basis 
of  assessed  health-care  need  carried  out  by  health 
care  professionals  and  there  is  no  means-testing.  
People are cared for at home under a wide variety 
of  arrangements,  both  formal  and  informal.  The 
HSE  provides  services  both  directly  and  through 
service  agreements  with  private  and  voluntary 
sector providers.   

Long-term care is  funded and delivered as part of 
the health services in Ireland under the auspices of 
the  HSE.  The  responsible  minister  is  the  Minister 

Home  Support  Services  provide  personal  and/or 
essential  domestic  care  to  dependent  people  to 
support  them  to  live  at  home.  In  particular,  they 

388 

 
 
Long-term care systems 

3.14. Ireland 

are aimed at older people living in the community 
who  are  in  acute  hospitals  and  are  at  risk  of 
admission to long-term residential care. 

included  in  the  financial  assessment  for  the  first 
three years of their time in care.  This is known as 
‘the three-year cap’ 

Eligibility criteria 

Applicants to the Nursing Homes Support Scheme 
must undergo care needs and financial assessments 
to  determine  a)  whether  long-term  nursing  home 
care  is  the  most  appropriate  option  (Care  Needs 
Assessment)  and  b)  what  they  can  afford  to 
contribute towards their cost of care. Anyone who 
is  assessed  as  requiring  long-term  nursing  home 
care  can  avail  of  the  scheme,  regardless  of  age. 
However,  nursing  home  care  must  be  appropriate 
to meet the individual’s care needs. The legislation 
underpinning the Nursing Homes Support Scheme 
requires  each  private  nursing  home  to  negotiate 
and  agree  a  price  for  long-term  residential  care 
services  with  the  National  Treatment  Purchase 
Fund (NTPF), should they wish to be an approved 
nursing  home  for  the  purposes  of  the  Scheme.  
This is a necessary feature of the scheme due to the 
commitment  by  the  State  to  meet  the  full  balance 
of  the  cost  of  care  over  and  above  a  person’s 
contribution.  

the  applicant  must 

To  access  Carer’s  Benefit,  Carer’s  Allowance, 
Constant  Attendance  Allowance  and  Carer’s 
Support  Grant, 
submit 
information  from  the  care  recipient’s  doctor  as  to 
the degree of care required. This is reviewed by a 
Department  of  Social  Protection  medical  assessor 
and the benefits are provided by the Department of 
Social Protection. 

Co-payments, out of the pocket expenses and 
private insurance 

Under 
the  NHSS  scheme  people  make  a 
contribution  of  up  to  80%  of  their  assessable 
income  and  a  maximum  of  7.5%  of  the  value  of 
any  assets  towards  the  cost  of  care  and  the  State 
will  pay  the  balance.  In  the  case  of  a  couple,  the 
applicant’s  means  are  assessed  as  50%  of  the 
couple’s  combined  income  and  assets.    The  first 
€36,000  of  assets,  or  €72,000  for  a  couple,  is  not 
counted  in  the  financial  assessment.  Where  assets 
include  land  and  property  in  the  State,  the  7.5% 
contribution based on such assets may be deferred 
and  collected  from  the  person's  estate.  This  is  an 
optional  Nursing  Home  Loan  element  of  the 
scheme. An individual’s principal residence is only 

Government  policy  is  to  support  older  people  to 
live  in  dignity  and  independence  in  their  own 
homes  and  communities  for  as  long  as  possible.  
This  is  achieved  through  a  range  of  community 
based  services  such  as  mainstream  Home  Support 
Services,  Meals-on-Wheels  and  Respite  or  Day 
Care.  Intensive  HCPs,  for 
those  with  high 
dependency levels were introduced in 2014. 

Role of the private sector  

Public,  voluntary  and  private  for  profit  providers 
provide long-term care in Ireland. In the past most 
long-term  care  was  either  provided  by  public  or 
publicly  funded  care  providers  (often  run  by 
Catholic  and  Protestant  churches)  or  informally 
typically  by  family  members  (Wren,  2009).  The 
last few years have seen a sharp increase in private 
providers  of  home  care.  There  is  no  official 
register  of  private  and  not-for-profit  home  care 
companies,  but  it  is  estimated  that  currently  there 
are  in  excess  of  130  such  providers  (including 
franchises). This reflects a decline in informal care 
and  a  significant  increase  in  the  HSE  budget 
allocation to home care services. 

Formal/informal caregiving 

in  Ireland 

to 
Overall  Government  policy 
maintain and support older people at home and in 
their  communities.  The  Department  of  Social 
Protection  operates  a  number  of  income  support 
schemes  for  people  who  stay  at  home  to  care  for 
elderly persons or persons with disabilities. 

is 

Carer's Allowance: Carer's Allowance is a means-
tested  payment  for  carers  who  look  after  certain 
people in need of care and attention on a full-time 
basis.  Those  in  receipt  of  another  social  welfare 
payment  and  providing  someone  with  full  time 
care and attention may qualify for a reduced rate of 
carer's  allowance  in  addition  to  the  original 
payment. 

Care  Sharing:  From  14  March  2005,  two  carers 
who  are  providing  care  on  a  part-time  basis  in  an 
established  pattern  can  be  accommodated  on  the 
carer's allowance scheme. 

389 

 
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

social 

Carer's  Benefit:  Carer's  Benefit  is  a  payment  for 
people  who  have  made 
insurance 
contributions  and  who  have  recently  left  the 
workforce and are looking after somebody in need 
of full-time care and attention. Carer's benefit may 
be  claimed  for  a  total  of  2  years  for  each  person 
being  cared  for.  Carers  Leave  (unpaid)  may  be 
applied for by those seeking to obtain leave to care 
from their place of work. 

Carer’s Support Grant: The Carer’s Support Grant 
is an annual payment for full-time carers who look 
after  certain  people  in  need  of  full-time  care  and 
attention.  The  payment  is  made  regardless  of  the 
carer's means but is subject to certain conditions. 

The  HSE  provides  respite  care  to  give  carers  a 
break  from  caring.  Respite  is  provided  based  on 
need and within available resources. 

and  highlights  many  of  the  positive  and  negative 
aspects  of  growing  old  in  Ireland.  A  second 
national  Positive  Ageing  Indicators  report  is  due 
for publication in late 2018. 

The  National  Carers  Strategy  was  published  in 
July  2012  and  sets  the  strategic  direction  for 
policies,  services  and  supports  provided  by 
Government Departments and agencies  for carers. 
It  sets  out  a  vision  to  work  towards  an  ambitious 
set  of  National  Goals  and  Objectives  to  guide 
policy development and service delivery, to ensure 
that  carers  feel  valued  and  supported  to  manage 
their  caring  responsibilities  with  confidence  and 
are empowered to have a life of their own outside 
of caring. 

Recently 
reforms  

legislated  and/or  planned  policy 

Prevention 
measures 

and 

rehabilitation 

policies/ 

Recently legislated and planned reforms  

The  National  Positive  Ageing  Strategy  was 
published in April 2013. This Strategy provides the 
blueprint for a whole of Government and whole of 
society approach to planning for an ageing society. 
The Strategy provides a vision for an age-friendly 
society  and  includes  four  National  Goals  and 
underpinning objectives to provide direction on the 
issues  that  need  to  be  addressed  to  promote 
positive ageing.   

to 

improve 

The  Department  of  Health  has  framed  a  new 
engagement  between 
approach 
relevant  Departments  and 
stakeholders  and 
Agencies.  The 
inaugural  Positive  Ageing 
Stakeholder  Forum  was  held  in  March  2017,  and 
was  attended  by  civic  society  organisations  who 
are representative of the needs and views of older 
people  in  Ireland.  On  foot  of  the  success  of  and 
interest in the Stakeholder Forum, a second Forum 
is due to be held in late 2018. 

The Cabinet Committee on Social Policy  oversees 
the implementation of the Strategy. As part of the 
NPAS  implementation  process,  a  Healthy  and 
Positive  Ageing  Initiative  has  been  established  to 
provide  evidence  of  the  factors  contributing  to 
level  and 
including  at 
healthy  ageing, 
ultimately  inform  policy  responses  to  population 
ageing  in  Ireland.  The  first  national  Positive 
Ageing  Indicators  report  was  published  in  2016 

local 

390 

The  Nursing  Homes  Support  Scheme  (NHSS), 
often referred to as the “Fair Deal” is a scheme of 
financial support for people who require long-term 
nursing  home  care.  The  statutory  based  scheme 
commenced  on  the  27th  October  2009  with  the 
enactment of the Nursing Homes Support Scheme 
Act  2009  and  replaced  the  scheme  of  Nursing 
Home  Subvention,  which  had  been  in  existence 
since  1993.    The  NHSS  is  operated  by  the  HSE. 
When 
in  2009,  a 
commitment  was  made  that  it  would  be  reviewed 
after  three  years.    The  Report  of  the  Review  was 
published in July 2015. 

the  Scheme  commenced 

The  Government  is  committed  to  promoting  care 
in  the  community  so  that  people  can  continue  to 
live in their own homes for as long as possible.  To 
support this, the Department of Health is currently 
engaged in the development of a new, stand-alone 
statutory  scheme  and  a  system  of  regulation  for 
home-care services. 

to 

in  relation 

The  new  home-care  scheme  will  introduce  clear 
the  services  for  which 
rules 
individuals  are  eligible  and  in  relation  to  service-
allocation. It will therefore be an important step in 
ensuring  that  the  system  operates  in  a  consistent 
and fair manner and will help to improve access to 
home-care 
services  on  an  affordable  and 
sustainable  basis.  The  introduction  of  a  system  of 

 
regulation for home-care will help to ensure public 
confidence in the services provided. 

Policy reforms under preparation/adoption 

It  is  estimated  that  there  are  currently  55,000 
people  with  dementia  in  Ireland.  This  number  is 
expected  to  treble  to  approximately  157,000  by 
2046.    Given  the  increasing  numbers  of  people 
with  dementia, 
the  Government  published 
Ireland’s  first  National  Dementia  Strategy  in 
December 2014.  

The  Irish  National  Dementia  Strategy  aims  to 
improve  dementia  care  to  allow  people  with 
dementia  to  live  well  for  as  long  as  possible  and 
have  services  and  supports  delivered  as  well  as 
possible.  A  National  Dementia  Office  was 
established  in  the  HSE  in  2015  to  drive  the 
Strategy’s  implementation.  A  mid-term  review  of 
the Strategy (May 2018) noted that good progress 
has  been  made  on  implementing  many  of  the 
Strategy’s  35  priority  and  additional  actions  but 
that additional financial and staffing resources will 
be  required  in  the  areas  of  diagnosis,  post-
diagnostic  supports,  primary  care,  acute  care, 
home care and housing if the Strategy is to be fully 
implemented. 

Possible future policy changes 

The  Review  of  the  Nursing  Homes  Support 
Scheme  included  a  general  examination  of  the 
Scheme, as well as the balance between residential 
care  and  care  in  the  community,  and  a  number  of 
key  issues  have  been  identified  for  more  detailed 
consideration  across  Departments  and  Agencies.  
To this end, an Interdepartmental/Agency Working 
to  oversee 
Group  has  been  established 
the 
recommendations 
implementation  of 
contained 
of 
recommendations  within  the  Review,  it  has  been 
undertaken  to  amend  the  scheme,  affording  farms 
and  small  businesses  similar  consideration,  in 
certain 
as  principle  private 
residences  with  regards  the  ‘three-year  cap’.  This 
is  in  progress.  As  the  Scheme  is  statutory  based, 
the  implementation  of  recommendations  arising 
from  the  Review  may  require  amendments  to  the 
Nursing Homes Support Scheme Act 2009. 

the  Review.  On 

circumstances, 

certain 

foot 

in 

Long-term care systems 

3.14. Ireland 

Challenges 

Ireland  has  taken  significant  steps  to  provide  its 
population  with  good  quality  care  and  to  provide 
care in the community. The main challenges of the 
system appear to be:  

•  Improving  the  governance  framework:  To 
set  the  public  and  private  financing  mix  and 
organise formal workforce supply; To face the 
growing  number  of  dependents,  and  provide  a 
strategy  to  deliver  high-performing  long-term 
care  services  to  face  the  growing  demand  for 
LTC services; To use care planning processes, 
based  on 
individualised  need  assessments, 
involving health and care providers and linking 
need assessment to resource allocation.  

•  Improving 

financing  arrangements:  To 
consider better pooling across generations, e.g. 
by levying LTC premia on those aged 40 years 
and  over  or  by  requiring  also  retirees  to 
contribute  premia  to  social  LTC  insurance, 
based on their pension; To explore the potential 
of  private  LTC  insurance  as  a  supplementary 
financing tool; To determine the extent of user 
cost-sharing on LTC benefits.  

•  Encouraging  home 

care 

legislative 

to 
new 

care:  To  develop 
institutional  care  by  e.g. 
alternatives 
frameworks 
developing 
encouraging  home 
regulation 
controlling  admissions  to  institutional  care  or 
the establishment of additional payments, cash 
benefits  or  financial  incentives  to  encourage 
home care; To monitor and evaluate alternative 
services, 
incentives  for  use  of 
including 
alternative settings. 

and 

•  Ensuring  availability  of  formal  carers:  To 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care; To seek options to increase the 
productivity of LTC workers.  

future  needs 

•  Supporting 

family  carers:  To  establish 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 

391 

 
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

encouraged 
market for caring reasons.  

to  withdraw  from 

the 

labour 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use for LTC; To create better rules, improving 
(and 
safe  care  pathways  and 
information  delivered  to  chronically-ill  people 
or circulated through the system; To steer LTC 
users towards appropriate settings. 

securing) 

•  Improving  value  for  money:  To  encourage 
competition  across  LTC  providers  to  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; To 
invest  in  ICT  as  an  important  source  of 
and 
information, 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people  with  chronic  care;  To  employ 
prevention  and  health-promotion  policies  and 
identify  risk  groups  and  detect  morbidity 
patterns earlier. 

392 

 
Table 3.14.1:  Statistical Annex - Ireland 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

170
32.7
4.1

:
:
:

81.3
76.7
64.0
62.9
:
:

185
33.8
4.2

:
:
:

81.7
76.9
64.9
63.2
25.4
6.1

197
35.1
4.3

:
:
:

82.1
77.3
65.6
62.9
24.9
5.9

188
32.1
4.5

:
:
:

82.4
77.9
65.1
63.5
24.5
5.5

170
30.6
4.5

:
:
:

82.7
77.8
65.2
63.9
26.2
5.4

168
33.1
4.5

:
:
:

83.1
78.5
66.9
65.9
28.3
5.2

172
34.2
4.6

:
:
:

83.0
78.6
68.3
66.1
26.5
4.9

176
34.5
4.6

:
:
:

83.1
78.7
68.5
65.9
26.7
4.9

180
34.5
4.6

1.8
574.9
4.5

83.1
79.0
68.0
65.8
27.7
5.6

195
37.1
4.6

1.7
582.9
4.6

83.5
79.3
67.5
66.3
27.1
5.8

262
47.8
4.7

1.4
624.0
4.7

83.4
79.6
67.9
66.6
26.8
5.4

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

161
:

:
:
:

:
:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

3
9
3

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

22
51
1.7

:
21

22
52
1.7

:
26

22
53
1.7

:
25

22
54
1.7

:
24

23
55
1.7

187
25

23
56
1.7

:
24

27
65
2.0

:
24

28
66
2.0

:
24

28
67
2.0

:
25

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
1
4
.

I
r

l

e
a
n
d

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
 
3
9
4

Table 3.14.2:  Statistical Annex - continued - Ireland 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

4.7

0.25

5.3

1.3

1.3

35,036

69,231

0

2.2

42.3

100.0

0.0

59.3

40.7

106.2

36.9

:

2020

4.9

0.26

5.4

1.4

1.4

38,024

75,509

0

2.3

43.0

100.0

0.0

59.3

40.7

103.3

35.7

:

2030

5.2

0.31

6.1

1.7

1.9

49,307

97,136

0

2.8

46.5

100.0

0.0

59.6

40.4

105.9

36.5

:

2040

5.4

0.36

6.7

2.1

2.6

2050

5.7

0.40

7.1

2.7

3.4

2060

5.9

0.44

7.5

3.1

4.3

2070

6.0

0.46

7.7

3.3

4.8

63,982

121,738

80,168

147,391

97,649

172,235

109,458

184,783

0

3.4

51.4

100.0

0.0

60.3

39.7

108.2

37.5

:

0

4.0

56.3

100.0

0.0

61.0

39.0

115.1

40.1

:

0

4.6

61.1

100.0

0.0

61.8

38.2

116.6

40.8

:

0

4.9

63.6

100.0

0.0

62.7

37.3

113.5

40.0

:

MS Change 2016-
2070

EU Change 2016-
2070

29%

88%

46%

145%

255%

212%

167%

:

119%

50%

0%

:

6%

-8%

7%

8%

:

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.15. ITALY 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

With almost 61 million inhabitants, Italy has more 
than 12% of the total EU population in 2016 (517). 
This makes it the fourth largest country in terms of 
population,  after  Germany,  France  and  the  United 
the 
Kingdom.  During 
population  of  Italy  will  steadily  decrease,  from 
60.8  million  inhabitants  in  2016  to  54.9  million 
inhabitants in 2070. This 9.6% decrease represents 
a  gap  of  about  11  pps  from  the  EU  average 
population,  which  is  overall  projected  to  increase 
by 2%. 

the  coming  decennia 

With a GDP of some €1,650 bn (11% of the EU's 
total GDP), or 26,100 PPS per capita, the value for 
2015  is  lower  than  the  EU  average  of  29,610. 
Based on the Ageing Report 2018 (518), total public 
expenditure  on  long-term  care  (health  and  social 
part)  (519)  is,  with  1.7%  of  GDP  in  2015,  slightly 
above  the  EU  average  in  the  same  year  (1.6%). 
However,  the  health  component,  with  0.7%  in 
2015, is lower than the EU average of 1.2% in the 
same year. 

Health status 

Life expectancy at birth for both  women and  men 
is  in  2015  respectively  84.9  years  and  80.3  years 
and is above the EU average (83.3 and 77.9 years 
respectively).  The  healthy  life  years  at  birth  for 
both  sexes  are  with  62.7  years  (women)  and  62.6 
years  (men)  similar  to  the  EU-average  (63.3  and 
62.6 
the 
respectively).  The  percentage  of 
population  having  a  long-standing  illness  has, 
though  with  fluctuations,  increased  through  the 
decade  going  from  21.6%  (2006)  to  24.8%,  in 
2015, but it is well below the EU-average (34.2% 
in 2015). On the other hand, the percentage of the 
population 
indicating  a  self-perceived  severe 
limitation  in  its  daily  activities,  which  has  also 
been increasing from 7.1% (2006) to 9.4% (2015), 
is above the EU-average (8.1% in 2015). 

(517) Based on Eurostat projections. 
(518) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(519) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living is projected to increase 
significantly over the coming 50 years. From 5.48 
million residents living with strong limitations due 
to health problems in 2016, an increase of 19% is 
envisaged until 2070 to around 6.53 million. That 
is less steep an increase than for the EU as a whole 
(25%).  Also  as  a  share  of  the  population  the 
dependents  are  becoming  a  bigger  group,  going 
from 9.0% in 2016 to 11.9% in 2070, an increase 
of  32%,  above  the  EU  average  of  21%  over  the 
same period (520). 

Expenditure projections and fiscal sustainability  

in 

the  demographic  changes, 

With 
the  public 
expenditure  on  long-term  care  as  a  percentage  of 
GDP  is  projected  to  steadily  increase.  In  the 
long-term 
"AWG  reference  scenario",  public 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is  a  projected  increase  in  spending  of  about  1.3  
pps of GDP, from 1.7% in 2016 to 3.0% by 2070 
(521).  The  "AWG  risk  scenario",  which  also 
captures  the  impact  of  additional  cost  drivers  to 
demography  and  health  status,  i.e.  the  possible 
effect of a cost and coverage convergence, projects 
an  increase  in  spending  of  2.2  pps  of  GDP  by 
2070,  bringing  long-term  care  spending  in  Italy 
from 1.7% to 3.9% over the same period. Overall, 
projected  long-term  care  expenditure  increase  is 
expected  to  add  to  budgetary  pressure.  Medium 
and 
long-term  sustainability  risks,  which  are 
classified as high for Italy, mainly derive from the 
high debt-to-GDP ratio and do not stem from long-
term  care  expenditure  and  the  projected  cost  of 
ageing (522). 

System Characteristics  

long-term  care  (LTC) 
Public  expenditure  on 
i) long-term  care 
includes 
services  to  dependent  people  provided  by  the 
public health care system, ii) the social component 

three  components: 

(520) The 2018 Ageing Report. 
(521) The 2018 Ageing Report. 
(522) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

long-term  care  provisions  provided  by 
iii)  attendance  allowances 

of 
municipalities  and 
(indennità di accompagnamento) (523). 

The  overall  expenditure  accounts 
for  1.7 
percentage points of GDP in 2016 and refers to all 
long-term  care  provisions  financed  by  public 
resources, regardless of the age of recipients. Since 
the  incidence  of  dependency  is  strongly  linked  to 
age,  about  three  quarter  of  the  expenditure  is 
directed at the elderly over 65. 

long-term  care 

is 
The  health  component  of 
provided  by  Regions  through  the  local  health 
authorities  (Aziende  Sanitarie  Locali,  ASLs)  and 
accounts  for  about  40%  of  the  total  public 
expenditure on long-term care.  

The  social  component  of  long-term  care  services 
includes a heterogeneous group of benefits, largely 
in  kind,  mainly  provided  at  a  local  level  by 
municipalities,  directly  or  in  association.  These 
provisions are generally means-tested. 

Both  health  and  social  long-term  care  provisions 
include  home  and  residential  care  services.  The 
admission  to  long-term  care  services  is  based  on 
needs but also on income levels: co-payments may 
play  a  relevant  role  and  together  with  the  waiting 
lists tend to shape the users’ profile.  

informally 

Investment  in  home  care  is  average  compared  to 
other  countries,  although  this  type  of  service  is 
fundamentally  and 
supported  by 
migrant  care  workers  that  are  paid  directly  by 
families,  also  through  the  use  of  the  attendance 
allowance.  This  partly  explains  the  fact  that 
investment  in  residential  care  is,  on  the  contrary, 
relatively  weak.  Nevertheless,  the  relatively  low 
coverage of residential care may create tensions on 
public home care provision insofar as severe cases, 
that  could  be  treated  through  different  forms  of 
residential  care  (last  stages  of  Alzheimer  or  other 
forms of dementia, etc.), might be left at home. 

Attendance  allowances  are  based  on  a  cash 
allowance  programme  for  individuals  with  very 
severe  disability.  They  are  not  means-tested  and 

they  are  run  by  the  National  Institute  of  Social 
Security  –  INPS  and  financed  through  general 
taxation.  The  attendance  allowance  accounts  for 
about  500  euros (524)  per  month  (for  12  months) 
and it is provided directly to the dependent person. 
Different  amounts  are  foreseen  for  particular 
categories  of  disability  such  as  the  blind  or  the 
deaf-mute.  Italy  spent  in  2017  the  equivalent  of 
0.89% of its GDP in long-term care cash benefits, 
of which 0.79% of GDP for attendance allowances 
alone.  The  share  of  this  type  of  care  was  in  2017 
about  52%  of  total  long-term  care  expenditure 
(46% for attendance allowances alone), nearly four 
fifty of which covers the frail elderly over 65 (525). 

Administrative organisation 

The actors directly involved in the organisation of 
long-term  care  services  are  municipalities,  local 
health  authorities 
-  ASLs),  nursing  homes 
(residenze  sanitarie  assistenziali-  RSAs)  and  the 
National  Institute  of  Social  Security  (INPS),  but 
other players are involved in planning and funding 
these  services  –  i.e.  the  central  state,  regions  and 
individual 
provinces.  Additionally, 
households  play  an 
the 
in 
organisation and provision of long-term care. 

in 
important 

Italy 

role 

Types of care 

In  Italy,  public  long-term  care  for  older  persons 
includes  three  main  kinds  of  formal  assistance: 
community care, residential care and cash benefits. 
The  Italian  National  Health  Service  (Servizio 
Sanitario  Nazionale,  SSN)  plans  and  manages, 
through 
local  health  units  (aziende  Sanitarie 
locali),  home  health-care  services  –  the  so-called 
‘integrated  domiciliary  care’  provided  by  the 
Assistenza Domiciliare Integrata (ADI) – and other 
health  services  provided  in  residential  settings. 
Personal  social  services,  both  domestic  and 
personal  care  tasks,  provided  at  home  by  the 
Servizi  di  Assistenza    Domiciliare  (SAD),  and 
institutional  social  care  are  managed  at  a  local 
level  by  municipalities,  although  this  should  be 
planned in coordination with the ADI. In practice, 
there  may  be  significant  differences  between 
different  municipalities  in  terms  of  spending  on 

(523) Ministero  dell’economia  e  delle  finanze - RGS  (2018),  Le 
tendenze di medio-lungo periodo del sistema pensionistico 
e socio-sanitario, Report  no. 19.  

http://www.rgs.mef.gov.it/VERSIONE-

I/attivita_istituzionali/monitoraggio/spesa_pensionistica/. 

(524) Specifically, 516.35 euros in 2018. 
(525) Ministero  dell’economia  e  delle  finanze - RGS  (2018),  Le 
tendenze di medio-lungo periodo del sistema pensionistico 
e socio-sanitario, Report  no. 19. 

396 

 
                                                           
                                                           
Long-term care systems 

3.15. Italy 

terms  of  shares  of 

care  provided.  Levels  of  institutionalisation  of 
patients  differs  also  between  regions.  Long-term 
care  is  delivered  by  both  public  and  accredited 
private  providers  of  health  and  personal  social 
care.  In 
long-term  care 
spending,  Italy  stands  well  above  average  (52.2% 
vs.  15.6%  for  the  EU  in  2016)  as  for  the  share  to 
is  paired  with 
fund 
comparatively generous allowances with respect to 
the EU average, with unit costs of cash benefits per 
recipients as a share of GDP per capita standing at 
28.9  vs.  11.8  in  2016.  This  measure  gives  an 
indication  of  the  proportion  between  the  spending 
on cash allowances and the available resources.  

cash  benefits.  This 

Eligibility criteria 

In  Italy  there  is  not  one  single,  national  legal 
definition of persons in need of care to which one 
can refer. 

To obtain services in-kind for long-term care, there 
is not the same unique system. Indeed, ASLs of the 
Italian National Health Service are responsible for 
assessing the degree of disability of citizens living 
in  their  catchment  area,  but  their  criteria  are  not 
homogeneous. For most health and social services, 
the  needs  assessments  are  carried  out  by  a 
multidisciplinary  team  of  the  ASL  –  in  most  of 
them  by  the  geriatric  evaluation  units  (Unità  di 
Valutazione  Geriatrica),  which  include  doctors, 
nurses, 
sometimes 
administrative employees. This team in some cases 
classifies the claimants into categories of need, sets 
out the care plan and chooses the type of provider. 

social  workers 

and 

to 

However,  to  obtain  the  cash  benefits  provided  by 
the  same 
the  INPS,  each  region  refers 
classification system: a claimant must apply to the 
Local Health Authority Service (ASL) in charge of 
deciding whether the health requirements (in terms 
of disability and dependence) are present, through 
its  medical  commission.  If  this  is  the  case,  the 
claimant is referred to an INPS commission, which 
makes the final decision. 

especially  considering  the  current  structure  of 
long-term  care  provision  with  generous  cash 
benefits.  The  Attendance  Allowance  is  provided 
only on the base of needs. The criteria of access to 
residential 
somewhat 
differentiated in the country as well as the criteria 
of  co-payment.  Practically  in  the  whole  country 
means-testing  is  applied  to  define  the  amount  of 
economic resources households have to provide in 
order to receive the service. 

and  home 

care 

are 

Role of the private sector 

Private providers of long-term care (both for-profit 
and  not-for-profit)  have  a  share  of  65%  of  all 
institutional long-term care beds. 

Private home care is increasingly important in the 
Italian  long-term  care  system,  although  there  are 
no  official  data  on  this  aspect.  According  to  the 
little  data  available,  6.6%  of  those  aged  over  65 
(NNA, 2009) received home care privately. Private 
home care is provided mainly by migrant workers 
on  individual  basis:  in  2008  it  was  estimated  that 
around 700,000 migrant workers were employed to 
provide  home  care  to  elderly  persons  (NNA, 
2009).  

Formal/informal caregiving 

Informal care is extremely important in the Italian 
social protection system, but the data available are 
limited. 

Generally speaking, in northern Italy the culture of 
public  (formal)  service  in  long-term  care  is  rather 
widespread,  partly  owing  to  the  high  level  of 
participation  by  women  in  the  labour  market. 
These  regions  –  and  municipalities  –  have  been 
making  an  effort  to  improve  their  long-term  care 
system,  thanks  also  to  their  more  developed 
management capabilities and their larger economic 
resources.  In  the  south,  by  contrast,  the  care 
burden 
(informal 
caregiving), with poor public (formal) support.  

rests  mostly  on 

families 

Co-payments, out of the pocket expenses and 
private insurance 

Prevention 
policies/measures 

and 

rehabilitation 

Neither  the  access  nor  the  amount  of  social 
transfers  related  to  the  cash  benefits  programme 
(the  “Attendance  Allowances")  are  means-tested. 
increase  efficiency, 
This  points 

to  scope 

to 

Rehabilitative health care services, included in the 
long-term care definition, are provided to disabled 
people at home or in residences, generally as a part 

397 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

of  more  general  assistance  programmes  related  to 
dependency.  

Recently 
reforms  

legislated  and/or  planned  policy 

for 

The  health  component 
long-term  care 
provisions  depends,  amongst  the  others,  on  the 
level  of  resources  for  the  financing  of  the  public 
health  care  system.  In  this  regard,  the  following 
interventions should be mentioned: 

−  Law  208/2015  (art.  1,  paragraph  508)  has 
redefined the level of the financing resources in 
111.002  million  euro  for  2016  and  set  it  to 
113.063 million euro for 2017, 114.998 million 
for  2018 and 117.988 euro million for 2019; 

−  The Stability law for 2017, Law 232/2016 (art. 
1,  paragraph  392)  has  downsized  the  level  of 
the financing resources to 113.000 million euro 
for  2017,  114.000  million  euro  for  2018  and 
115.000 million euro for  2019; 

−  Decree  foreseen  by  Law  232/2016,  art.  1, 
paragraph 394 has further reduced the level of 
the financing resources to 112.577 million euro 
for    2017, 113.396  million  euro  for   2018  and 
114.396 million euro for  2019. 

the  budget 

Furthermore, 
law  for  2017  has 
increased  the  Fund  for  dependents  in  the  State 
budget  (Fondo  per  la  non  autosufficienza)  up  to 
450  million  euro  per  year  and  made  it  permanent 
as  of  2017.  Resources  in  the  Fund  are  transferred 
to  Regions  to  finance  services  and  benefits, 
for  people  with  severe 
generally 
disabilities. 

in  kind, 

Lastly,  the  Law  112/2016  allocated  financial 
resources  of  above  50  million  euro  per  year  to  a 
new  Fund  targeted  to  support  severely  disabled 
people surviving their parents. 

Challenges 

Italy  has  a  system  of  long-term  care  that  focuses 
on  cash  benefits  as  much  as  on  residential  and 
home care. Based on the current features, the main 
challenges of the system appear to be: 

398 

state 

responsibilities 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
authorities 
of 
of 
concerning  the  provision  of  long-term  care 
services;  to  strategically  integrate  medical  and 
social  services  via  such  a  legal  framework;  to 
define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  establish 
good information platforms for LTC users and 
providers;  to  deal  with  cost-shifting  incentives 
across health and care. 

•  Improving 

financing  arrangements: 

to 
determine  the  extent  of  user  cost-sharing  on 
long  term  care  benefits;  to  extend  means-
testing  to  cash  benefit  provisions,  to  include 
assets  in  the  means-test  used  to  determine 
individual cost-sharing (or entitlement to public 
support)  for  B&L  costs  better  reflects  the 
distribution  of  economic  welfare  among 
individuals. 

•  Providing adequate levels of care to those in 
need of care: to adapt and improve long term 
care  coverage  schemes,  setting  a  homogenous 
need-level  triggering  entitlement  to  coverage; 
the depth of coverage, that is, setting the extent 
of user cost-sharing on long term care benefits; 
to  provide  targeted  benefits  to  those  with 
highest LTC needs. 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons. 

the 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
the  allocation  of  care  co-
information, 
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 

 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  long  term  care;  to  create  better  rules, 
improving  (and  securing)  safe  care  pathways 
and  information  delivered  to  chronically-ill 
people  or  circulated  through  the  system;  to 
steer  long  term  care  users  towards  appropriate 
settings. 

•  Improving value for money: to invest in ICT 
as  an  important  source  of  information,  care 
management  and  coordination;  to  invest  in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services.  

centeredness, 

and 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies  and identify risk 
groups and detect morbidity patterns earlier. 

•  Improving administrative efficiency.  

Long-term care systems 

3.15. Italy 

399 

 
 
4
0
0

Table 3.15.1:  Statistical Annex – Italy 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2005

1,490
27.8
57.9

:
:
:

83.6
78.1
67.8
66.6
:
:

2006

1,548
28.6
58.1

:
:
:

84.1
78.6
64.7
65.2
21.6
7.1

2007

1,610
29.2
58.2

:
:
:

84.2
78.8
62.6
63.4
21.2
7.6

2008

1,632
28.4
58.7

:
:
:

84.2
78.9
61.8
62.9
22.6
8.2

2009

1,573
26.1
59.0

:
:
:

84.3
79.1
62.6
63.4
22.1
8.0

2010

1,605
26.5
59.2

:
:
:

84.7
79.5
:
:
22.6
:

2011

1,637
26.7
59.4

:
:
:

84.8
79.7
62.7
63.5
26.7
8.7

2012

1,613
26.3
59.4

0.7
186.9
1.4

84.8
79.8
61.5
62.1
24.9
9.5

2013

1,605
25.3
59.7

0.7
184.8
1.4

85.2
80.3
60.9
61.8
25.3
9.5

2014

1,622
25.3
60.8

0.7
185.8
1.4

85.6
80.7
62.3
62.5
24.8
9.0

2015

EU 2009

EU 2011

EU 2013

EU 2015

1,652
26.1
60.8

0.7
188.6
1.4

84.9
80.3
62.7
62.6
24.8
9.4

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

165
359
0.9

:
:

201
498
1.2

:
:

237
637
1.5

:
:

273
775
1.8

:
:

276
782
1.8

:
:

280
791
1.8

:
:

294
754
1.8

:
:

299
767
1.8

:
:

302
777
1.8

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.15.2:  Statistical Annex - continued – Italy 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

60.8

5.48

9.0

1.7

1.7

2020

60.7

5.68

9.4

1.8

1.8

2030

60.3

6.16

10.2

2.0

2.1

2040

60.0

6.68

11.1

2.3

2.6

2050

58.9

7.12

12.1

2.8

3.3

2060

56.8

7.02

12.4

3.1

3.8

2070

54.9

6.53

11.9

3.0

3.9

684,968

673,543

709,591

721,887

762,424

829,866

841,051

968,574

1,886,527

1,990,604

2,212,474

2,509,581

947,077

1,144,280

2,889,635

983,824

1,208,538

3,014,888

910,855

1,113,783

2,781,765

5.3

59.2

47.8

52.2

73.2

26.8

53.5

19.9

28.9

5.6

60.2

47.0

53.0

73.4

26.6

53.3

19.0

29.1

6.3

61.8

45.9

54.1

74.0

26.0

53.9

17.4

29.6

7.2

64.7

46.8

53.2

74.4

25.6

58.1

17.3

29.8

8.5

70.0

47.2

52.8

74.9

25.1

61.2

16.9

29.9

9.2

74.2

46.8

53.2

75.5

24.5

62.3

16.4

30.6

8.8

73.6

46.6

53.4

75.6

24.4

62.6

16.5

31.1

MS Change 2016-
2070

EU Change 2016-2070

-10%

19%

32%

71%

128%

33%

65%

47%

64%

24%

-3%

2%

3%

-9%

17%

-17%

7%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

4
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3.16. LATVIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

With a GDP of around €24 bn or 16,200 PPS per 
capita  in  2015,  Latvia  is  below  the  EU  average 
GDP per capita of €29,600.  

During  the  coming  decennia  the  population  of 
Latvia  will  gradually  decline,  from  2.0  million 
inhabitants  in  2016  to  1.3  million  inhabitants  in 
2070. This 32% fall contrasts sharply with the EU 
average increase of 2%.  

the 

of  GDP  by  2070  (526).  However,  the  "AWG  risk 
scenario",  which  in  comparison  to  the  "AWG 
reference  scenario"  captures 
impact  of 
additional  cost  drivers  to  demography  and  health 
status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending of 2.6 pps of GDP by 2070. Latvia faces 
only  low  fiscal  sustainability  risks  in  the  short, 
medium  and  long-term.  Nonetheless,  addressing 
the underfinancing of the healthcare services might 
lead  to  higher  public  spending  in  the  medium  to 
long term (527). 

Health status 

System Characteristics (528) 

the  EU-average 

Life expectancy at birth for men and women was, 
in  2015,  respectively  69.7  years  and  79.5  years, 
below  the  EU  average  (77.9  and  83.3  years 
respectively). In 2015 the healthy life years at birth 
were  54.1  years  (women)  and  51.8  years  (men) 
62.6 
below 
respectively).  At the same  time, the percentage of 
the  Latvian  population  having  a  long-standing 
illness  or  health  problem  is  higher  than  in  the 
Union  as  a  whole  (41.2%  and  34.2%  respectively 
in  2015).  The  percentage  of 
the  population 
indicating  a  self-perceived  severe  limitation  in  its 
daily activities was in 2015 10.1%, above the EU-
average (8.1%). 

(63.3 

and 

Dependency trends 

The share of dependents in Latvia is set to increase 
over this period from 8.5% in 2016 to 11.1% of the 
total population in 2070, an increase of 31%. This 
is slightly below the EU-average increase of 21%. 
From  0.17  million  residents  living  with  strong 
limitations  due  to  health  problems  in  2016,  a 
decrease  of  11%  is  envisaged  until  2070  to  0.15 
million.  This  is  in  contrast  to  the  increase  in  the 
EU as a whole (25%).  

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 
percentage of GDP is set to gradually increase. In 
the  AWG  reference  scenario,  public  long-term 
expenditure  is  driven  by  the  combination  of 
the  population  structure  and  a 
changes 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 0.2 pps 

in 

402 

Administrative organisation 

LTC  is  organised  in  a  relatively  fragmented  way: 
services  provided  for  different  target  groups  are 
organised  in  different  ways  and  financed  from 
different  sources  of  public  financing.  Latvian 
legislation stipulates that in a situation when there 
is a need for care, municipalities need to organise 
the  provision  of 
the 
municipality itself, NGOs or private providers.  

services,  either  by 

the 

All  types  of 
long-term  care  for  the  elderly 
(institutional  and  residential  –  such  as  home  care, 
responsibility  of 
day  centres,  etc.)  are 
municipalities  while  long-term  institutional  social 
care for persons with mental disorders (children as 
well as adults) and long-term care (including both 
social  and  health)  of  chronic  psychiatric  patients 
are  the  responsibility  of  the  Ministry  of  Welfare 
and the Ministry of Health. 

 Institutional care for children deprived of  parental 
care  up  to  age  of  2  years  is  responsibility  of  the 
Ministry  of  Welfare  and  institutional  care  for 
children from age of 2 years up to age of 18 years 
is  responsibility  of  municipalities.  Institutional 
care is provided in cases when care in a family-like 
environment  —  foster  family  or  with  a  guardian 
cannot be provided for respective child.   

Public  spending  on  long-term  care( 529)  reached 
0.4% of GDP in 2016 in Latvia, below the average 

(526) The 

2018 

Ageing 

Report 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(527) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(528) This section draws on OECD (2011b) and ASISP (2014). 

 
                                                           
Long-term care systems 

3.16. Latvia 

EU  level  of  1.6%  of  GDP.  84.7%  of  the  benefits 
were in-kind, while 15.3% were cash-benefits (EU: 
84.4 vs 15.6%).  

and children with mental disorder and 66 children 
deprived of parental care up to age of 2 years.. 

In  the  EU,  in  2016,  the  base  year  of  the  Ageing 
Report  projections  50%  of  dependents  are 
receiving formal in-kind long-term care services or 
cash-benefits for long-term care. This share is with 
26%  lower  in  Latvia.  Overall,  2.2%  of  the 
population  (aged  15+)  receives  formal  long-term 
care  in-kind  and/or  cash  benefits  (EU:  4.6%).  On 
the one hand, low shares of coverage may indicate 
a  situation  of  under-provision  of  long-term  care 
services. On the other hand, higher coverage rates 
may 
increased  fiscal  pressure  on 
government  budgets,  possibly  calling  for  greater 
needs of policy reform. 

imply  an 

The expenditure for institutional services makes up 
82.3% of public in-kind expenditure (EU: 66.3%), 
17.7%  being  spent  for  long-term  care  services 
provided  at  home  (EU:  33.7%).  Thus,  relative  to 
other  Member  States  Latvia  seems  might  have 
some potential to focus more on home care, which 
may  be  cost-efficient.  As  institutional  care  is 
relatively  costly,  Member  States  with  shares  well 
above  the  EU  levels  may  benefit  from  efficiency 
gains  by  shifting  some  coverage  (and 
thus 
expenditure)  from  institutional  to  other  types  of 
care. 

Types of care 

In 2016 there were 85 municipal nursing homes for 
elderly  (known  as  “social  care  centres”  in  the 
Latvian long-term care systems) providing care for 
6344  recipients.  As  explained  above,  nursing 
homes  for  elderly  are  run  by  local  municipalities. 
There  are  as  well  several  institutional  care  homes 
for the elderly run by the private sector and NGOs. 
These  are  often  contracted  by  municipalities  to 
provide  services  for  their  recipients,  subject  to 
means-testing  of  clients  and  under  a  price 
negotiated with the provider. Additionally, in 2016 
there  were  28  state  owned 
long-term  care 
institutions  and  12  long-term  care  institutions 
contracted  by  state  provided  care  for  5194  adults 

(529) Long-term care benefits in the system of Health Accounts  
classification can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

social 

including 

Home  care  is  provided  formally  by  a  range  of 
providers, 
services  of 
the 
municipalities,  NGOs,  charities,  private  sector 
agencies  and  individuals.  The  provision  of  home 
care  encompasses  as  well  other  forms  of  support 
for  the  elderly,  such  as  help  with  daily  activities 
(laundry,  delivery  of  warm  meals),  assistant 
service  and  security  buttons  that  can  be  activated 
by  the  recipient  if  urgent  help  is  needed.  The 
number of recipients receiving home care has been 
increasing over the last few years, with a slight fall 
during  the  economic  crisis,  but  from  2010  it  has 
grown again. At the end of 2016 there were 14,022 
elderly  and  disabled  recipients  of  home  care 
financed by the municipalities. The majority of the 
services  were  provided  by  carers  from 
the 
municipal social services. 

Alternative  forms  of  long-term  care  include  day 
care  centres  for  pensioners  and  persons  with 
psychosocial 
residential 
facilities  as  well  as  group  houses.  These  services 
are however relatively underdeveloped. 

disabilities, 

social 

Recipients  of  home  care  and  institutional  care  for 
elderly  persons  normally  cover  the  expenses  of 
care . For recipients who live in a household with 
an  average  income  below  the  defined  "needy" 
threshold  (128  euro  per  month  per  person)  and 
who  have    no  spouse  or  child  who  is  legally 
obliged to support them financially, municipalities 
will  fully  cover  expenses  of  care.  Municipalities 
can  however  set  a  higher  level  income  threshold 
for access free of charge services.  

In parallel to formal home care, a great proportion 
of  home  care  services  are  provided  informally 
without  payment  by  family  members,  relatives  or 
neighbours.  Municipalities  are  obliged  to  provide 
home  care  services  in  situations  when  the  elderly 
or  disabled  person 
itself  or  persons’  family 
members  are  not  able  to  take  care  of  elderly  or 
the 
disabled 
municipalities  can  decide  to  provide  additional 
long-term  care  cash  benefits  to  recipients  or  to 
those 
responsibilities, 
although  they  have  no  legal  obligation  to  do  so. 
Due to this, the amount of support can vary greatly 
between  different  municipalities.  Care  benefit  is 
granted  by  local  governments  mostly  in  cases 

relatives  with  caring 

person  mentioned. 

Finally, 

403 

 
                                                                                   
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

where  they  cannot  provide  the  service  themselves 
or  in  cases  where  there  are  several  service 
providers  available  in  the  municipality  and  the 
client can choose between them 

by  low  affordability  (especially,  if  the  service  is 
provided  by  private  service  providers)  or  non-
availability  of  home  care  services 
the 
community.  

in 

Additionally,  there  is  a  universal  state  benefit  for 
disabled people introduced in 2008. 

Eligibility criteria 

In principle there is no means-testing threshold for 
access  to  home  care.  According  to  the  Law  on 
Social  Services  and  Social  Assistance  (LSSSA), 
social services shall be provided only on the basis 
of  an  evaluation  of  the  individual  needs  and 
resources of a person carried out by a social work 
specialist. 

There  is  a  specific  dependency  threshold  set  for 
each different form of long-term care service.  

For home care, dependents are eligible if they are 
unable  to  take  care  of  themselves  and  perform 
everyday activities. 

Recipients  of    state  provided  long-term  care  have 
to  pay  for  long-term  care  up  to  90%  of  their 
pension.  The  rest  of  the  expenses  are  covered  by 
the  state  budget.  The  amount  of  money  paid  by 
social  care  recipients  for  state  institutional  long-
term care was 6,827,506 euro in 2016.  

In  case  of  long-term  care  services  financed  from 
the State budget, there is no duty of payment for in 
case  of  persons  (both  children  and  adults)  with 
severe  mental  disability  and  in  case  of  small 
children  (between  ages  0  and  2)  deprived  of 
parental care.  

to  provide  services 

Municipalities  have 
to 
everybody who needs them. If the recipient has no 
income or spouse or child who is legally obliged to 
support  them  financially,  then  the  municipality  
will  partially  or  fully  share  the  costs  of  care.  The 
state defines the amount of remaining income after 
the  services  received  are  paid  for  (the  amount  of 
monthly  minimum  wage  for  the  first  family 
member and half the minimum wage for each next 
family  member).  Municipalities  can  introduce 
provisions  above  that  if  they  show  wish.  The 
threshold is  set at a relatively low level, therefore 
access  to  long-term  care  for  people  with  the 
income  above  this  threshold  can  be  limited  either 

404 

In  2016  the  amount  of  money  paid  by  recipients 
and  /or  their  financial  supporters  for  municipal 
institutional long-term care for elderly persons was 
17685,592 euro.  

Role of the private sector  

As  long-term  care  recipients  in  Latvia  mostly 
cannot afford to pay the full cost of care in nursing 
homes, 
that 
commission  services  from  private  nursing  homes. 
relatively 
this 
However, 
underdeveloped. 

some  municipalities 

there  are 

area 

still 

is 

Private home care services are available mostly in 
the  cities;  even  then,  costs  of  the  services  are  too 
high  to  afford  for  the  most  of  the  families, 
depending on the municipality services can be co-
financed. Depending on the municipality those can 
be available outside the cities as well, including in 
more remote areas, organised by service providers 
(530). 

Formal/informal caregiving 

As explained above, municipalities are also free to 
grant their own long-term care cash benefits. If the 
municipality  does  not  have  its  own  home  care 
services,  it  will often  grant the benefits in cash to 
the recipients or their relatives. As a consequence, 
depending  on  the  municipality  financial  situation 
support  is  granted  to  care-takers  or/and  care-
givers. 

In 2016 only 19 municipalities out of 119 reported 
spending  for  financial  support  to  carers;  the 
amount  of  resources  for  this  purpose  has  been 
growing  in  recent  years:  It  was  539,000  euro  in 
2010, 786,000 euro in 2012, 848,543 euro in 2014 
and  1404,181  euro  in  2016.  About  50%  of 
municipalities  have  reported  expenditures  for 
financial  support  to  care  receivers  or  carers  over 
the  years. Depending on the municipality, support 
can  be  granted  as  a  simple  cash  benefit  to  the 

(530) For example – 
http://www.samariesi.lv/lv/pakalpojumi/aprupe-majas-novados  

http://www.aprupemajas.lv/pakalpojumi.html   

 
                                                           
family member providing the informal care or can 
be  formulated  as  a  formal  payment  for  care 
services  on  the  basis  of  a  contract,  therefore 
formalising  what  was  informal  care.  Most  often 
these  types  of  contracts  are  made  between  a 
neighbour or a relative and the municipality. 

Prevention 
policies/measures 

and 

rehabilitation 

social 

funded 

Government 
rehabilitation 
programme  (14  or  21  days  long)  for  persons  with 
different  functional  disorders  is  available.  For 
persons above the age 62 (old age pensioners) this 
service  is  available  only  if  persons  are  still  in 
employment. 

Recently 
reforms  

legislated  and/or  planned  policy 

Ministry  of  Welfare  is  planning  to  support  more 
community-based  services  (primarily  for  children 
and  persons  with  mental  disabilities),  and  thus  to 
promote  deinstitutionalisation  by  creating  more 
affordable and more diverse services for the target 
groups. 

Long-term care legislation provides some changes 
in  the  calculation  of  person’s  payments  for  long-
term institutional care. Since year 2017 in addition 
to  State  pensions  (including  a  supplement  to  the 
pension)  in  receiver’s  income,  from  which  to  pay  
for  long-term  care  service,  the  following  are  also 
included: (i) a service pension, (ii) a  special State 
pension,  (iii)  a  compensation  for  the  loss  of 
capacity to work, (iv) a compensation for harm, (v) 
a  survivor's  compensation  due  to  an  accident  at 
work  or  occupational  disease,  (vi)  income  from  a 
life-long  pension  insurance  contract  regarding  the 
receipt  of  the  accrued  funded  pension  capital  as 
well  as  (vii)  pensions  granted  in  accordance  with 
foreign  laws  and  regulations.    From  year  2020 
onwards,  it  is  planned  to  decrease,  the  part  of 
income  paid  for  the  institutional  long-term  care 
from 90 to 85%.  

Long-term care systems 

3.16. Latvia 

Challenges 

The main challenges of the system appear to be:  

•  Improving  the  governance  framework:  To 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of  responsibilities  of  state  authorities  wrt.  the 
long-term  care  services.  To 
provision  of 
strategically 
integrate  medical  and  social 
services via such a legal framework. To define 
a  comprehensive  approach  covering  both 
policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing  taking  into 
account  the  fiscal  constraints.  To  establish 
good information platforms for LTC users and 
providers.  To  set  guidelines  to  steer  decision-
making  at 
level  or  by  practising 
providers.  To  use  care  planning  processes, 
individualised  need  assessments, 
based  on 
involving health and care providers and linking 
need  assessment  to  resource  allocation.  To 
share  data  within  government  administrations 
the  management  of  potential 
to  facilitate 
interactions  between  LTC  financing,  targeted 
personal-income  tax  measures  and  transfers 
(e.g.  pensions),  and  existing  social-assistance 
or  housing  subsidy  programmes.  To  deal  with 
cost-shifting incentives across health and care. 

local 

•  Improving 

financing  arrangements:  To 
explore the potential of private LTC insurance 
as a supplementary financing tool. To consider 
adjusting  the  extent  of  user  cost-sharing  on 
LTC benefits. 

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  LTC 
coverage  schemes,  to  assess  the  need-level 
triggering  entitlement  to  coverage;  the  breadth 
of coverage, i.e. the extent of user cost-sharing 
on LTC benefits; and the depth of coverage, i.e. 
the 
the 
coverage; To explore the potential of providing 
targeted benefits to those potential recipients of 
LTC  care  with  highest  LTC  needs.  To  reduce 
the  risk  of  impoverishment  of  recipients  and 
informal carers.  

types  of  services 

included 

into 

•  Encouraging  home 

alternatives 

to 

care:  To  develop 
institutional  care  by  e.g. 

405 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Changing payment incentives for providers: 
To  consider  a 
focused  use  of  budgets 
negotiated  ex-ante  or  based  on  a  pre-fixed 
share of high-need users. 

•  Improving  value  for  money:  To  invest  in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services. To 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people  with 
employ 
prevention  and  health-promotion  policies    and  
identify  risk  groups  and  detect  morbidity 
patterns earlier. 

care.  To 

chronic 

to 

and 

care 

home 

institutional  care  or 

assessing 
encouraging 
admissions 
the 
establishment  of  additional  payments,  cash 
benefits  or  financial  incentives  to  encourage 
home 
fiscal 
constraints; to monitor and evaluate alternative 
services, 
incentives  for  use  of 
including 
alternative settings. 

account 

taking 

care 

into 

•  Encouraging 

living: 

To 
independent 
encourage  additional  provision  of  effective 
home  care, 
to 
recipients,  as  well  as  improving  home  and 
general living environment design. 

tele-care  and 

information 

•  Ensuring  availability  of  formal  carers:  To 
for 
determine  current  and 
qualified  human  resources  and  facilities  for 
long-term care.  

future  needs 

•  Supporting  family  carers:  Assessing 

the 
possibility  to  introduce  policies  for  supporting 
informal  carers,  such  as 
through  flexible 
working  conditions, 
respite  care,  carer’s 
allowances  replacing  lost  wages  or  covering 
expenses  incurred  due  to  caring,  cash  benefits 
paid to the care recipients,  while ensuring  that 
incentives  for  employment  of  carers  are  not 
diminished  and  women  are  not  encouraged  to 
withdraw  from  the  labour  market  for  caring 
reasons.  

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
the  allocation  of  care  co-
information, 
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  create  better 
improving  (and  securing)  safe  care 
rules, 
pathways 
to 
chronically-ill people or circulated through the 
system.  To 
towards 
appropriate settings. 

information  delivered 

steer  LTC  users 

and 

406 

 
 
Table 3.16.1:  Statistical Annex – Latvia 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

14
15.9
2.2

0.2
:
0.6

76.3
64.9
53.2
50.8
:
:

17
15.7
2.2

0.2
:
0.6

76.1
65.0
52.5
50.8
36.1
10.3

23
15.0
2.2

0.2
:
0.6

76.2
65.3
54.8
51.4
33.6
9.1

24
13.8
2.2

0.2
:
0.6

77.5
66.5
54.3
51.6
34.4
8.2

19
12.7
2.2

0.2
:
0.5

77.7
67.5
56.0
52.6
34.3
6.9

18
13.4
2.1

0.2
:
0.5

78.0
67.9
56.4
53.1
35.6
7.5

20
14.0
2.1

0.3
:
0.7

78.8
68.6
56.6
53.6
36.4
6.7

22
14.6
2.0

0.2
:
0.7

78.9
68.9
59.0
54.6
36.0
7.1

23
14.9
2.0

0.2
42.8
0.7

78.9
69.3
54.2
51.7
39.7
10.1

24
15.4
2.0

0.3
46.1
0.7

79.4
69.1
55.3
51.5
40.6
9.6

24
16.2
2.0

0.3
50.1
0.7

79.5
69.7
54.1
51.8
41.2
10.1

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
0
7

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

6
6
0.6

:
:

8
8
0.7

:
:

9
9
0.8

:
:

11
10
1.0

:
:

11
11
1.0

:
:

11
11
1.0

:
:

11
9
1.0

:
:

11
9
1.0

:
:

11
9
1.0

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
1
6
.

L
a

t
v
a

i

L
o
n
g

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-
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c
a
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4
0
8

Table 3.16.2:  Statistical Annex - continued – Latvia 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

2.0

0.17

8.5

0.4

0.4

13,003

14,573

15,935

2.2

26.0

84.7

15.3

82.3

17.7

45.6

8.8

8.2

2020

1.9

0.17

8.8

0.4

0.5

13,160

14,743

16,150

2.3

26.3

83.9

16.1

81.1

18.9

43.1

9.0

8.3

2030

1.7

0.17

9.6

0.5

0.6

13,108

14,792

16,566

2.6

26.6

83.3

16.7

78.3

21.7

42.5

10.4

8.6

2040

1.6

0.17

10.6

0.5

0.9

12,951

15,008

16,909

2.8

26.6

82.5

17.5

74.9

25.1

40.5

11.7

8.8

2050

1.5

0.17

11.1

0.6

1.4

12,862

15,070

17,551

3.0

27.2

82.0

18.0

71.6

28.4

39.4

13.3

8.8

2060

1.4

0.16

11.2

0.6

2.1

12,427

14,434

17,411

3.1

27.8

81.8

18.2

69.5

30.5

38.7

14.7

8.9

2070

1.3

0.15

11.1

0.6

3.0

11,766

13,831

16,841

3.2

28.5

80.7

19.3

67.7

32.3

36.1

14.7

8.9

MS Change 2016-
2070

EU Change 2016-
2070

-32%

-11%

31%

34%

591%

-10%

-5%

6%

43%

9%

-5%

26%

-18%

83%

-21%

68%

9%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
3.17. LITHUANIA 

General  context:  Expenditure  projections, 
fiscal sustainability and demographic trends 

GDP per capita in PPS, at 19,600 PPS per capita is 
below the EU average GDP per capita of €29,600 
in 2015. Lithuania has a population of around 2.9 
million  inhabitants.  Over  the  coming  decades,  the 
population  of  Lithuania  will  gradually  decline, 
from 2.9 million inhabitants in 2016 to 1.7 million 
inhabitants in 2070. This 40% fall is very different 
from the EU average increase of 2%. 

Health status 

Life expectancy at birth for both  men and  women 
was,  in  2015,  respectively  69.2  and  79.7  years, 
which  is  below  the  EU  average  (77.9  and  83.3 
years  respectively).  In  2015  the  healthy  life  years 
at  birth  for  both  sexes  were  58.8  years  (women) 
and 54.1 years (men) below (particularly for men) 
the  EU-average  (63.3  and  62.6  respectively).  At 
the  same  time,  the  percentage  of  the  Lithuanian 
population having a long-standing illness or health 
problem  is  higher  than  in  the  Union  as  a  whole 
(34.7%  and  34.2%  respectively  in  2015).  The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  its  daily  activities 
was  in  2015  around  7%,  below  the  EU-average 
(8.1%). 

Dependency trends 

The  share  of  people  depending  on  others  to  carry 
out  activities  of  daily  living  in  Lithuania  is  set  to 
increase over the next 50 or so years, from 9.3% in 
2015 to 12.2% of the total population in 2070, an 
increase  of  31%.  This  is  above  the  EU-average 
increase  of  21%.  From  0.27  million  residents 
living  with  strong 
to  health 
problems in 2016, a decrease of 21% is envisaged 
until 2070 to 0.21 million. That is in contrast with 
the increase in the EU as a whole (25%).  

limitations  due 

Expenditure projections and fiscal sustainability  

reference 

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage of GDP is expected to increase. In the 
AWG 
long-term 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 

scenario,  public 

in 

is a projected increase in spending of about 1 pp of 
GDP  by  2070  (531).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 3.6 pps of GDP 
by 2070.  

Overall,  Lithuania  presents  no  significant  risks  of 
fiscal  stress  in  the  short,  medium  or  long-term 
(532). 

System Characteristics (533) 

In Lithuania there is no unified specific legislation 
on  the  provision  LTC.  Care  is  granted  through 
different  channels:  social  services,  invalidity  and 
sickness services. Social  services are provided for 
all  residents  who  are  in  need.  Health  care  is 
provided  on  the  basis  of  social  insurance  and 
financed  by  the  central  government  budget,  local 
budgets and the Health Insurance Fund, as well as 
cost-sharing  from  the  recipient  (or  their  family). 
LTC recipients are provided with benefits in kind, 
and  there  are  also  cash  benefits  for  severely 
disabled people. 

Public spending on LTC (534) reached 1% of GDP 
in  2016  in  Lithuania,  below  the  average  EU  level 
of  1.6%  of  GDP.  64.8%  of  the  benefits  were  in-
kind,  while  35.2%  were  cash-benefits  (EU:  84  vs 
16%).  

In the EU, 50% of dependents are receiving formal 
in-kind  LTC  services  or  cash-benefits  for  LTC. 
This  share  is  with  76%  higher  in  Lithuania. 
Overall, 7.1% of the population (aged 15+) receive 
formal  LTC  in-kind  and/or  cash  benefits  (EU: 
4.6%), one of the highest shares in the EU. On the 
one  hand,  low  shares  of  coverage  may  indicate  a 
situation  of  under-provision  of  LTC  services.  On 
the other hand, higher coverage rates may imply an 
increased  fiscal  pressure  on  government  budgets, 

(531) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf  

(532) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(533) This section draws on OECD (2011b) and ASISP (2014). 
(534) Long-term  care  benefits  can  be  disaggregated  into  health- 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily to assistance with IADL tasks). 

409 

 
                                                           
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possibly calling for greater needs of policy reform 
or,  alternatively,  relatively 
low  benefits  per 
recipients. 

The expenditure for institutional (in-kind) services 
makes  up  33.6%  of  public  in-kind  expenditure 
(EU: 66.3%), 66.4% being spent for LTC services 
provided at home (EU: 33.7%).  

Administrative organisation 

Long-term  care  in  Lithuania  is  organised  as  a 
central  system  at  national  level  supplemented  by 
the  municipalities  at  regional  level.  The  central 
government  is  responsible  for  making  long-term 
national  programmes  and  strategies  as  well  as 
setting  requirements  and  standards.  At  the  local 
level,  municipalities  prepare  and 
implement 
municipal programmes aiming at social integration 
of  disabled  people,  being  responsible  for  the 
organisation  of  social  services  provision,  the 
determination of local need for social services; for 
the  supervision  of  social  services  as  well  as  the 
organisation  and  provision  of  primary  health  care 
(including  nursing  hospitals).  LTC  is  provided 
through  day  centres,  home  care 
services, 
residential  social  care  institutions  and  nursing 
hospitals. 

Types of care 

Depending  on  their  level  of  dependency  and  care 
needs,  disabled  people  may  receive  permanent 
home  care  (assistance  provided  for  recipients  that 
continue  living  in  their  own  home)  or  permanent 
nursing care in an institutional setting. LTC in the 
health sector is mostly provided as inpatient care in 
in  specific 
specialised  nursing  hospitals  or 
departments in general hospitals. During the period 
2005-2010, the number of beds in separate nursing 
homes  in  the  health  care  sector  increased  from 
2,735  to  2,835,  while  the  number  of  hospitals 
decreased from 59 to 49. During the same period, 
the  total  number  of  nursing  beds  (both  in  nursing 
homes and in other health care facilities) increased 
from 3,527 to 4,614. 

need  is  assessed  on  an  individual  basis  of  the 
person’s  dependency 
to 
level  and  potential 
develop,  taking 
into  account  the  individual’s 
preferences  and  needs.  The  social  services  are 
aimed  at  compensating  the  level  of  dependency. 
Home  care  and  institutional  care  may  also  be 
provided to disabled people. The level of need of a 
disabled person is determined by an official list of 
health  conditions.  Provision  of  long-term  medical 
treatment  depends  on  the  health  condition.  In  the 
health  care  sector,  LTC  is  mostly  provided  as 
inpatient  services  in  separate  nursing  homes  or 
specialised departments in general hospitals. 

Co-payments, out of the pocket expenses and 
private insurance 

Recipients  contribute  through  cost-sharing  to  pay 
for  LTC  services  in  social  care  homes  for  elderly 
and disabled. No more than 80% of the recipient’s 
income can be taken as payment. n most cases the 
difference  will  be  covered  by 
the  central 
government  and  local  budgets.  Nursing  hospital 
stays  are  financed  by  the  Compulsory  Health 
Insurance budget (up to 120 days per year). Longer 
stays  can  be  paid  by  municipalities  or  by  the 
recipients themselves. 

Role of the private sector  

In  cases  where  local  authorities  are  not  able  to 
directly  provide  LTC  to  a  recipient,  they  may 
provide  the  recipient  with  ‘money  for  care’  that 
should  enable  them  to  buy  the  services  needed 
from private providers. Cash benefits are only paid 
directly  to  the  recipient.  Compensation  for  home 
care  nursing  expenses  was  between  1.5  and  2.5 
times  the  social  insurance  basic  pension  and 
depended  as  well  on  the  need  category  of  the 
recipient. Since 1 January 2007, this allowance has 
been  set  at  2.5  times  the  social  insurance  basic 
pension  for  all  categories.  The  compensation  for 
care  corresponds  to 0.5  times  the  social  insurance 
basic  pension.  Cost-sharing  of  the  provision  of 
these  services  depend  on  the  income  of  the 
recipient and/or their family. 

Eligibility criteria 

Formal/informal caregiving 

The  need  for  LTC  is  assessed  on  the  basis  of 
principles 
participation, 
complexity, accessibility, social justice, relevance, 
efficiency,  and  comprehensiveness.  The  level  of 

cooperation, 

of 

410 

The recent extension of ‘money for care’ measures 
financially 
enables 
carers 
compensated 
attendance 
allowances)  as  providers  of  care  for  the  care  they 

to  be 
care  or 

(e.g.  by 

informal 

 
deliver.  They  can  also  benefit  from  some  training 
and  social  rights,  as  well  as  from  the  recognition 
that informal carers are also often clients of formal 
care services, with their own need for support. The 
extensive  use  of  both  live-in  and  live-out  migrant 
care  workers  is  a  relatively  new  trend  in  LTC 
provision.  Their  status  is  somewhere  between  the 
two  distinct  categories  of  formal  and  informal 
carers,  and  they  may  be  initially  selected  by 
families  on 
factors  such  as 
trustworthiness. 

the  basis  of 

Prevention 
policies/measures 

and 

rehabilitation 

licensed  providers.  The 

Rehabilitation  services  are  paid  by  the  NHIF  and 
first 
provided  by 
rehabilitation  stage  comprises  those  interventions 
provided  at  the  health  care  facility  where  the 
patient  is  treated  and  its  cost  is  included  in  the 
price  of  the  treatment.  Second  stage  rehabilitation 
is provided in specialised units in general hospitals 
as  well  as  in  specialised  hospitals/sanatoriums. 
Rehabilitation  units  are  required 
to  have  a 
minimum  number  of  beds  as  well  as  service 
availability  of  6  days  per  week.  The 
third 
rehabilitation stage involves rehabilitation either in 
an outpatient or tertiary level setting. In 2010 there 
were  4  rehabilitation  hospitals  (with  705  beds  in 
total)  and  7  other  medical  rehabilitation  facilities 
(3  for  children  and  4  for  adults).  The  number  of 
rehabilitation  beds  has  increased  since  2002  from 
1092  in  2002  to  up  to  1378  in  2010.  Beds  in 
rehabilitation  hospitals  have  an  occupancy  rate  of 
at  80%  with  the  Average  Length  of  Stay  (ALOS) 
being  about  20  days.  In  sanatoriums  the  bed 
occupancy rate is lower (at 74%), while the ALOS 
is  higher  (21  days).  Increasing  quality  and 
availability  of 
in  an 
outpatient  setting  is  one  of  the  goals  in  the 
strategic  health  policy  documents.  This  is  being 
outpatient 
implemented 
rehabilitation  units  in  existing  municipal  health 
care  facilities  and  making  larger  investments  in 
infrastructure,  as  well  as 
through  regulatory 
measures  such  as  forbidding  primary  health  care 
providers 
to 
specialised  inpatient  rehabilitation  and  instead 
directing  patient 
towards  outpatient 
flows 
rehabilitation.  Since  2005 outpatient  rehabilitation 
services  have 
to 
implementation  of  specific  projects  financed  by 
the  establishment  of 
Structural  Funds  and 

increased  by  30%  due 

referring  adult  patients 

rehabilitation  provided 

establishing 

from 

by 

Long-term care systems 

3.17. Lithuania 

specialised 
rehabilitation.  

departments 

for 

ambulatory 

Recently 
reforms  

legislated  and/or  planned  policy 

New  Guidelines  for  Deinstitutionalisation  of  the 
Social Care Homes of Disabled Children Deprived 
of Parental Care and Adult Disabled Persons were 
approved at the end of 2012. These guidelines are 
meant  to  provide  the  framework  until  2030  for 
transition  from  institutional  LTC  towards  home 
care.  The  aim  of  deinstitutionalisation  is  to  form 
consistent  and  coordinated  system  care  services 
that  create  the  conditions  for  each  disabled  child 
deprived of parental care and each disabled person 
to  receive  individual  personalised  services  and 
involved 
assistance  while 
and 
participating 
life  without 
in 
experiencing social exclusion.  

remaining 
community 

Ambulatory  nursing  and  care 
services  are 
relatively  recent.  Those  services  have  been  well 
received  by  the  population  and  have  improved 
access to long-term care services in  Lithuania.  As 
explained  above,  ‘money  for  care’  measures 
enable  informal  carers  to  be  compensated  for  the 
care  they  deliver  and  to  benefit  from  some 
training, social rights and recognition as recipients 
of care themselves.  

As  explained  above,  there  is  a  duration  ceiling  of 
four months (120 days) per year on each inpatient 
nursing  care  episode  (financed,  as  all  services 
provided  in  public  hospitals,  by  the  National 
Health  Insurance  Fund  (NHIF).  After  this  period 
patients  can  be  transferred  to  the  social  care 
institution  in  their  municipality.  A  proposal  to 
increase  the  duration  limit  in  the  inpatient  health 
care nursing departments  from 120 to 180 days is 
currently under negotiation. 

From 2010 special compensation for care expenses 
and special compensation  for attendance expenses 
were  reduced  to  the  85%  level.  Since  2014  there 
has  been  a  debate  about  whether  to  restore  to  the 
100% level. 

Challenges 

The main challenges of the system appear to be:  

411 

 
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Supporting 

family  carers:  To  establish 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  coordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

for  care  coordination  and 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  LTC;  To  steer  LTC  users  towards 
appropriate settings. 

•  Improving  value  for  money:  To  invest  in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services; To 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people  with  chronic  care;  To  employ 
prevention  and  health-promotion  policies  and 
identify  risk  groups  and  detect  morbidity 
patterns earlier. 

state 

responsibilities 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
authorities 
of 
of 
concerning  the  provision  of  long-term  care 
services;  to  strategically  integrate  medical  and 
social  services  via  such  a  legal  framework;  to 
define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  use  care 
planning  processes,  based  on  individualised 
need  assessments,  involving  health  and  care 
providers  and  linking  need  assessment  to 
resource  allocation; 
to  share  data  within 
government  administrations  to  facilitate  the 
management  of  potential  interactions  between 
LTC  financing,  targeted  personal-income  tax 
measures  and  transfers  (e.g.  pensions),  and 
existing  social-assistance  or  housing  subsidy 
cost-shifting 
to  deal  with 
programmes; 
incentives across health and care. 

•  Improving 

financing  arrangements: 

to 
explore the potential of private LTC insurance 
as a supplementary financing tool; to determine 
the extent of user cost-sharing on LTC benefits.  

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage; the depth of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits;  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage; To provide targeted 
benefits to those with highest LTC needs. 

•  Encouraging  independent  living:  To  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

future  needs 

•  Ensuring  availability  of  formal  carers:  To 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care; To improve recruitment efforts, 
including 
the  migration  of  LTC 
workers and the extension of recruitment pools 
of workers. 

through 

412 

 
Table 3.17.1:  Statistical Annex – Lithuania 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

21
15.5
3.4

0.2
:
0.7

77.4
65.2
54.6
51.4
:
:

24
16.1
3.3

0.2
:
0.6

77.1
65.0
56.5
52.6
33.5
10.3

29
17.1
3.2

0.3
:
0.9

77.2
64.5
58.1
53.3
31.7
9.4

33
16.2
3.2

0.5
:
1.2

77.6
65.9
59.6
54.5
30.7
7.9

27
14.1
3.2

0.7
93.1
1.5

78.7
67.1
61.2
57.2
29.7
7.6

28
15.4
3.1

0.6
92.8
1.4

78.9
67.6
62.3
57.4
28.1
7.0

31
16.4
3.1

0.5
89.8
1.2

79.3
68.1
62.0
57.0
29.0
8.0

33
17.2
3.0

0.5
89.7
1.3

79.6
68.4
61.6
56.6
29.6
8.2

35
17.9
3.0

0.5
91.9
1.3

79.6
68.5
61.6
56.8
31.2
8.2

37
18.8
2.9

0.5
113.8
1.5

80.1
69.2
61.7
57.6
32.3
7.6

37
19.6
2.9

0.5
122.7
1.5

79.7
69.2
58.8
54.1
34.7
7.0

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
1
3

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

32
7
1.2

:
:

40
38
2.4

:
:

48
69
3.7

:
:

56
100
5.0

:
:

56
102
5.2

:
:

57
104
5.4

:
:

61
67
4.3

:
:

61
68
4.4

:
:

61
69
4.5

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
1
7
.

L
i
t
h
u
a
n
a

i

L
o
n
g

r

-
t
e
m
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a
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s

 
 
 
 
 
 
 
 
 
 
 
4
1
4

Table 3.17.2:  Statistical Annex - continued – Lithuania 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

2.9

0.27

9.3

1.0

1.0

88,506

58,973

55,425

7.1

75.8

78.7

21.3

33.6

66.4

8.6

25.5

11.1

2020

2.7

0.27

9.7

1.0

1.1

88,763

61,586

55,934

7.5

77.5

77.9

22.1

32.9

67.1

8.2

24.1

11.2

2030

2.4

0.26

11.0

1.3

1.6

88,558

66,619

57,427

8.9

81.1

79.7

20.3

31.8

68.2

9.2

26.3

11.4

2040

2.1

0.26

12.4

1.7

2.3

87,079

72,643

59,841

10.4

83.9

80.8

19.2

30.8

69.2

10.3

27.6

11.5

2050

2.0

0.26

13.2

2.0

3.3

85,449

82,562

63,148

11.8

89.9

81.6

18.4

28.9

71.1

11.0

28.0

11.6

2060

1.8

0.23

12.7

2.2

4.1

78,097

80,655

60,259

12.0

93.8

82.3

17.7

28.0

72.0

11.7

29.2

11.6

2070

1.7

0.21

12.2

2.0

4.6

69,711

73,636

55,399

11.6

94.4

81.4

18.6

27.9

72.1

11.3

27.7

11.7

MS Change 2016-
2070

EU Change 2016-
2070

-40%

-21%

31%

101%

360%

-21%

25%

0%

63%

24%

3%

-13%

-17%

9%

31%

9%

5%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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3.18. LUXEMBOURG 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

roughly  half 

a  million 
Luxembourg  has 
inhabitants,  less  than  1%  of  the  EU  population. 
Despite  its  limited  population,  Luxembourg  has 
the  highest  GDP  per  capita  with  68.8  thousand 
PPS  in  2015,  which  is  almost  2.5  as  much  as  the 
EU  average  of  29.6  thousand  PPS  for  the  same 
year. The population is projected to almost double 
in  the  next  decades,  reaching  1.0  million  in  2070 
from an initial value of 0.6 in 2016 (535). Based on 
the  Ageing  Report  2018,  total  public  expenditure 
on long-term care (health and social part) (536) was, 
with 1.3% of GDP in 2016, below the EU average 
in 
the  same  year  (1.6%).  In  2015,  public 
expenditure  on  long-term  care  (health) was  1.2% 
of GDP, in line with the overall EU level (1.2% of 
GDP). 

Health status 

same 

In  2015  life  expectancy  at  birth  for  both  women 
and men was respectively 84.7 and 80.0 years and 
was slightly above the EU average (83.3 and 77.9 
years  respectively).  In  the  same  year,  the  healthy 
life  years  at  birth  were  with  60.6  years  (women) 
and  63.7  years  (men)  respectively  below  and 
slightly above the EU-average (63.3 and 62.6). At 
the 
the 
Luxembourgish population having a long-standing 
illness  or  health  problem  was  significantly  lower 
than in the Union as a whole (23.3% vs. 34.2% for 
the EU in 2015). The percentage of the population 
indicating  a  self-perceived  severe  limitation  in  its 
daily activities has been increasing in the last few 
years,  and  has  recently  exceeded  the  EU-average 
(9.0% against 8.1% in 2015). 

percentage 

time, 

the 

of 

Dependency trends 

The  trends  for  dependency  are  increasing  for 
Luxembourg  over  the  next  50  years,  as  indicated 
by  the  projections.  The  number  of  people  living 
with  health  limitations  is  projected  to  rise  from 
0.04  million  in  2016  to  0.1  million  in  2070,  an 
increase  of  141%  compared  to  the  EU  value  of 

(535) Based on Eurostat projections. 
(536) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

25%  for  that  period.  Similarly,  the  share  of  the 
dependent  group  in  the  whole  population  is 
foreseen to increase from 7.3% in 2016 to 9.8% in 
2070; the corresponding change is higher than the 
EU  average  over  the  same  period  (36%  vs.  21% 
EU average).  

Expenditure projections and fiscal sustainability  

The  expenditure  projections  reveal  a  heightened 
requirement for spending in the future ( 537). As far 
as  demographic  drivers  are  concerned,  the  "AWG 
reference scenario" forecasts public expenditure on 
long-term care as  share of GDP to grow  from 1.3 
to  4.1,  increasing  by  2.8  pps.  According  to  this 
scenario,  the  projected  increase  for  Luxembourg 
over the period 2016-2070, 219%, is considerably 
higher  than  the  EU  average  of  73%.  The  "AWG 
risk  scenario",  which  captures  additional  cost 
drivers  to  demographic  and  health-status  related 
increase  of  even  bigger 
factors,  projects  an 
magnitude  (5.2  pps)  bringing  public  spending  on 
long-term  care  from  1.3%  to  6.5%  of  GDP  by 
2070,  an  increase  of  405%,  again  well  above  the 
EU average of 170%. 

faces 

low  medium-term 

Luxembourg 
fiscal 
sustainability risks, primarily due to the initial low 
level  of  government  debt  and  the  favourable 
budgetary  position,  which  compensate  for  the 
projected ageing costs. Over the long run however, 
Luxembourg 
fiscal 
sustainability.  These  risks  are  entirely  driven  by 
the  necessity  to  meet  future  increases  in  ageing 
costs  (notably  pension,  health  care  and  long-term 
care expenditures) (538). 

faces 

risks 

high 

to 

System Characteristics  

Long-term  care  insurance  was  introduced  in  1999 
as  a  new  pillar  of  the  social  security  scheme  in 
order  to  cover  needs  of  assistance  and  care  for 
activities  of  daily  living.  The  law  was  mainly 
inspired by the long-term care set up in Germany; 
however, the principle of classifying the dependent 

(537) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(538) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

415 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

persons  into  three  levels  was  not  upheld  for 
Luxembourg. 

There  is  a  political  commitment  to  the  longest 
possible provision of home care, and the long-term 
care  law  is  based  on  four  principles:  priority  to 
home  care,  priority  to  benefits  in-kind,  priority  to 
rehabilitation  and  prevention  measures  and 
continuity of long-term caregiving. 

request it, depending on which form of care is the 
most  appropriate,  be  it  home  or  institutional  care. 
AEC is also responsible for quality monitoring and 
for  ensuring  that  the  provided  services  match  the 
needs  of  the  dependent  person.  Lastly,  AEC  also 
has the task of providing informing and advising to 
protected  persons  and  the  bodies  concerned  on 
prevention  and  care  of  dependent  persons.  It 
comprises two consultation bodies: 

Administrative organisation 

Benefits  are  granted  to  all  persons  covered  by 
sickness  insurance  and,  in  addition,  there  is  the 
possibility  of  voluntary  insurance.  Compulsory 
social insurance is financed by social contributions 
and  by  a  State  contribution  (40%  of  total  current 
expenditure),  providing  benefits  to  all  persons 
recognised  as  being  dependent,  regardless  of  age, 
income  or  residence.  Contributions  to  the  long-
term  care  insurance  have  to  be  paid  at  a  rate  of 
1.4% on all earnings (including fringe benefits and 
capital) without any upper threshold. 

The  long-term  care  insurance  also  covers  non-
dependents. If a person is not technically classified 
as  dependent,  but  needs  assistance  in  the  form  of 
devices  (e.g.  wheelchair,  walking  frame)  or  a 
modification  of  the  home  (e.g.  installation  of  a 
shower on one level) to support activities of daily 
living, these costs will be reimbursed. 

The  organisation  of  care  insurance  was  entrusted 
to  two  bodies,  namely  the  Caisse  Nationale  de 
Santé (CNS) and Administration d’évaluation et de 
contrôle de l’assurance dépendance (AEC).  

care 

the 
The  Caisse  Nationale  de  Santé  (CNS), 
National Health Insurance, manages the budget for 
the long-term care and takes the decision about the 
care  needed  by  long-term  care  beneficiaries  and 
defined  by  the  Administration  d’évaluation  et  de 
contrôle  de  l’assurance  dépendance  (AEC  -  State 
Office for Assessment and Monitoring of the long-
term 
insurance).  The  Administration 
l’assurance 
d’évaluation  et  de  contrôle  de 
dépendance (AEC) latter is a public body under the 
authority of the Ministry for Social Security, and it 
is  in  charge  of  assessing  the  needs  in  activities  of 
daily  living  and  the  other  long-term  care  services 
and  of  designing  care  plans.  Indeed,  based  on  the 
assessment,  it  draws  up  a  structured  care  plan 
providing  the  necessary  assistance  to  those  who 

416 

• 

• 

the  Advisory  Committee, 
composed  of 
government  representatives,  representatives  of 
beneficiaries and providers, social partners and 
the  CNS,  which  consults  on  the  evaluation  of 
activities  run  by 
the 
regulations on technical aids,  quality standards 
and the negotiation procedure of tariffs; 

insurance, 

the  care 

the  "Concerted  Action",  which  gathers  to 
examine  the  functioning  of  the  care,  care 
networks,  institutions  for  elderly  or  disabled 
persons  and  propose  improvements  in  the 
system.  This  brings  together  the  ministers 
responsible  for  family  affairs,  health  and 
budget  or  their  representatives,  organisations 
active in the fields of health, family and social 
action,  and  associations 
the 
representing 
beneficiaries of long-term care insurance. 

Role of the private sector  

Market entry to the care-giving sector is restricted 
to  organisations  approved  by  the  Ministry  of 
Family  Affairs  based  on  the  fulfilment  of  certain 
quality  standards  and  after  adhesion 
to  a 
framework  contract  with  the  National  Health 
Insurance,  which  determines 
rights  and 
obligations for executing the nursing care services. 
The  following  types  of  care  providers,  mostly 
private, were registered by the end of 2016:  

the 

•  24  ambulatory  networks  offering  nursing  care 

at home; 

•  53 day-care institutions; 

•  42 

intermittent-care  centres  for  alternating 

short-term stays; 

•  52  nursing  homes  and  so-called  integrated 

homes for elderly. 

 
Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

Benefits  under  the  dependency  insurance  are 
granted  if  the  dependent  person  is  in  need  of 
assistance and care for basic everyday activities for 
at  least  3.5  hours  per  week  and  if  his/her 
dependency  condition  is  likely  to  last  longer  than 
six months or to be irreversible. 

Co-payments, out of the pocket expenses and 
private insurance 

The  benefit  package  for  long-term  care  is  offered 
without any co-payment. If the beneficiary resides 
in  an  institution,  the  price  of  accommodation 
(board,  lodging,  basic  domestic  services,  laundry, 
etc.)  has  to  be  paid  by  the  resident  (539).  The 
government  provides  means-tested 
financial 
support  for  those  residents  in  nursing  homes  and 
integrated  homes  for  the  elderly  whose  own 
revenues do not allow to cover for accommodation 
and  services  costs  (accueil  gérontologique).  The 
medical component of these services is covered by 
the  national  health 
insurance  according  co-
payments  defined  by  statutes. The  share  of  public 
spending  on  formal  care  dedicated  to  institutional 
care  is  above,  but  relatively  close  to  the  EU 
average  (70.3%  vs.  66.3%  in  2016).  However, 
when  looking  at  unit  costs  per  recipient  (108.6  in 
2016  vs  77.1  for  the  EU)  Luxembourg  seems  to 
have 
for 
institutional  care,  which  is  also  projected  to 
increase above average up to 2070 (24% projected 
increase  vs  10%  for  the  EU).  This  points  at  an 
existing  and  increasing  pressure  to  finance  this 
service in fiscally sustainably way. 

costly  package 

comparatively 

a 

Formal/informal caregiving 

Beneficiaries cared for at home can receive ADLs 
or  domestic  tasks  (so-called  in-kind  services)  that 
they  are  entitled  to  from  professional  carers  or 
from informal caregivers of their choice (generally 
a family member). Both types of service provision 
can  be  combined,  which  represents  the  most 
preferred type of care provision (used by 63.4% of 
the  home-care  beneficiaries  in  2016).  Special 
à 
support 
services 
l’indépendance) 

(activités 
social 

activities 

d’appui 

care 

and 

(539) Introducing  the  concept  of  “Accueil  gérontologique”  (cf. 
http://www.legilux.public.lu/leg/a/archives/2004/0070/a07
0.pdf#page=2). 

Long-term care systems 

3.18. Luxembourg 

expenditure, 

rationalisation  of 

(individual  or  in  group)  can  only  be  offered  by 
professional  caregivers.  The  share  of  formal  in-
kind  spending  going  to  home  care  was  in  2016 
slightly below the average,  with 29.7% vs. 33.9% 
for  the  EU  in  the  same  year.  This  points  to  a 
potential 
as 
normally  home-care  is  a  comparatively  cost-
effective  way  to  provide  long-term  care  (when 
institutionalisation  can  be  avoided).  Lower  than 
average unit costs measured as a share of GDP per 
capita  (24.3  in  2016  vs.  33.9  for  the  EU  in  2016) 
also  suggest  that  there  is  scope  to  shift  resources 
towards home care and improve the system from a 
cost-efficiency  profile.  Although  the  number  of 
beneficiaries  is  currently  higher  in  the  home  care 
setting,  more  recently  the  number  of  persons  in 
residential  care  has  been  increasing  more  rapidly, 
and this is projected to continue in the future at an 
accelerating  rate  which  increases  the  projected 
budget  impact  of  the  institutional  component  of 
long-term care (540). 

There are no figures available on the exact number 
of informal caregivers; however in 2016, a total of 
6,609  beneficiaries  received  cash  benefits  or  cash 
and  in-kind  benefits  (79.1%  of  at-home  care 
recipients).  The 
insurance 
long-term 
furthermore takes over the costs for counselling of 
the informal caregiver. However, in 2016 only 266 
persons  received  counselling  activities.  Secondly, 
if  the  informal  caregiver  does  not  benefit  from  a 
personal pension, the long-term care insurance can 
pay  the  pension  contribution  of  the  informal 
caregiver (3,429 recipients until 2016) (541). 

care 

Recently 
reforms  

legislated  and/or  planned  policy 

The  government  program  of  2009  announced  a 
review of the operation and the fiscal sustainability 
of  the  long-term  care  insurance  with  a  report 
published  in  2013.  Following  its  publication, 
highlighting the fiscal sustainability risks related to 
the  current  features  of  the  nursing  care  insurance, 
the  government  has  decided  to  reform  the  system 
to  ensure  long-term  fiscal  viability,  focussing  on 
enhancing  cost-efficiency.  The  debate,  both  in 

(540) Pacolet,  J.  and  F.  De  Wispelaere  (2018),  ESPN  Thematic 
Report  on  challenges  in  long-term  care  –  Luxembourg. 
Brussels:  European  Commission  -  Directorate-General  for 
Employment, Social Affairs and Inclusion. 

(541) IGSS  (2017),  "Rapport  général  sur  la  sécurité  sociale", 

Luxembourg. 

417 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Parliament  and  amongst  stakeholders  started  in 
2014. 

tackle.  The  main  challenges  of  the  system  appear 
to be: 

Meanwhile, the 2014 Law setting State budget for 
2015 financial year calls for a freeze of tariffs (542) 
at  the  2014  level.  In  addition,  a  new  collective 
agreement  with  an  important  revalorisation  of  the 
career of the nurses was negotiated in 2017. Due to 
this  change,  the  fees  per  hour  paid  by  the  long-
term care insurance will increase in 2018, and the 
annual impact is estimated to be an increase of 5%. 
In  combination  with  the  reform  of  the  long-term 
care the expected impact amounts to an increase in 
long-term  care  spending  of  8.2%  of  expenditures 
in 2018. 

The  reform,  coming  into  force  on  1st  of  January 
2018 focuses on: 

−  simplification  and  standardisation  of 

the 
evaluation process by combining LTC services 
and introducing flat-rates; 

−  new  definition  and  grouping  of  LTC  services 

and more focussed on ADL; 

−  new  services    reimbursed  by  LTC  (ex:  night 

guards); 

−  redefining the roles of informal caregivers and 
cash  services  strengthening  the  link  between 
services given and those covered; 

−  development  of  a  transparent  and  effective 

quality policy and control; 

− 

the  Cellule  l’Evaluation  et  d’Orientation  will 
be  named  Administration  d’évaluation  et  de 
contrôle  de  l’assurance  dépendance  (State 
Office  for  Assessment  and  Monitoring  of  the 
long-term  care  insurance)  and  is  placed  under 
the  authority  of  the  Ministry  of  social  security 
and  is  no  longer  attached  at  the  administrative 
level  of  the  General  Inspectorate  of  social 
security. 

Challenges 

•  Improving  the  governance  framework:  to 
ensure  long-term  fiscal  sustainability  of  the 
long-term  care  system,  to  set  the  public  and 
private  financing  mix  and  organise  formal 
workforce  supply  to  face  the  growing  number 
of dependents, and provide a strategy to deliver 
high-performing long-term care services to face 
the  growing  demand  for  LTC  service;  to 
establish  good  information  platforms  for  LTC 
users and providers. 

•  Improving  financing  arrangements:  to  face 
the  increased  LTC  costs  in  the  future  e.g.  by 
tax-broadening, which means financing beyond 
revenues 
the  working-age 
by 
population;  to  foster  pre-funding  elements, 
which  implies  setting  aside  some  funds  to  pay 
for future obligations. 

earned 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
the  need-level 
coverage  schemes,  setting 
triggering entitlement to coverage; the depth of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage; to provide targeted 
benefits to those with highest LTC needs. 

•  Encouraging  home  care 

to 
monitor  and  evaluate  alternative  services, 
including  incentives  for  use  of  alternative 
settings. 

to  continue 

•  Ensuring  availability  of  formal  carers:  to 
seek  options  to  increase  the  productivity  of 
LTC workers. 

•  Changing payment incentives for providers: 
to adapt provider payments for LTC, including 
the nomenclature of nursing care services, and 
consider  a  focused  use  of  budgets  negotiated 
ex-ante  or  based  on  a  pre-fixed  share  of  high-
need users. 

Luxembourg  has  a  high  quality  system  of  long-
term  care,  with  high  levels  of  satisfaction  among 
users  but  important  future  sustainability  issues  to 

(542) Measure no. 256 of the New Generation Budget (BNG). 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 

418 

 
                                                           
Long-term care systems 

3.18. Luxembourg 

financial  incentives  to  discourage  acute  care 
use for LTC. 

•  Improving  value  for  money:  to  encourage 
competition across  LTC providers to stimulate 
productivity  enhancements; 
in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

invest 

care 

and 

to 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

419 

 
4
2
0

Table 3.18.1:  Statistical Annex – Luxembourg 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

30
68.7
0.5

1.1
:
2.5

82.3
76.7
62.4
62.3
:
:

34
71.4
0.5

1.0
:
2.6

81.9
76.8
62.1
61.2
23.6
6.9

37
75.4
0.5

1.0
:
2.5

82.2
76.7
64.6
62.3
26.1
6.7

38
71.9
0.5

1.1
:
2.7

83.1
78.1
64.2
64.8
24.4
6.9

37
64.8
0.5

1.2
:
2.6

83.3
78.1
65.9
65.1
22.0
6.2

40
65.4
0.5

1.2
:
2.7

83.5
77.9
66.4
64.4
21.9
6.0

43
66.1
0.5

1.0
620.4
2.4

83.6
78.5
67.1
65.8
20.9
6.0

44
64.4
0.5

1.2
720.7
2.7

83.8
79.1
66.4
65.8
20.2
5.8

46
64.0
0.5

1.2
750.5
2.7

83.9
79.8
62.9
63.8
23.6
7.8

50
67.2
0.5

1.2
778.7
2.8

85.2
79.4
63.5
64.0
22.7
7.8

52
68.8
0.6

1.2
792.1
2.8

84.7
80.0
60.6
63.7
23.3
9.0

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

3
4
1.6

:
:

3
5
1.8

:
:

4
6
2.0

:
:

4
7
2.2

2
:

4
7
2.2

2
:

5
7
2.3

:
:

4
9
2.4

:
:

4
9
2.5

:
:

5
9
2.5

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.18.2:  Statistical Annex - continued – Luxembourg 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

0.6

0.04

7.3

1.3

1.3

4,705

8,906

1,789

2.6

36.4

97.5

2.5

70.3

29.7

108.6

24.3

10.5

2020

0.6

0.05

7.3

1.4

1.4

5,470

9,925

1,993

2.7

37.2

97.5

2.5

70.7

29.3

109.7

25.0

11.0

2030

0.8

0.06

7.8

1.6

1.8

7,270

13,066

2,549

3.0

38.7

97.6

2.4

70.7

29.3

112.4

25.9

11.2

2040

0.9

0.07

8.3

2.0

2.5

10,365

17,190

3,191

3.6

42.6

97.9

2.1

71.5

28.5

119.2

28.7

11.4

2050

0.9

0.08

9.0

2.8

3.7

14,882

21,878

3,935

4.3

48.1

98.3

1.7

72.7

27.3

125.2

32.0

11.6

2060

1.0

0.09

9.5

3.5

5.0

19,120

25,726

4,582

5.0

52.5

98.5

1.5

73.6

26.4

131.3

35.1

11.7

2070

1.0

0.10

9.8

4.1

6.5

22,939

29,223

5,131

5.5

56.1

98.6

1.4

74.1

25.9

134.8

37.0

11.8

MS Change 2016-
2070

EU Change 2016-2070

78%

141%

36%

219%

405%

388%

228%

187%

109%

54%

1%

-43%

5%

-13%

24%

53%

13%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

4
2
1

3
.
1
8
.

L
u
x
e
m
b
o
u
g

r

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
3.19. MALTA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

In  2015,  the  GDP  at  market  prices  in  PPS  per 
capita  stood  at  24,200,  which  is  below  the  EU 
average  of  29,600.  Population  was  estimated  by 
Eurostat at 0.4 million in 2016 and it is expected to 
reach  half  a  million  by  2070  with  the  fastest 
expansion occurring in the next years.  

Health status 

Life expectancy at birth with 84.0 years for women 
and 79.7 years for men is above the respective EU 
averages  of  83.3  and  77.9  years  in  2015.  Healthy 
life  year  expectancy  is  very  high  with  74.6  years 
for women and 72.6 for men in Malta versus 63.3 
and 62.6 in 2015 in the EU. The percentage of the 
population  in  2015  having  a  long-standing  illness 
or other health problem is lower than in the Union 
(29.2%  in  Malta  against  34.2%  in  the  EU).  The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  daily  activities 
stands  at  2.5%,  which  is  considerably  lower  than 
the EU-average (8.1%). 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living is projected to increase 
significantly  over  the  coming  60  years.    In  2016, 
the  number  of  dependent  people  stood  at  17,000 
and is projected to increase by 108% to 37,000 by 
2070. That is a steeper increase than in the EU as a 
whole  (25%).  Also,  as  a  share  of  the  population, 
the dependents are becoming a bigger group, from 
3.5%  to  6.2%,  an  increase  of  74%.  This  is  much 
more than the EU-average increase of 21%. 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
"AWG  reference  scenario",  public 
long-term 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 1.4 pps 

in 

of  GDP  by  2070  (EU:  1.2  pps)  (543).  The  "AWG 
risk scenario", which in comparison to the "AWG 
reference  scenario"  captures 
impact  of 
additional  cost  drivers  to  demography  and  health 
status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending  of  3.3  pps  of  GDP  by  2070  (EU:  2.7 
pps).  

the 

Medium fiscal sustainability risks appear for Malta 
over  the  long-run.  These  risks  are  entirely  related 
to the strong projected impact of age-related public 
spending  (notably  pensions,  healthcare  and  long-
term care) (544). 

System Characteristics  

Public provision of LTC is provided at both central 
and  regional  levels.  In  addition,  there  are  also 
private  residential  homes  and  several  day  centres 
for the elderly and persons with disabilities. There 
has  also  been  an  expansion  in  the  provision  of 
community-based  services  and  residential  care 
places.  In  2013,  the  number  of  licensed  beds  in 
LTC institutions amounted to more than 4,000. 

Public  spending  on  LTC ( 545)  reached  0.9%  of 
GDP  in  2015  in  Malta,  below  the  EU  average  of 
1.6% of GDP. 0.7% of GDP was spent on in-kind 
benefits  (EU:  1.4%),  while  0.2%  of  GDP  were 
provided  as  cash-benefits  (EU:  0.2%).  It  is  not 
clear which role private co-payments for formal in-
kind LTC play in the financing of LTC services.  

Types of care 

The expenditure for institutional (in-kind) services 
makes  up  85%  of  public  expenditure  (EU:  56%), 
15%  being  spent  for  LTC  services  provided  at 
home  (EU:  28%).  Institutional  care  is  relatively 
costly,  Member  States  with  high  shares  of 
spending  in  institutional  care  may  benefit  from 
efficiency  gains  by  shifting  some  coverage  (and 

(543) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(544) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(545) Long-term  care  benefits  can  be  disaggregated  into  health- 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily to assistance with IADL tasks). 

422 

 
                                                           
thus  expenditure)  from  institutional  to  other  types 
of care. 

user 
Eligibility 
dependency, care needs, income 

criteria 

and 

choices: 

in 

for 

Eligibility 
state-run 
long-term  care 
institutions  that  cater  for  permanent  residents  is 
granted to persons over 60 years and/or those with 
a  disability  that  leaves  them  unable  to  cope  with 
living  within  their  own  home.  For  all  cases, 
eligibility  is  determined  by  a  multi-disciplinary 
evaluation.  Cash  and  in-kind  benefits  are  partly 
means-tested and others are  needs-based,  with the 
majority being of a needs-based type.  

Prevention and rehabilitation measures 

the 

Acknowledging 
importance  of  preventive 
strategies  that  target  the  elderly,  a  vast  range  of 
community care services exist in Malta, which are 
intended to enable the elderly to continue living at 
home  and/or  in  his  community.  Amongst  such 
services, one can cite as examples: (a) the Telecare 
Plus Service which allows the subscriber to call for 
assistance when required; (b) the Meals on Wheels, 
which supports elderly persons and others who are 
still living in their own home but who are unable to 
system  was 
prepare  a  decent  meal.  The 
successfully  overhauled  in  2016,  which  in  turn 
resulted  in  the  introduction  of  menus  which  are 
sensitive  to  client  needs  and  demands,  and  the 
elimination  of  a  significant  waiting  list  which 
existed  prior  to  the  reform;  (c)  a  Handyman 
Service  that  helps  older  adults  and  persons  with 
special  needs  to  continue  living  as  independently 
as  possible  in  their  own  home  by  offering  a  wide 
range  of  repair  jobs;  (d)  a  Home  Help  Service 
which  offers  non-clinical,  personal  help  and  light 
domestic work to older adults.  

The past years saw the consolidation of a  number 
of  traditional  services  and  the  introduction  of  a 
series  of  new  ones  to  meet  the  emergent  client 
needs.  Improvement  in  operations  resulted  in 
service  user  gains  in  Home  Help,  Handyman, 
Night  Shelters  and  Continence  service,  while 
technological  improvements  made  it  possible  to 
develop Telecare (where beneficiaries approximate 
9,000 persons). 

Dementia  has  been  put  on  the  national  agenda  by 
launching  the  National  Dementia  Strategy  (2015-

Long-term care systems 

3.19. Malta 

Implementation  of 

2023). 
this  strategy  saw 
appointment of a Dementia Care Coordinator and 
the  setting  up  of  Dementia  Intervention  Teams, 
multi-disciplinary  team  specialising  in  Dementia 
Care  and  support  for  families  caring  for  older 
persons with Dementia.  

“Dementia  Day  Centres”  provide  specialised  day 
care for persons with dementia and offer respite to 
carers  who  have  family  members.  Options  are 
being  considered  to  open  similar  facilities  in 
different parts of the island. “Memory Cafés“ were 
introduced in 2017 as an innovative concept where 
informal carers are provided with informal support 
from professionals and other people going through 
the same experience. 

“Respite  in  care  homes”  is  a  highly  demanded 
community service. The number of beds available 
for  this  service  has  nearly  doubled  over  the  past 
year such that 30 respite beds are available in eight 
care  homes  to  meet  clients’  needs  and  requests. 
“Respite  at  Home”  was  launched  in  May  2017, 
where the family is provided with a qualified carer 
to  provide  respite  in  their  own  home.  Different 
modes  of  service  provision  are  offered  to  suit 
family needs. 

The  “Carer  at  Home  Scheme”  was  launched  in 
2016 to reimburse families who employ a qualified 
carer  to  care  for  an  older  person  within  a 
community  setup.  The  range  of  domiciliary  care 
services  was  extended  in  2016-2017  through  the 
introduction 
occupational 
therapy,  podiatry  and  a  geriatrician  service  for 
home-bound  persons.  A 
total  of  1,700  new 
referrals were received and followed until October 
2017 (a total of 1450 in 2016).  

physiotherapy, 

of 

Efforts  are  ongoing  to  make  effective  use  of 
community  based  services.  This  achieved  through 
policies  and  procedures,  professional  assessment, 
follow-up  and  communication,  which  control 
abuse  without  limiting  access  for  persons  who 
genuinely require domiciliary care.  

care 

acute 

services  while 

Rehabilitation  services  are  key  to  reduce  pressure 
on 
delaying 
institutionalisation and securing the availability of 
beds  allocated  for  long-term  nursing  care.  Older 
patients  admitted  to  Mater  Dei  Hospital  are 
referred  and  considered  for  transfer  and  further 
management  as  necessary.  The  aim  is  to  continue 

423 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

and 

care,  promote 
and  nursing 
their  medical 
mobilisation 
functional 
help 
independence.  An  interdisciplinary  team  approach 
helps provide holistic care and enable reintegration 
into the community.  

regain 

Formal/informal care-giving 

Informal  care  plays  an  important  role  in  Maltese 
society,  due  to  the  strong  traditional  role  of  the 
family.  Support  measures  offered  to  informal 
carers  in  Malta  include  a  combination  of  cash 
benefits  and  care  leave.  Respite  and  support  for 
informal  carers  is  provided  through  benefits  in-
kind via community services and the "Commcare" 
unit,  which  provides  assessment  and  case 
management  services  via  a  team  of  nurses,  allied 
health  professionals,  social  workers  and  carers 
who  provide  services  to  clients  that  are  house-
bound. 

Recently 
reforms  

legislated  and/or  planned  policy 

Malta is in the process of implementing a National 
Strategic  Policy  for  Active  Ageing  (2014-2020), 
three  distinct  pillars:  active 
namely  within 
participation 
social 
labour  market; 
in 
participation; and independent living. 

the 

security 

financial 

With regards to the first pillar, the policy supports 
employers to assist the ageing workforce to remain 
active  and  productive  within  the  labour  market.  It 
also supports the ageing employees to continue to 
develop  their  skills  in  order  to  meet  the  changing 
needs  of  the  work  organisation.  The  second  pillar 
focuses  on 
in  old  age, 
encouraging  active  participation  in  society,  which 
includes  volunteering,  grandparenthood, 
and 
involvement  in  civic  engagement.  The  policy 
promotes  lifelong  learning  and  offers  support  to 
informal  carers  and  inter-generational  solidarity. 
The  third  pillar  promotes  independent  living  and 
addresses  health  prevention  and  promotion  within 
the  community  sector.  It  links  acute  and  geriatric 
rehabilitation,  psychiatric  mental  health  and  well-
being  with  community  care  services.  It  further 
promotes  age-friendly  communities  to  support 
good quality of life for older people within society. 
It  finally  looks  at  issues  on  abuse  and  end-of-life 
care. 

424 

initiatives  and  programs  within 

Several 
this 
National  Strategic Policy  have been implemented, 
or are in the process of being, implemented.  

the 

that  foster 

initiatives  which 

initiatives  were  held 

Amongst 
support 
participation  in  the  labour  market,  a  seminar  was 
held in collaboration with the Occupational Health 
and  Safety  Authority  to  promote  occupational 
health  and  safety  principles 
the 
employability  of  older  and  age  workers  up,  and 
even  subsequent,  to  statutory  retirement  age.  Pre-
retirement  programs  were  held  with  different 
entities  to  assist  in  the  smooth  transition  to 
retirement.  Several 
to 
encourage  social  participation  by  older  adults. 
Associations  of  members  of  day  centres  and 
associations of residents in residential homes have 
been  set  up  to  strengthen  the  voice  of  vulnerable 
groups.  Active  ageing  centres  have  been  piloted 
and set up on a permanent basis and are now being 
learning  hubs  and 
transformed 
collaboration with local councils is ongoing to set 
up  new  Active  Ageing  hubs  which  provide 
informal  learning  opportunities  to  older  adults. 
Similar  sessions  are  also  being  held  in  residential 
homes for the elderly.  

lifelong 

into 

Collaboration  with  the  Malta  Communications 
Authority  is  ongoing  and  several  information  and 
communication  training  programs  are  held  based 
on  best  practice  models  so  as  to  support  digital 
inclusion.  Older  adults  are  encouraged  to  lead  an 
independent  and  active  life  while  support  is 
provided  to  those  who  are  frailer.  Information 
sessions  for  informal  carers  of  older  persons  and 
information sessions for informal carers of persons 
with  dementia  were  held.   Community  services, 
including  respite  service,  are  being  reinforced  to 
support older adults to continue living in their own 
homes.   Innovative  financial  support  models  for 
personal  care  at  home  have  been  introduced. 
intergenerational  programs  are  held 
Several 
including  programs  with  Malta  College  of  Arts, 
Science  and  Technology  (MCAST),  main  stream 
and  special  schools,  and  with  Eko  Skola  (Eco-
(from 
Schools). 
Elderly  to  Elderly)  is  a  pilot  project  which  was 
designed  and 
the  aim  of 
launched  with 
encouraging older citizens in to care for and assist 
older  persons  who  live  with  the  same  community 
where  they  live.  The  outcome  of  this  project  is 
being evaluated.  

“Mill-Anzjan  ghall-Anzjan” 

 
With  regards  to  the  second  and  third  pillars,  the 
government  has also undertaken various  measures 
to  enhance  long-term  care  and  services  for  the 
elderly.  These  measures  include:  (a)  National 
minimum standards for residential homes to ensure 
adequate environment and care of residents; (b) the 
upgrading  of  the  national  “Telecare”  service  to 
“Telecare  Plus”,  which  now  offers  valuable  add-
ons  and  also  the  upgrading  of  the  pendant  to  a 
‘smart  accessory’; 
‘carer  at  home’ 
(c)  a 
programme  that  provides  older  persons  with  full-
time  carers  to  support  them  to  live  in 
the 
community. Besides, the government also offers a 
number  of  respite  beds  at  various  care  homes  to 
alleviate  the  responsibilities  of  informal  carers 
towards  their  elder  relatives.  “Respite  at  Home” 
was  launched  in  May  2017,  where  the  family  is 
provided  with  a  qualified  carer  to  provide  respite 
in  their  own  home.  Different  modes  of  service 
provision  are  offered 
to  suit  family  needs. 
Moreover,  the  majority  of  care  homes  were 
upgraded 
to  nursing  homes  and  have  also 
undergone  refurbishment  and  have  been  upgraded 
with wi-fi facilities.  

In  order  to  raise  more  awareness,  two  seminars 
were held, one on end-of-life care and the other to 
raise  recognition  of  elder  abuse  and  neglect. 
Leaflets  have  been  distributed  to  the  general 
public.  Lectures  on  crime  prevention  related  to 
older  persons  are  being  provided  with 
the 
cooperation of the Malta Police Force.  

(a) 

In  relation  to  dementia,  the  measures  undertaken 
include: 
the  setting  up  of  a  dementia 
intervention  team  to  further  support  persons  with 
dementia  in  the  community;  (b)  the  opening  of  a 
dementia day activity centre at St Vincent de Paule 
Residence for the elderly and a dementia centre in 
Gozo,  the  second  largest  island  of  the  Maltese 
archipelago;  and  (c)  the  introduction  of  a  24/7 
dementia  helpline  service  (d)  establishing  a 
National  Commission  on  Dementia.  Moreover,  a 
pilot 
friendly 
on 
communities  has  been  running  since  January  to 
December  2016  while  booklets  on  dementia  were 
published targeting both the general public as well 
as informal carers.   

programme 

dementia 

In  addition  to  pursuing  a  policy  of  active  ageing, 
other  policy  initiatives  are  being  pursued  in  order 
to further improve the provisions of long-term care 

Long-term care systems 

3.19. Malta 

and  services  offered  in  the  country.  Some  of  the 
new policy initiatives are hereby reported. 

After  the  publication  of  the  White  Paper  on 
National  Minimum  Standards  for  care  homes  for 
older  people,  the  standards  have  been  published. 
Enforcing  legislation  has  also  been  drafted  and  is 
being  vetted  prior  to  presentation  to  Cabinet  of 
Ministers. 

The  National  Dementia  Strategy  has  been 
published  and  is  already  being  implemented  (see 
measures  above).  As  part  of  a  comprehensive 
strategy  for  elderly  care,  Malta  is  also  embarking 
on  a  new  service  dealing  with  geriatric  mental 
health  rehabilitation.  Policy  guidelines  have  been 
recently  adopted  at  the  state  run  St.  Vincent  de 
Paul  Residence  for  the  elderly,  which  caters  for 
long 
term  residential  and  nursing  care.  The 
intention is to have these policy guidelines adopted 
by  other  government  residential  and  nursing 
homes.  

Challenges 

The main challenges of the system appear to be:  

•  Improving the governance framework: to set 
the  public  and  private  financing  mix  and 
organise  formal  workforce  supply  to  face  the 
growing  number  of  dependents,  and  provide  a 
strategy  to  deliver  high-performing  long-term 
care  services  to  face  the  growing  demand  for 
LTC services; to strategically integrate medical 
and social services via such a legal framework; 
to  define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  establish 
good information platforms for LTC users and 
providers. 

•  Improving financing arrangements: to foster 
pre-funding  elements,  which  implies  setting 
aside some funds to pay for future obligations; 
the  potential  of  private  LTC 
to  explore 
insurance as a supplementary financing tool. 

•  Encouraging  home 

alternatives 
developing 
encouraging  home 

to 
new 

to 

care: 

develop 
institutional  care  by  e.g. 
frameworks 
regulation 

legislative 

care 

and 

425 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

controlling  admissions  to  institutional  care  or 
the establishment of additional payments, cash 
benefits  or  financial  incentives  to  encourage 
home care. 

services 

•  Encouraging  independent  living:  to  explore 
alternative 
encourage 
independent  living,  provide  effective  home 
care, tele-care and information to recipients, as 
well  as  improving  home  and  general  living 
environment design. 

which 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care.  

future  needs 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  coordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
the  allocation  of  care  co-
information, 
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

426 

 
Table 3.19.1:  Statistical Annex – Malta 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

5
21.9
0.4

:
:
:

81.4
77.3
70.4
68.6
:
:

5
21.7
0.4

:
:
:

82.0
77.0
69.5
68.3
20.3
4.0

6
22.5
0.4

:
:
:

82.2
77.5
71.1
69.2
24.9
3.3

6
22.1
0.4

:
:
:

82.3
77.1
72.1
68.8
24.7
2.6

6
20.6
0.4

:
:
:

82.7
77.9
71.0
69.4
27.5
3.7

7
21.3
0.4

:
:
:

83.6
79.3
71.3
70.1
28.5
3.9

7
21.1
0.4

:
:
:

83.0
78.6
70.7
69.9
30.4
4.0

7
21.3
0.4

:
:
:

83.0
78.6
72.2
71.5
30.5
3.1

8
21.5
0.4

:
:
:

84.0
79.6
72.7
71.6
29.5
3.2

8
22.5
0.4

0.8
192.9
1.9

84.2
79.8
74.3
72.3
28.2
2.8

9
24.2
0.4

:
:
:

84.0
79.7
74.6
72.6
29.2
2.5

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

2
9
2.7

:
:

5
7
2.9

:
:

7
5
3.1

:
:

10
4
3.3

:
:

10
4
3.3

:
:

10
4
3.4

:
:

1
8
2.2

:
:

1
8
2.2

:
:

1
9
2.3

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

Source: EUROSTAT, OECD and WHO. 

4
2
7

3
.
1
9
.

M
a

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4
2
8

Table 3.19.2:  Statistical Annex - continued – Malta 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

0.4

0.02

3.5

0.9

0.9

3,973

8,092

4,679

3.8

100.0

80.0

20.0

85.0

15.0

67.3

5.8

16.8

2020

0.5

0.02

3.8

1.0

1.0

4,725

9,353

4,818

4.2

100.0

81.4

18.6

85.3

14.7

64.8

5.7

17.0

2030

0.5

0.02

4.7

1.3

1.4

7,126

13,021

5,634

5.3

100.0

84.8

15.2

86.0

14.0

66.5

5.9

17.5

2040

0.5

0.03

5.3

1.6

1.9

9,314

15,591

5,596

6.0

100.0

88.0

12.0

86.8

13.2

67.8

6.2

17.7

2050

0.5

0.03

5.4

1.8

2.4

9,942

16,419

5,482

6.2

100.0

89.2

10.8

86.8

13.2

70.2

6.4

17.8

2060

0.5

0.03

5.6

2.0

3.0

10,678

17,528

5,350

6.5

100.0

90.7

9.3

86.9

13.1

74.8

6.9

17.6

2070

0.5

0.03

6.2

2.3

4.2

12,529

19,601

5,224

7.2

100.0

92.3

7.7

87.2

12.8

76.5

7.2

17.6

MS Change 2016-
2070

EU Change 2016-
2070

19%

108%

74%

154%

364%

215%

142%

12%

87%

:

15%

-61%

3%

-15%

14%

23%

5%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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3.20. THE NETHERLANDS 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

the 

The  size  of  the  population  in  the  Netherlands  in 
2016  accounted  for  3.4%  of 
total  EU 
population,  and  it  is  projected  to  increase  up  to 
19.6 million by 2070 (546). In 2015, it generated a 
GDP of roughly €683 billion or 4.7% of the GDP 
of the Union as a whole. With a GDP per capita of 
almost  36,000  PPS  per  capita,  the  Netherlands  is 
also among the richest Member States (EU 29,610 
PPS  in  2015).  Public  expenditure  on  long-term 
care (health and social part) (547) was in 2016 with 
3.5% of GDP, more than double the EU average of 
1.6%. 

Health status 

Life expectancy at birth for both  women and  men 
is respectively 83.2 and 79.5 years, above the EU 
average for men and broadly in line for women in 
2015 (83.3 and 77.9 years respectively). As for the 
healthy life years at birth however, these are lower 
than the EU-average both for women and for men, 
though more markedly for females, with 57.2 years 
vs  63.3  for  the  EU;  for  men,  the  2015  value  is  of 
61.1  vs.  62.6  years  for  the  EU.  At  the  same  time, 
the  percentage  of  the  Dutch  population  having  a 
long-standing  illness  or  health  problem  is  slightly 
higher  than  in  the  Union  as  a  whole  (35.3%  and 
34.2% 
the 
population 
indicating  a  self-perceived  severe 
limitation  in  its  daily  activities  is  also  lower  than 
the EU-average (7.3% vs. 8.1% in 2015). 

respectively).  The  percentage  of 

Dependency trends 

The  amount  of  people  living  in  the  Netherlands 
depending on others to carry out activities of daily 
living is projected to significantly increase over the 
coming  decades.  From  slightly  less  than  1.16 
million residents living with strong limitations due 
to health problems in 2016, an increase of 42% is 
envisaged  until  2070 
to  approximately  1.64 
million.  That  is  a  steeper  increase  than  in  the  EU 
as a whole (25% for the EU over the same period). 
Also  as  a  share  of  the  population,  the  dependents 

(546) Based on Eurostat projections. 
(547) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

are expected to become a bigger group, from 6.8% 
to 8.4% by 2070, an increase of 24%, which is also 
higher  than  the  EU-average  projected  increase  of 
21%. 

Expenditure projections and fiscal sustainability  

With the demographic changes in the Netherlands, 
the  public  expenditure  on  long  term  care  as  a 
percentage of GDP is projected to steadily increase 
by 2.5 pps, from 3.5 percent in 2016 to 6.0 percent 
in  2070  in  the  "AWG  reference  scenario" (548).  In 
this  scenario,  public  long-term  expenditure  is 
driven  by  the  combination  of  changes  in  the 
population  structure  and  a  moderately  positive 
evolution of the health (non-disability) status. The 
"AWG  risk  scenario",  which  captures  in  addition 
the 
to 
impact  of  additional  cost  drivers 
demography  and  health  status,  i.e.  the  possible 
effect of a cost and coverage convergence, projects 
an  increase  in  spending  of  4.8  pps  of  GDP  by 
care 
2070.  Overall, 
projected 
expenditure 
to 
budgetary 
fiscal 
sustainability  risk  indicator  S2,  which  shows  the 
adjustment effort needed to ensure that the debt-to-
GDP  ratio  is  not  on  an  ever-increasing  path,  is  at 
3.0%  of  GDP.  In  the  long  term,  the  Netherlands 
fiscal 
therefore 
sustainability risks. This is primarily related to the 
projected  increase  in  the  costs  of  ageing  where  in 
particular  the  projected  increase  in  long-term  care 
costs contribute 2.0% of GDP to the indicator (549). 

increase 
pressure.  The 

face  medium 

is  expected 

long-term 

long-term 

to  add 

appears 

to 

System Characteristics  

lived 

insured  under 

In  the  Netherlands,  a  system  of  public  long-term 
care  insurance  had  been  in  place  since  1968  until 
in 
recent  years.  Everyone  who 
the 
the  AWBZ 
Netherlands  was 
(Algemene  Wet  Bijzondere 
Ziektekosten; 
Exceptional  Medical  Expenses  Act).  The  AWBZ 
covered  not  only  care  for  the  elderly,  but  in 
principle  all  chronic  care,  especially  concerning 
large  expenses  where  insurance  on  a  private 
market would not be feasible. This act covered at-

(548) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(549) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

429 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

for 

and 

institutions 

home  care  and  care  in  institutions  for  the  elderly, 
the  mentally  and  physically 
institutions 
chronic 
handicapped 
for 
income-
psychiatric  patients.  Some  form  of 
dependent  cost-sharing  existed  for  practically  all 
long-term care services. Moreover, in institutions a 
contribution had to be paid for the comprehensive 
package of care and board and lodging. However, 
in 2016, the Netherlands spent a very high share of 
long-term  care  public  spending  on  institutional 
care  (92.7%),  which  is  largely  above  the  average 
of 56% for the EU in the same year. This points to 
an inefficient use of resources, as institutional care 
is  typically  the  most  expensive  way  to  provide 
long-term  care.  Looking  more  closely  at  the 
figures  for 
institutional  care,  unit  costs  per 
recipient,  measured  as  a  share  of  GDP  per  capita, 
stood  at  185  in  2016,  which  is  more  than  double 
the  EU  average  of  77.1  for  the  same  year.  This 
measure  expresses  the  pressure  on  the  budget 
deriving from the current provision of institutional 
care  and  suggests  that  there  is  ample  scope  to 
improve  long-term  care  provision  from  a  cost-
efficiency perspective. Accordingly, the long-term 
care system has recently undergone a major reform 
with  the  aim  to  promote  and  support  independent 
living. Indeed, the Netherlands spent in 2016 only 
7.3% of the total long-term care budget is spent on 
home  care,  and,  with  unit  costs  of  8.4,  home  care 
stands well below the EU average value of 33.9 in 
terms of unit cost per recipient as a share of GDP 
per  capita,  which  suggests  that  shifting  resources 
to  this  mode  of  provision  could  be  an  efficiency 
enhancing measure.  

The  Exceptional  Medical  Expenses  Act,  close  to 
becoming  unmanageable  due  to  the  breadth  of 
covered  services,  was  repealed.  Whereas  some  of 
those  previously  covered  under 
this  act  are 
currently covered under the Health Insurance Act, 
the  Social  Support  Act  (Wmo)  or  the  Youth  Act, 
the most vulnerable categories, i.e. those requiring 
permanent supervision or 24-hour care nearby, are 
entitled to care services under the Long-Term Care 
Act (Wlz). 

Administrative organisation 

The  Exceptional  Medical  Expenses  Act  (AWBZ), 
in  place  since  1968,  used  to  cover  the  bulk  of 
expenditures, and  was a truly national and largely 
contribution-based  scheme  which  covered  for  the 
costs  of  personal  and  nursing  care,  guidance, 

430 

accommodation  and,  on  certain  conditions,  even 
medical  treatment.  The  basket  of  covered  benefit 
had  grown  to  such  an  extent  over  time  that  the 
system  was  close  to  becoming  unmanageable  in 
the  previous  setting.  In  2007,  the  provision  of 
home help for domestic activities was delegated to 
the  municipalities 
a  broader 
decentralising  pattern.  In  2015,  the  Exceptional 
Medical  Expenses  Act  was  repealed  and  was 
replaced  in  its  scope  by  other  acts  like  the  Social 
Support  Act  (Wmo),  the  Health  Insurance  Act 
(Zvw)  and  Youth  Act.  Under  the  Wmo,  the  local 
authorities are in charge of provision of care and of 
the needs assessment,  which they formulate based 
on an interview with the citizen. 

as  part  of 

The  Long-Term  Care  Act  (Wlz),  a  compulsory 
health 
insurance  policy  based  on  solidarity, 
focusses a smaller group of high-need individuals. 
The  amount  of  the  premium  is  (9.65%)  of  the 
income  tax,  with  a  ceiling  of  33,589  euros.  In 
addition, there is an income-dependent co-payment 
for adults. This depends on whether the client lives 
at  home  or  in  a  care  facility,  is  younger  or  older 
than  65,  and  is  single,  married  or  has  a  domestic 
partner. 

financial 

the  Wlz,  31 

Under 
regional  care  offices 
(zorgkantoren)  are  in  charge  to  provide  care 
purchased  with  public  funds.  The  agencies  are 
generally independent subsidiaries of the dominant 
health insurer in each region. Although they have a 
contracting  budget,  these  agencies  have  no  funds 
of  their  own  (except  for  administrative  costs),  as 
care  providers  are  directly  paid  from  a  general 
public  fund  on  the  basis  of  contracts  concluded 
with the agencies. Hence, purchasing agencies bear 
risk  on  purchasing  care.  All 
no 
contributions  collected  under  Wlz  are  deposited 
into the Long-Term Care Fund, which is managed 
by  the  National  Healthcare  Institute.  The  central 
government tops up the fund using public funds if 
these  funds  are  too  low.  Although  the  care  costs 
are  paid  from  the  Wlz  fund,  the  care  offices  are 
charged with keeping costs within the national and 
regional  budget  and  with  purchasing  care  as 
efficiently  as  possible.  In  addition,  the  purchasing 
agencies  can  set  quality  standards  and  check 
services  invoiced  by  the  healthcare  providers 
match  the  required  standards.  All  long  term  care 
tariffs  are  regulated  by  the  Dutch  Healthcare 
Authority  (NZa).  The  NZa  set  maximum  prices, 

 
Long-term care systems 

3.20. The Netherlands 

where  under  bargaining  between  purchasing 
agencies and providers is allowed. 

givers  cooperate 
patients. 

in  offering  custom  care 

to 

Types of care 

Eligibility criteria  

The  main  recipients  of  long-term  care  include 
persons  with 
learning,  physical  or  sensory 
disabilities,  elderly  persons  and  persons  with 
psychiatric  disorders.  The  Long-Term  Care  Act 
(Wlz)  covers  the  most  vulnerable  categories,  i.e. 
those  requiring  permanent  supervision  or  24-hour 
care  nearby,  providing  a  broadly  defined  set  of 
services  including  residential  care.  The  Wmo 
covers  a  broad  package  of  services,  such  as 
personal  care,  nursing  and  domiciliary  care  for 
individuals  that  need  assistance  but  are  not  as 
(including 
severe  cases.  All 
treatment  and  stay 
institution)  were 
previously delivered under AWBZ.  

these  services 
in  an 

Most  clients  apply  for  care-in-kind,  but  since  the 
mid-1990s they may also opt for a personal budget 
to  purchase  health  services  privately  (under  both 
Wlz and Wmo). The cost explosion of the personal 
budget  scheme  from  413  million  euro  in  2002  to 
2.2 billion in 2010 highlights the popularity of this 
scheme.  However,  experts  worry  that  it  did  not 
equally lower the demand for in-kind care and also 
tends to crowd out informal care.  

In providing support under the Social Support Act, 
the  local  authorities  distinguish  between  general 
provisions  and  personalised  provisions.  General 
provisions  are  designed  for  the  community  and 
cover  a  range  of  services  from  recreational 
activities to transportation. Personalised provisions 
are designed for a single person; this might include 
domestic  assistance  and  support.  Currently,  the 
assistance 
live 
is  aimed  at  being  able 
independently  (for  example,  help  with  organising 
the household or with administration). 

to 

To facilitate the elderly living at home (as opposed 
to  living  in  a  rest  home  or  care  institution),  the 
government  encourages  municipalities,  social 
housing  associations  and  care  institutions  to  build 
homes  adapted  to  the  needs  of  older  people. 
Accessible  local  care  also  plays  a  part  in  helping 
the  elderly  to  be  independent  for  as  long  as 
possible. In order to achieve this, a new focus has 
been placed on creating local health care networks 
where  general  practitioners,  nurses  and  other  care 

Patients’ eligibility for Wlz care is assessed by an 
independent Care Assessment Centre (CIZ). There 
are  no  financial  incentives  for  CIZ:  its  financial 
position is not affected by its decisions. CIZ’s task 
is  to  carry  out  independent,  objective  and  integral 
assessments.  The  procedure  is  the  same  for  care 
reimbursed  in  cash  and  for  in-kind  care.  CIZ 
adopts  certain  standards  to  determine  different 
‘profiles’  (packages),  in  which  the  eligibility  is 
determined on the needs and characteristics of the 
client. 

is 

that 

(“personal  budget”) 

The centre decides if patients are eligible  for Wlz 
care and how much care they are entitled to. Once 
assessed, patients can opt either to receive in-kind 
care (either in an institution or at home) or a cash 
benefit 
roughly 
equivalent to 100% of the care related costs of in-
kind  care.  The  cash-reimbursement  option  is  not 
commonly  used  for  treatment  and  stay  in  an 
institution, except for some small-scale initiatives. 
For  most of the budget, patients are obliged to be 
able  to  show  that  they  did  spend  the  money  on 
care.    Out  of  the  2016  budget  of  19.9  billion,  1.3 
billion  is  the  amount  attributed  to  the  personal 
budget.  Based  on  these  figures,  cash  benefits 
amount  to  roughly  6.5%  of  total  expenditure  for 
Wlz (550). 

Clients  who  prefer  in-kind  care  have  some  say 
with  regard  to  which  care  organisation  delivers 
their  care,  however, 
for 
organising  and  purchasing  this  care  remains  with 
the ‘zorgkantoren’ (regional care offices).  

responsibility 

the 

Under the Wmo, the local authorities are in charge 
of  delivery  and  discuss  the  client’s  request  for 
support together with the client. It is then up to the 
local  authority  to  provide  the  appropriate  type  of 
support  and  determine  how  this  support  is  to  be 
organised.  People  can  either  contact  the  local 
authority or be referred by a GP. A meeting is set-
up  to  assess  the  request  for  support,  in  light  of 

(550)

https://www.rijksoverheid.nl/onderwerpen/prinsjesd

ag/documenten/begrotingen/2015/09/15/xvi-
volksgezondheid-welzijn-en-sport-rijksbegroting-2016, 
p.138. 

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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

the 

factors  such  as  the  possibility  of  the  individual  to 
draw  on  their  personal  network  or  on  a  general 
provision.  Hence 
local  authority  decides 
whether  to  accept  or  reject  a  request  of  support, 
which, if granted, can materialise into services of a 
personal budget with or without a co-payment. As 
for  the  financing,  the  local  authorities  receive 
funds  from  the  central  government  through  the 
Municipal  Fund,  which  they  can  allocate  to 
services  discretionally.  They  then  pay  providers 
for  services  or  transfer  funds  to  the  Social 
Insurance Bank for personal healthcare budgets. 

Co-payments, out of the pocket expenses and 
private insurance 

The  long-term  care  system  is  funded  by  social 
security  premiums,  taxes  and  co-payments.  Since 
co-payments  are  income-  and  wealth-dependent, 
care  users  will  not  run  into  severe  financial 
difficulties.  But  it  is  quite  well  possible  that 
persons in institutions  have to contribute so  much 
that  they  just  have  ‘a  clothing  allowance  and 
pocket money’ left to spend according to their own 
preferences.  At  the  same  time,  the  income-related 
co-payment covers only a small portion of the total 
costs  of  long-term  care  (10%  of  total  for  Wlz  in 
2015). 

Role of the private sector 

Institutional  care  providers  must  be  non-for-profit 
organisations,  while  the  home  care  market  has 
been opened to for-profit companies. 

Formal/informal caregiving 

Since  its  inception  in  1968,  the  Exceptional 
Medical  Expenses  Act  has  been  expanded  and 
improved.  However, 
long-term  care  has  also 
changed  in  its  nature  and  extent  through  a  whole 
range of supplementary regulations. This has led to 
an  increased  demand  for  care,  rising  costs  and  a 
sizeable  bureaucracy.  Moreover,  it  has  led  to  a 
system that is aimed too much at the provision of 
care  (by  institutions)  and  too  little  on  the  patient. 
In some cases, the appeal for Exceptional Medical 
Expenses  Act  care  has 
increased  needlessly, 
without clear benefits for the patients. There is also 
the  threat  of  a  shortage  of  care  workers.  In  2010 
there  were  1.3  million  employees  in  the  care  and 
welfare  sector.  According  to  calculations  by  the 
and 
National 

of  Public  Health 

Institute 

Environmental  Protection 
(Rijksinstituut  voor 
Volksgezondheid  en  Milieuhygiëne  or  RIVM), 
over  the  coming  15  to  20  years  at  least  400,000 
extra  care  providers  will  be  needed  in  the  care 
sector  alone,  if  the  policy  remains  unchanged.  At 
the same time, the working population will decline 
during  the  coming  decades.  To  respond  to  this 
future  challenge,  the  Netherlands  has  carried  out 
projections  of  future  needs  for  carers,  and  is 
implementing  a  reorganisation  of  the  labour  force 
(including  financial  support  for  institutions)  in 
long-term  care.  Nonetheless,  given  the  size  of  the 
challenge,  this  area  deserves  regular  monitoring. 
During  the  last  few  years  there  have  been  several 
reports  published  in  which  the  conclusion  is  put 
forward  that  measures  were  needed  in  order  to 
allow  the  Exceptional  Medical  Expenses  Act  to 
take  future  developments  into  account.  Besides 
these  reports,  analyses  have  also  been  compiled 
within  the  care  sector  itself  by  organisations  such 
as  ActiZ  (organisation  for  care  providers  in  the 
Netherlands)  as  well  as  a  collaboration  of  client 
organisations,  which  show  that  the  Exceptional 
Medical  Expenses  Act  does  not  make  sufficient 
use  of  the  strengths  of  the  people  involved  and 
those around them. 

Recently 
reforms  

legislated  and/or  planned  policy 

The  main  objective  of  the  recent  reform  of  long-
term care  was to guarantee its fiscal sustainability 
in  future.  As  such,  substantial  cuts  were  made  in 
the system, including the delisting of day care and 
personal  counselling  under  the  Awbz,  lifting  the 
entrance barrier of residential care for persons with 
severity-package 1-3 and a substantial reduction of 
the state budget for municipalities to carry out the 
Wmo. 

(extramural) 

long-term  support 
the  new  Wmo,  (b) 

The  reform  of  long-term  care  includes  a  radical 
revision  of  the  institutional  structure.  The  most 
important changes are: (a) decentralisation of non-
residential 
to 
municipalities  under 
the 
abolishment  of  the  Awbz  and  the  simultaneous 
introduction of the Long-term Care Act (Wlz: Wet 
Langdurige  Zorg)  to  cover  care  for  the  most 
vulnerable  and  (c)  the  transfer  of  personal  care  at 
home  from the  Awbz to the  Health Insurance  Act 
(for people who are not meeting the Wlz criteria). 
the 
In  addition,  municipalities  are  attributed 

432 

 
responsibility  for  most  (551)  of  the  youth  care  as 
established  by  the  new  Youth  Law  approved  in 
2014.  The  reform  of  long-term  care  has  not  only 
institutional and budgetary implications but also a 
normative  component  consisting  of  three  main 
elements emphasising the importance of individual 
responsibility, 
promoting 
independent whenever possible.  

encouraging 

and 

The  first  significant  step  was  the  introduction  of 
the Wmo in 2007, a key element of which was the 
decentralisation of parts of long-term care from the 
became 
to  municipalities,  which 
AWBZ 
responsible  for  household  cleaning.  Under  the 
arrangement  municipalities  must  give  support  to 
people  who  cannot  run  a  household  on  their  own 
and participate in social life. Each municipality has 
discretionary  power  as  regards  need  assessment, 
which may lead to unequal access.  

(extramural) 
Later  on,  some  non-residential 
services in LTC  were transferred to municipalities 
(and insurers), and, together with a 40% cut in the 
budget  for  household  cleaning,  a  revision  of  the 
Wmo along the following lines was adopted: 

− 

the  Wmo  stresses 
responsibility; 

individual  and  social 

−  municipalities 

are 

responsible 

for 

the 

implementation of the Wmo; 

− 

− 

the  municipalities  deliver  tailor-made  services 
(maatwerk)  based  on  a  need  assessment 
procedure (keuken-tafelgesprek); 

the  municipalities  decide  on  whether  to  assign 
a personal budget; 

−  means-testing  is  forbidden,  but  municipalities 

can set co-payments. 

Wlz  (552)  is  set  up  as  a  social  health  insurance 
scheme  based  on 
income  contributions  and 
covering  the  entire  population,  who  has  a  right  to 
long-term care subject to need. As for the range of 
benefits, the Wlz covers either services in-kind or 

(551) Some  aspects  of  youth  care  are  regulated  under  Zvw  or 

Wlz. 

(552) It covers groups of people that need constant assistance due 
to  the  nature  of  the  condition  or  to  the  risk  that  the 
condition  would  worsen  with 
lack  of  support  and 
supervision. 

Long-term care systems 

3.20. The Netherlands 

a  personal  budget  or  a  total  package  at  home 
(volledig  pakket  thuis).  The  system  of  severity-
adjusted packages (zorgzwaartepakketten) remains 
in  place.  The  new  Wlz  has  many  features  in 
common  with  the  former  Awbz.  For  instance,  the 
care offices have been preserved and are in charge 
of  contracting  LTC  providers,  the  system  of 
regional  budgets  is  still  in  place  and  the  Nza  sets 
maximum tariffs. 

It is yet not known whether the reform of the long-
term  care  has  started  to  deliver  results  and 
quantifications  of  projected  savings  are  not  yet 
available.  In  terms  of  fiscal  sustainability  this 
therefore  leaves  the  Netherlands  exposed  to  the 
high  long-term  risks  driven  by  the  projected 
increase  in  long-term  care  spending  mentioned 
above.  

Challenges 

The Netherlands has undergone a major reform of 
the  long-term  care  system  to  tackle  the  high 
projected costs of its long-term care system  while 
are 
preserving 
acknowledged  as  the  main  challenges  for  the 
Dutch 
long-term  care  system  and  many  are 
included in their policy agenda: 

following 

quality. 

The 

state 

responsibilities 

•  Improving  the  governance  framework:  to 
ensure  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
authorities 
of 
of 
concerning  the  provision  of  long-term  care 
services;  to  share  data  within  government 
administrations to facilitate the management of 
potential  interactions  between  LTC  financing, 
targeted  personal-income  tax  measures  and 
transfers  (e.g.  pensions),  and  existing  social-
assistance  or  housing  subsidy  programmes;  to 
deal with cost-shifting incentives across health 
and care. 

•  Improving 

financing  arrangements: 

to 
consider  reviewing  the  extent  of  user  cost-
sharing  on  LTC  benefits  or  to  consider  pre-
funding  elements,  which  implies  setting  aside 
some funds to pay for future obligations. 

•  Support 

to  provide 
effective  home  care,  tele-care  and  information 

independent 

living: 

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to  recipients,  as  well  as  improving  home  and 
general living environment design. 

•  Supporting  family  carers:  to  further  the 
efforts  in  establishing  policies  for  supporting 
informal  carers,  such  as 
through  flexible 
working  conditions, 
respite  care,  carer’s 
allowances  replacing  lost  wages  or  covering 
expenses  incurred  due  to  caring,  cash  benefits 
paid to the care recipients,  while ensuring  that 
incentives  for  employment  of  carers  are  not 
diminished  and  women  are  not  encouraged  to 
withdraw  from  the  labour  market  for  caring 
reasons.  

•  Ensuring  availability  of 

formal  carers: 
further  the  efforts  in  determining  current  and 
future needs for qualified human resources and 
facilities  for  long-term  care,  with  a  focus  on 
ensuring their future availability. 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
to 
through  a  single  point  of  access 
as 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
the 
structures  for  care  co-ordination  and 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

centeredness, 

•  Improving  value  for  money:  to  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination,  to  encourage  competition  across 
LTC  providers 
stimulate  productivity 
enhancements. 

management 

care 

and 

to 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and  health-promotion  policies    and    identify 
risk  groups  and  detect  morbidity  patterns 
earlier. 

•  Improving administrative efficiency. 

434 

 
Table 3.20.1:  Statistical Annex – Netherlands 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

546
34.4
16.3

2.0
638.0
4.6

81.7
77.2
63.5
65.4
:
:

579
35.6
16.3

2.0
675.9
4.5

82.0
77.7
63.5
65.2
32.0
8.2

613
37.2
16.4

2.1
780.6
5.0

82.5
78.1
64.3
66.1
31.6
8.0

639
36.7
16.4

2.2
834.4
5.1

82.5
78.4
59.9
62.5
31.3
5.8

618
33.8
16.5

2.7
824.5
5.5

82.9
78.7
60.1
61.7
32.7
5.4

632
34.1
16.6

2.7
826.7
5.6

83.0
78.9
60.2
61.3
32.6
5.5

643
34.7
16.7

2.7
840.8
5.7

83.1
79.4
59.0
64.0
34.1
6.2

645
34.8
16.7

2.7
942.4
5.8

83.0
79.3
58.9
63.5
34.6
5.8

653
34.7
16.8

2.7
921.7
5.7

83.2
79.5
57.5
61.4
36.2
5.7

663
34.7
16.8

2.6
921.8
5.7

83.5
80.0
59.0
63.3
34.7
5.5

683
36.0
16.9

2.4
859.0
5.2

83.2
79.9
57.2
61.1
35.3
7.3

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
300

:
300

:
:
:

:
:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
3
5

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

123
499
3.8

:
296

196
539
4.5

3,500
303

268
580
5.1

:
297

340
621
5.8

:
289

346
632
5.9

:
288

353
645
6.0

:
260

383
544
5.5

:
252

389
552
5.6

:
240

396
561
5.7

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
2
0
.

T
h
e
N
e
t
h
e

r
l

a
n
d
s

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o
n
g

r

-
t
e
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c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
 
 
4
3
6

Table 3.20.2:  Statistical Annex - continued – Netherlands 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

17.0

1.16

6.8

3.5

3.5

2020

17.5

1.21

6.9

3.7

3.7

2030

18.4

1.41

7.7

4.4

4.7

2040

19.1

1.53

8.0

5.3

5.9

2050

19.2

1.62

8.4

5.8

6.8

2060

19.3

1.63

8.4

6.0

7.5

2070

19.6

1.64

8.4

6.0

8.3

302,600

520,886

323,061

559,734

405,482

709,656

493,287

825,104

558,504

896,694

583,530

898,625

581,921

916,233

0

4.8

71.2

100.0

0.0

92.7

7.3

185.0

8.4

:

0

5.1

72.8

100.0

0.0

92.8

7.2

183.8

8.2

:

0

6.0

79.0

100.0

0.0

93.0

7.0

187.7

8.0

:

0

6.9

86.0

100.0

0.0

93.4

6.6

191.8

8.1

:

0

7.6

89.8

100.0

0.0

93.6

6.4

187.7

8.0

:

0

7.7

90.8

100.0

0.0

93.8

6.2

185.5

8.0

:

0

7.7

91.3

100.0

0.0

93.7

6.3

188.8

8.0

:

MS Change 2016-
2070

EU Change 2016-2070

15%

42%

24%

69%

134%

92%

76%

:

59%

28%

0%

:

1%

-13%

2%

-4%

:

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
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p
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t
o
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H
e
a

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C
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a
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d
L
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d
F
i
s
c
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a
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i

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-

C
o
u
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D
o
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m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.21. POLAND 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

In  2015,  GDP  per  capita  (18,500  PPS)  in  Poland 
was  below  the  EU  level  of  29,600  PPS.  In  2016, 
the  population  was  estimated  at  38  million  and  is 
projected to decrease to 31 million until 2070.  

Health status 

In 2015, life expectancy at birth was 81.6 years for 
women  and  73.5  years  for  men,  below  the  EU 
averages (EU: 83.3 for women and 77.9 for men). 
However,  in  2015  healthy  life  years  were    at  the 
EU  average  for  women  (63.2  vs.  63.3  years),  but 
below  the  EU  average  for  men  (60.1  vs.  62.6 
years).  The  percentage  of  the  Polish  population 
having a long-standing illness or health problem is 
slightly  higher  than  in  the  EU  (35.8%  in  Poland 
versus  34.2%  in  the  EU).  The  percentage  of  the 
indicating  a  self-perceived  severe 
population 
limitation  in  its  daily  activities  stands  at  7.4%, 
which is lower than the EU average (8.1%). 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living increases significantly 
over  the  coming  50  years.  From  2.55  million 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  30%  is 
envisaged  until  2070  to  more  than  3.3  million. 
This  applies  to  the  "AWG  reference  scenario"  of 
the  2018  Ageing  Report,  which  assumes  that  half 
of the projected gains in life  expectancy are spent 
without disability That is a steeper increase than in 
the  EU  as  a  whole  (25%).  Also  as  a  share  of  the 
population,  the  dependents  are  becoming  a  bigger 
group  and  an  increase  of  60%  is  projected  (from 
6.7%  to  10.7%).  This  is  considerably  above  the 
EU-average increase of 21%. 

Expenditure 
sustainability  

projections 

and 

fiscal 

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
"AWG  reference  scenario",  public  long-term  care 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 

in 

is a projected increase in spending of about 0.8 pps 
of  GDP  by  2070  (553).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 1.6 pps of GDP 
by 2070. This reflects that coverage and unit costs 
of care are comparatively low in Poland, and may 
experience  an  upward  trend  in  future,  driven  by 
demand side factors. 

There  are  no  short-term  fiscal  sustainability  risks 
and the medium-term risks are low. Over the long 
run,  however  Poland  does  face  medium  risks  to 
fiscal sustainability. These risks are largely due to 
an unfavourable initial budgetary position, but also 
to the necessity to meet future increases in ageing 
costs (notably healthcare and long-term care) ( 554).  

System Characteristics  

There  is  no  explicit  and  separate  LTC  insurance 
scheme 
is  very 
in  Poland.  Long-term  care 
fragmented  and  governed  by  several  laws  relating 
to healthcare, social care, family benefits (nursing 
benefits  and  nursing  allowance),  pensions  and 
rehabilitation. The coverage by formal LTC is low, 
and  traditionally,  LTC  in  Poland  is  provided  by 
family members at home. LTC is financed by both 
the  public  and  private  stakeholders.  There  are  co-
payments  on  formal  care,  and  the  large  provision 
of care is delivered informally by family members, 
and as such are privately financed.  

Polish  legislation  includes  two  kinds  of  separate 
LTC  benefits:  cash  benefits  and  in-kind  benefits. 
Institutional  care  in  Poland  is  split  between  the 
health  sector  (financed  by  the  National  Health 
Fund)  and  social  assistance  sector  (financed 
indirectly  by  the  Ministry  of  Family,  Labour  and 
Social  Policy).  The  range  of  health  benefits 
available to a patient in need of care is contained in 
the provisions of the regulation of the Ministry of 
Health  on  the  guaranteed  benefits  (under  the 
general  health  insurance),  which  determines  the 

(553) The 

2018 

Ageing 

Report, 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

(554) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

437 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

list and the terms of the guaranteed benefits of the 
above range. 

assistance  house",  care  and  treatment  facilities, 
nursing and care facilities.  

Total  public  spending  on  LTC (555)  reached  0.5% 
of GDP in 2016 in Poland, well below the average 
EU  level  of  1.2%  of  GDP.  Nearly  70%  of  the 
benefits  were  in-kind,  while  30%  were  cash 
benefits in 2016 (EU: 84% vs. 16%). Thus, Poland 
seems  to  have  above  average  usage  of  cash 
benefits.  

In the EU, 50% of dependents are receiving formal 
in-kind  LTC  services  or  cash-benefits  for  LTC. 
This  share  is  with  73.5%  higher  in  Poland. 
However,  overall  only  8.2%  of  these  dependents 
receive  formal  in-kind  LTC  services,  while  the 
remainder  91.8%  receive  a  relatively  low  amount 
of  cash  benefits.  Overall,  4.9%  of  the  population 
(aged 15+) receive formal LTC in-kind and/or cash 
benefits (EU: 4.6%). On the one hand, low shares 
of  coverage  may  indicate  a  situation  of  under-
provision  of  LTC  services.  On  the  other  hand, 
higher  coverage  rates  may  imply  an  increased 
fiscal  pressure  on  government  budgets,  possibly 
calling for greater needs of policy reform. 

The expenditure for institutional (in-kind) services 
makes  up  82.1%  of  public  in-kind  expenditure 
(EU: 66.3%), 17.9% being spent for LTC services 
provided  at  home  (EU:  33.7%).  Thus,  relative  to 
other  Member  States  Poland  has  a  focus  on 
institutional  care  (within  formal  care),  which  may 
not  be  surprising  regarding  the  fact  that  overall 
little formal care is provided. 

Types of care 

in-kind  benefits  are 
Both  cash  benefits  and 
available. Cash benefits include, apart from social 
assistance  benefits  which  may  also  be  awarded  to 
persons  in  need  of  long-term  care  in  difficult 
situations:  medical  care  supplement  and  medical 
care  allowance.  Three  types  of  care  are  provided: 
home  care,  semi-residential  care  and  residential 
care.  Home  care  includes  in-kind  nursing  and 
social  services  as  well  as  cash  benefits.  Semi-
residential care is provided in day care and support 
centres. Residential care is provided via the "social 

(555) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

438 

user 
Eligibility 
dependency, care needs, income 

criteria 

and 

choices: 

In  the  health  sector  eligibility  is  defined  by 
severity of needs measured on a “Barthel scale” of 
disability.  In  the  social  assistance  sector,  and 
according  to  the  Act  on  social  assistance,  the 
provided care services are granted on the basic of a 
special individual needs evaluation (including age, 
level  of  illness  or  disability).  If  the  recipient  of 
care  requires  all  day  care,  which  cannot  be 
provided at home, then that person is entitled to a 
place  in  the  social  assistance  house.  The  income 
situation  of  the  patient,  however,  is  taken  into 
account to determine the payment for care services 
and  charge  for  staying  in  the  social  assistance 
house.  The  eligibility  for  other  in-kind  benefits 
which  are  provided  within  the  social  assistance  is 
defined by an income-test. Nursing care for people 
treated in residential homes is provided as a part of 
general  costs  of  stay.  There  are  co-payments  for 
this  kind  of  services,  residents  cover  70%  of  the 
accommodation  costs,  except  for  people  with  the 
lowest  income  (in  this  case  co-payment  is  shared 
with the municipality).  

Persons  requiring  long-term  care  are  also  entitled 
to long-term care in home settings and institutional 
long  term  care.  The  Ministry  of  Health  regulates 
access  to  guaranteed  benefits  in  this  field.  In 
accordance  with the regulations, a patient,  who in 
the "Barthel scale" received 40 points or less, shall 
be  awarded  general  health  services  within  the 
institutional  or  home-based 
term  care. 
Patients  cared  for  in  institutional  settings  are 
financed  by 
the  National  Health  Fund.  For 
institutional care there is also co-payment in place, 
with  the  patients'  coverage  of  the  accommodation 
costs set at 70%. 

long 

A nursing allowance is given to entitled recipients 
as  a  supplement  to  an  old-age,  disability  or 
survivors' pension at the age of 75 or more, as well 
as  to  recipients  of  any  age  entitled  to  an  old-age, 
disability  or  survivors'  pension  being  incapable  to 
do  paid  work  and  requiring  assistance  in  daily 
in-kind  benefits  require  a  co-
activities.  All 
payment by the patient. A medical care allowance 
is given to recipients  fulfilling specific  health and 
age  criteria,  independent  of  family  income.  These 

 
                                                           
are  children  up  to  the  age  of  16  requiring 
permanent  assistance  from  another  person  and 
children  older  than  16  years  with  a  moderate 
degree (level) of disability that began at the age of 
entitlement  to  the  family  allowance,  or  disabled 
persons  with  severe  degree  (level)  of  disability, 
without age criteria, and persons aged 75 or more. 

Recently 
reforms 

legislated  and/or  planned  policy 

in 

to 

referred 

Since  2012,  there  have  not  been  any  significant 
the  field  of  LTC  within  social 
reforms 
assistance.  Minor  changes 
the 
standardisation  of  certain  services,  which  regulate 
rehabilitation  activities  and  others.  However, 
income criteria were verified in 2018 (verification 
is done every three years) as well as the amount of 
cash  benefits  from  social  assistance.  As  a  result, 
increased  income  criteria  were  established:  for  a 
single  person  –  701  PLN  (increase  by  67  PLN; 
10.5%  in  comparison  to  the  previous  criteria 
established in 2015); for one person in a family  – 
528  PLN  (increase  by  14  PLN;  2.7%).  The 
regulation  came  into  force  on  July  11,  2018. 
Income criteria form the basis of social assistance 
benefits,  the  amount  of  payment  for  care  services 
and payment for staying in residential care homes.  

Planned reforms in the field of LTC include among  
others  the  further  standardisation  of  services, 
support  for  the  development  of  services  and  the 
creation  of  daily  care  residential  homes  for  the 
elderly  and  dependent  in  local  environments, 
reconstruction  of 
institutional  care  buildings, 
including  modifying  the  method  of  payment  for 
staying in residential care homes. In 2017, 130,300 
persons  benefited  from  social  assistance  benefits, 
whereas  the  number  of  people  benefiting  from 
residential care homes equalled 109,200. 

Moreover,  several  government  resolutions  were 
passed in the 2013-2015 period related to "elderly 
people policy". Among others, these include:  

on 

The  Cabinet  Resolution  No  237  from  December 
2013 
establishing  The  Governmental 
Programme  for  Social  Activity  of  Elderly  People 
in 2014-2020: the aim of the Programme for Social 
(The  ASOS 
Activity 
Programme) is to improve the quality and level of 
living  of  elderly  people  to  allow  ageing  with 
dignity  through  social  activity.  It  is  planned  that 

of  Elderly  People 

Long-term care systems 

3.21. Poland 

the  State  budget  will  spend  280  mln  PLN  (appx. 
€65.4  mln)  in  total  on  this  Programme  during  the 
2014-2020 period. 

The  Cabinet  Resolution  No  238  from  December 
2013  on  accepting  the  Assumptions  of  the  Long-
Term  Elderly  People  Policy  in  Poland  in  2014-
2020: this resolution fulfils the commitment stated 
in 
the  Governmental  Programme  for  Social 
Activity  of  Elderly  People  in  2012-2013  (The 
ASOS Programme). The ASOS Programme is the 
first  nation-wide  programme  prepared  on  such  a 
large  scale,  designed  for  elderly  people  and  cross 
generational  cooperation.   A  draft  document  on 
"Social  policy  towards  the  elderly  people  2030: 
safety,  participation,  solidarity"  was  presented  in 
September  2018.  It  constitutes  an  element  of  the 
Strategy  for  Responsible  Development  and  will 
replace  the  above  mentioned  resolution  of  the 
Council of Ministers. 

The  Cabinet  Resolution  No  34  from  March  2015 
on  establishing  a  multi-year  programme  “Senior-
WIGOR”  in  2015-2020:  the  strategic  aim  of  the 
programme  is  supporting  elderly  people  through 
subsidising  the  activities  of  the  local  government 
units  intended  to  develop  networks  of  Day  Care 
Centres  “Senior-WIGOR”.  Special  focus  of  the 
programme  is  on  local  government  units  which 
have low income or high share of elderly people in 
the  total  population  or  have  no  infrastructure  of 
social  services  for  providing  care  services  for  the 
elderly  outside  their  home.  In  2016,  the  name  of 
the  programme  and  the  networks  were  changed 
from  "Senior-WIGOR"  to  "Senior  +",  the  total 
amount  for  the  period  2015-2020  allocated  from 
the  budget  to  this  programme  was  changed  from 
370 million PLN to 340 million PLN.  

Challenges 

Poland has a relatively fragmented system of LTC, 
with  low  coverage  and  a  large  provision  of 
informal  care  that  is  privately  financed.  The  main 
challenges of the system appear to be: 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of  responsibilities  of  state  authorities  with 
respect  to  the  provision  of  long-term  care 
services; to set the public and private financing 
mix  and  organise  formal  workforce  supply  to 

439 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health and long-term care: to steer LTC users 
towards appropriate settings. 

•  Improving value for money: to invest in ICT 
as  an  important  source  of  information,  care 
management and coordination. 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and  identify risk 
groups and detect morbidity patterns earlier. 

face  the  growing  number  of  dependents,  and 
provide  a  strategy  to  deliver  high-performing 
long-term  care  services  to  face  the  growing 
demand  for  LTC  services;  to  strategically 
integrate medical and social services via such a 
legal  framework;  to  define  a  comprehensive 
approach  covering  both  policies  for  informal 
(family and friends) carers, and policies on the 
formal  provision  of  LTC  services  and  its 
financing; 
information 
to  establish  good 
platforms for LTC users and providers; to share 
data  within  government  administrations 
to 
potential 
the  management 
facilitate 
interactions  between  LTC  financing,  targeted 
personal-income  tax  measures  and  transfers 
(e.g.  pensions),  and  existing  social-assistance 
or  housing  subsidy  programmes;  to  deal  with 
cost-shifting incentives across health and care. 

of 

earned 

•  Improving  financing  arrangements:  to  face 
the  increased  LTC  costs  in  the  future  e.g.  by 
tax-broadening, which means financing beyond 
revenues 
the  working-age 
by 
population;  to  foster  pre-funding  elements, 
which  implies  setting  aside  some  funds  to  pay 
for  future  obligations;  to  explore  the  potential 
of  private  LTC  insurance  as  a  supplementary 
financing tool. 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage; the depth of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits;  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage; to reduce the risk of 
impoverishment  of  recipients  and  informal 
carers. 

care: 

home 

•  Encouraging 
alternatives 
developing 
encouraging  home 
controlling admissions to institutional care. 

develop 
institutional  care  by  e.g. 
frameworks 
regulation 

to 
new 

legislative 

care 

and 

to 

•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

440 

 
 
Table 3.21.1:  Statistical Annex – Poland 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

246
13.7
38.2

0.4
:
0.8

79.3
70.8
66.9
61.2
:
:

275
14.2
38.2

0.4
:
0.8

79.7
70.9
62.9
58.4
32.6
6.3

314
15.2
38.1

0.4
:
0.8

79.8
71.0
61.5
57.6
32.1
6.9

366
15.3
38.1

0.4
:
0.8

80.0
71.3
63.0
58.6
30.9
6.6

317
14.8
38.1

0.4
:
0.8

80.1
71.5
62.5
58.3
32.8
7.4

362
15.9
38.0

0.4
:
0.8

80.7
72.2
62.3
58.5
33.6
7.9

380
16.5
38.1

0.4
:
0.9

81.1
72.5
63.3
59.1
34.1
7.3

389
16.8
38.1

0.4
:
1.0

81.1
72.6
62.8
59.1
34.5
7.5

395
16.9
38.1

0.4
69.8
0.8

81.2
73.0
62.7
59.2
34.1
8.1

411
17.5
38.0

0.3
70.1
0.8

81.7
73.7
62.7
59.8
34.0
7.6

430
18.5
38.0

0.4
78.3
0.9

81.6
73.5
63.2
60.1
35.8
7.4

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

1,214
:

:
:
:

:
:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
4
1

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

46
5
0.1

:
:

73
18
0.2

:
:

100
32
0.3

:
:

127
45
0.5

:
:

130
46
0.5

:
:

133
46
0.5

:
:

86
118
0.5

:
:

88
121
0.5

:
:

90
123
0.6

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
2
1
.

l

P
o
a
n
d

L
o
n
g

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4
4
2

Table 3.21.2:  Statistical Annex - continued – Poland 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

38.0

2.55

6.7

0.5

0.5

2020

37.9

2.65

7.0

0.5

0.5

2030

37.2

2.95

7.9

0.7

0.7

2040

35.8

3.23

9.0

0.9

1.0

2050

34.3

3.26

9.5

1.0

1.3

2060

32.8

3.32

10.1

1.2

1.6

2070

30.9

3.30

10.7

1.3

2.1

86,288

121,737

93,727

131,992

112,806

159,198

138,530

194,922

150,476

212,348

159,361

225,719

172,431

244,929

1,665,190

1,760,265

2,015,419

2,346,351

2,505,151

2,607,693

2,799,789

4.9

73.5

56.0

44.0

82.1

17.9

100.3

15.5

5.0

5.2

74.9

56.7

43.3

82.4

17.6

100.4

15.3

5.0

6.2

77.6

59.2

40.8

82.8

17.2

108.1

15.9

5.0

7.5

83.1

63.4

36.6

83.6

16.4

117.9

16.4

4.8

8.4

88.1

66.2

33.8

83.7

16.3

127.7

17.6

4.7

9.1

90.2

67.9

32.1

83.9

16.1

135.5

18.4

4.7

10.4

97.4

69.8

30.2

84.3

15.7

139.1

18.2

4.4

MS Change 2016-
2070

EU Change 2016-
2070

-19%

30%

60%

166%

330%

100%

101%

68%

111%

32%

25%

-31%

3%

-12%

39%

18%

-12%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.22. PORTUGAL 

General  context  of  long-term  care  system: 
Expenditure, fiscal sustainability 

In  2015,  Portugal’s  GDP  was  around  €180  bn  or 
21,400 PPS per capita, below the EU average GDP 
per  capita  of  €29,600. The  population  of  Portugal 
is estimated to be around 10 million inhabitants in 
2016.  Over  the  coming  decades  it  is  projected  to 
fall gradually to 8.0 by 2070. This decrease of 23% 
contrasts with the expected increase of 2% for the 
EU as a whole. 

Health status 

the  EU-average 

Life expectancy at birth for men and women was, 
in  2015,  respectively  78.1  years  and  84.3  years, 
close  to  the  EU  average  (77.9  and  83.3  years 
respectively). In 2015 the healthy life years at birth 
were  55  years  (women)  and  58.2  years  (men) 
below 
62.6 
respectively).  At the same  time, the percentage of 
the  Portuguese  population  having  a  long-standing 
illness  or  health  problem  is  higher  than  in  the 
Union  as  a  whole  (42.7%  and  34.1%  respectively 
the  population 
in  2015).  The  percentage  of 
indicating  a  self-perceived  severe  limitation  in  its 
daily  activities  was  in  2015  9.4%,  far  above  the 
EU-average (8.1%). 

(63.3 

and 

Dependency trends 

The  share  of  dependents  in  Portugal  is  set  to 
increase  from  8.3%  in  2016  to  11.5%  of  the  total 
population  in  2070,  an  increase  of  38%.  This  is 
well above the EU-average  increase of21%. From 
0.86  million 
strong 
limitations  due  to  health  problems  in  2016,  an 
increase  of  7%  is  envisaged  until  2070  to  0.92 
million.  

living  with 

residents 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on  long-term  care  (LTC)  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
long-term 
"AWG  reference  scenario",  public 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 0.9 pps 

in 

of  GDP  by  2070  (556).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 2.6 pps of GDP 
by 2070.  

Portugal faces low fiscal sustainability risks in the 
short  run.  Nonetheless,  there  are  some  indications 
that the fiscal side of the economy poses potential 
short-term challenges. 

Risks  appear,  on  the  contrary,  to  be  high  in  the 
medium  term  from  a  debt  sustainability  analysis 
perspective due to the still high stock of debt at the 
end  of  projections  (2028).  In  contrast,  in  the  long 
term,  Portugal  appears  to  face  medium  fiscal 
sustainability risks ( 557).  

System Characteristics (558) 

is  provided 

long-term  care 

Public 
through 
residential structures for elderly (ERPI - Estrutura 
Residencial  para  Pessoas  Idosas)  and  Long-term 
Care National Network (RNCCI - “Rede Nacional 
de Cuidados Continuados Integrados”).  

accommodation 

The  ERPI  were  designed  to  provide  temporary  or 
permanent 
at 
retirement  age,  without  autonomy  and  without 
need  of  continuous  access  to  nursing  and  medical 
care,  therefore  promoting  a  healthy  ageing  and 
higher quality of life. 

persons 

for 

The  ERPI  is  managed  by  the  Ministry  of  Labour, 
Solidarity  and  Social  Security  and  is  financed  by 
budget  transfers  and  a  monthly  user  co-payment 
determined  by  a  percentage  of  the  per  capita 
household income, variable between 75% to 90%, 
according to the user dependency degree. 

following 

The 
table  shows 
agreements and users of ERPI in December 2017: 

the  number  of 

(556) The  2018  Ageing  Report                                      : 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf . 

(557) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(558) This section draws on OECD (2011b) and ASISP (2014). 

443 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Table 2.22.1:  Number of agreements and users by degree 

of dependency 

No. total of agreem ents

No. total of users

No. agreements f or users w ith 2nd degree of  dependency

No. users w ith 2nd degree of  dependency identif ied on 
agreements f or users w ith 2nd degree of  dependency
No. agreements exclusively f or users w ith 2nd degree of  
depnedency (1 agreement f or Alzheimer's patients)f or 
users w ith 2nd degree of  dependency

No. users of  agreements exclusively f or users w ith 2nd 
degree of  dependency (the agreements f or Azheimer's 
patients is f or 30 users)

No. agreements w ith positive discrimination and 
consequently w ith a higher f unding

of  w hich:

f or users w ith dependency of  20%

f or users w ith dependency betw een 21% and 40%

f or users w ith dependency betw een 41% and 60%

f or users w ith dependency betw een 61% and 80%

f or users w ith dependency higher than 80%

No. positive discrimination users identif ied on agreements 
f or users w ith positive discrimination

of  w hich:

f or users w ith dependency of  20%

f or users w ith dependency betw een 21% and 40%

f or users w ith dependency betw een 41% and 60%

f or users w ith dependency betw een 61% and 80%

f or users w ith dependency higher than 80%

1623

59151

713

3486

40

1573

23

6

3

4

6

4

817

208

155

98

223

133

Source: Portugal Ministry of Labour, Solidarity and Social 
Security.  

The  Long-term  Care  National  Network  (RNCCI  - 
“Rede  Nacional  de  Cuidados  Continuados 
Integrados”) was established in 2007. Its aim is to 
provide post-acute health care and social assistance 
for persons who are dependent (whether this is due 
to  age  and/or  illness)  who  are  referred  to  it  by 
hospitals as well as health primary care units. It is 
under  the  coordinated  jointly  by  the  Ministries  of 
Health and of Social Solidarity. 

Since the beginning of RNCCI, monitoring reports 
are published twice a year including analysis of its 
structure,  processes  and  outcomes.  This  is  based 
on  a  mandatory  minimal  data  set  for  all  levels  of 
the system.  

Public  spending  on  LTC  ( 559)  reached  0.5%  of 
GDP  in  2016  in  Portugal,  below  the  average  EU 
level of 1.6% of GDP. 99.8% of the benefits were 
in-kind,  while  0.2%  were  cash-benefits  (EU:  84.4 
vs 15.6%).  

In the EU, 50% of dependents are receiving formal 
in-kind  LTC  services  or  cash-benefits  for  LTC. 

(559) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care 
(relating primarily to assistance with IADL tasks). 

444 

This  share  is  with  38.6%  lower  in  Portugal. 
Overall, 3.2% of the population (aged 15+) receive 
formal  LTC  in-kind  and/or  cash  benefits  (EU: 
4.6%).  On  the  one  hand,  low  shares  of  coverage 
may indicate a situation of under-provision of LTC 
services. On the other hand, higher coverage rates 
may 
increased  fiscal  pressure  on 
government  budgets,  possibly  calling  for  greater 
needs of policy reform. 

imply  an 

The expenditure for institutional (in-kind) services 
makes  up  13.4%  of  public  in-kind  expenditure 
(EU: 66.3%), 86.6% being spent for LTC services 
provided at home (EU: 33.7%).  

Administrative organisation 

As  explained  above,  from  2007  onwards,  the 
provision of both long-term health care and social 
assistance  to  dependent  persons  made  vulnerable 
by  age  and/or  disease  has  been  fostered  by  the 
RNCCI  and  coordinated  by  Ministries  of  Health 
and of Labour, Solidarity and Social Security. 

The RNCCI is responsible for monitoring both the 
health care provided by units within the network as 
well  as  the  quality  of  their  organisation.  It  has 
defined  standards  and  measures  of  quality  and 
audits them on a regular basis, in parallel with the 
assessment and review of recipient satisfaction and 
claims.  Units  and  teams  in  the  network  are 
periodically  evaluated  by  regional  coordination 
teams.  The  RNCCI  employs  more  than  3,000 
professionals,  coached  through  a  comprehensive 
the 
training  plan.  The  five  regions, 
Regional  Coordinating  Teams 
in 
conjunction  with  the  Local  Coordination  Teams 
(ECL),  have  the  skills  to  ensure  the  criteria 
application  relating  to  the  referral  of  users  to  the 
Long  Term  Care  National  Network  (RNCCI) 
circuit, 
continuous  monitoring  of 
its 
providers 
structure,  process  and  results,  to  consolidate  good 
practices,  obtain  autonomy  gains  and  guarantee 
continuity  of  care  beyond  the  permanence  in  the 
network, sharing information with other health and 
social services and discharge support.  

improve  aspects  related 

through 
(ECR) 

ensuring 

to 

to 

In complying with the "Strategy for Quality" set by 
RNCCI,  some  actions  have  been  progressively 
implemented in order to improve the system. Thus, 
it  is  important  to  have  periodic  monitoring  visits 
conducted  by  the  ECL  provision  units,  in  which 

 
 
 
 
                                                           
Long-term care systems 

3.22. Portugal 

invest 

in  some 

training  areas, 

entity who delayed the implementation of training 
for subsequent  years. On the  other hand, the  need 
to 
including 
coordination  and  functioning  of  the  network, 
decreased,  due  to  the  network  consolidation  and 
also  due  to  financial  restrains  and  limitations  in 
human  resources  influence  the  dynamics  of  the 
courses. 

in 

Training  carried  out  the  following  themes,  among 
others: Skills and strategies in the development of 
RNCCI;  Work  Methodologies 
LTC; 
Organisation  and  operation  of  the  RNCCI  units/ 
teams;  Bioethics;  Training  professionals 
in 
inpatient  reference  units;  Implementation  of  the 
Status  of  Resources  Law  in  RNCCI;  Continuous 
Improvement  in  LTC;  Quality  evaluation  and 
auditing;  Dementia 
in  LTC;  Assessment  and 
intervention  in  situations  of  elderly  violence  and 
mistreatment;  Palliative  Care:  Basic  course  of 
Palliative  Care,  Intervention  in  Grief  and  Loss; 
Respect  for  Human  Dignity  in  RNCCI;  Chronic 
Pain;  Geriatrics 
and  Gerontology;  Clinical 
Training  in  geriatric  syndromes,  treatment  of 
wounds / pressure ulcers, compression therapy and 
non-invasive 
Risk 
Management  in  LTC;  Prevention  and  Control  of 
Infection  in  LTC;  Individual  Intervention  Plan; 
Nutritional  intervention  in  LTC;  Implementation 
of  International  Classification  of  Functionality 
(ICF); Diabetes in LTC. 

ventilation; 

Clinical 

in 

the  consensual 
the  parameters,  contained 
follow-up  grids,  agreed  between 
the  Health 
Ministry  and  the  Social  Security,  are  checked. 
These  grids  are  related  with  the  definitions  of 
values,  goals  and  key  factors,  as  well  as  the 
assessment of compliance with the agreements and 
the  appropriate  use  of  the  resources  units.  It  is  a 
battery  of  measurable  items  from  which  it  is 
possible  to  develop  a  plan  of  ECL  feasible 
recommendations.  One  of  the  main  constraints 
pointed  out,  regarding  the  organisation  of  these 
teams, relates to the fact that the elements of ECL 
perform  functions  other  than  those  assigned  to 
RNCCI, both in of Health and Social Security. The 
population  covered  by  the  ECL  can  be  different 
according  to  the  different  regions.  The  ECL  are 
present  in  all  Health  Center  Groupings  (ACES) 
and  in  some  cases  they  also  exist  in  some 
extensions of these groupings. 

Considering  the  importance  that  training  plays  in 
developing the skills of professionals, RNCCI has 
developed,  since  the  beginning  of  the  network, 
several  training  events  regarding  coordination, 
monitorisation, referral and care. Thus, there were 
several training courses organised by the Regional 
Health  Authorities,  Social  Security  Institute  and 
District  Centres.  The 
training  provided,  with 
different  pedagogical  approaches,  covered  18,853 
graduates  and  totalled  10,335  hours  of  training, 
according to the following table. 

Table 2.22.2:  Number of training courses, hours and 

graduates per year 

Types of care 

Training 
courses

Training 
hours

Graduates

75

246

110

138

141

67

38

51

24

21

20

345

1752

908

1208

2238

1475

543

951

328

380

207

3312

1842

2756

2331

2404

1443

1075

1113

871

729

977

931

10,335

18,853

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Total

Source: Portugal Ministry of Health. 

The decrease in training hours since 2011 relates to 
certain  management  constraints  by  the  financing 

RNCCI offers a range of  formal care on the basis 
of  diversified  coordinated  interventions  that  take 
place in different types of RNCCI units.  

For  adults  it  provides  convalescence  care,  post-
acute  rehabilitation  services,  medium  and  long-
term care and home care. Palliative care moved to 
an autonomous network of care since 2017.  

In  2016,  Paediatric 
care  was 
implemented,  institutional  (Integrated  paediatric 
care unit Level 1- UCIP N1) and ambulatory care 
(Paediatric Ambulatory care – UAP). 

Integrated 

In 2017 began pilot-experiments of Mental Health 
inpatient  units, 
long-term  care,  consisting  of 
ambulatory  care  and  home  care.  The  different 
types  of  care  in  this  area  are  shown  in  the  table 
below. 

445 

 
 
 
 
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Table 2.22.3:  RNCCI Mental Health – Pilot-experiments 

Table 2.22.5:  Providers of institutional long-term care 

RA

RAMa

Autonomus Home (Residência Autónoma)
Home w ith maximum support (Residência de Apoio Máximo 
Adultos)

RAMo Home w ith medium support (Residência de Apoio Moderado)

RTA

RTA/A

USO

USO/IA

EAD

Home w ith developing training autonomy (Residência de Treino de 
Autonomia)
Home w ith developing training autonomy - childhood and youth 
(Residência de Treino de Autonomia - Tipo A infância e 
adolescência)

Occupational health unit (Unidade Sócio Ocupacional)
Occupational health unit - childhood and youth (Unidade Sócio 
Ocupacional - Infância e Adolescência)

Home care teams (Equipa de Apoio Domiciliário)

Source: Portugal Ministry of Health 

to 

network 

according 

operates 
split. 

a 
The 
  The  portfolio  of 
purchaser/provider 
institutional  care  services  within  RNCCI  by 
typology is shown in Table 2.22.4, where it can be 
seen  that  long  and  medium  term  care  are  largely 
the predominant types of care.  

Table 2.22.4:  Portfolio of institutional long-term care services 

end of 2018 

Type of service

Convalescence care

Adults

Medium term and Rehabilitation care

Long term and maintenance care

Integrated Pediatric Care (RNCCI-CPI)

Integrated pediatric care level 1 (UCIP N1)

Mental Health Integrated Care (RNCCI SM)

RA - Autonomous Residence

RAMa - Adults Maximum support residence

RAMo - Adults Moderate support residence

RTA - Adults Autonomy training residence

RTA-A - Pediatric Autonomy training 
residence

Total

Source: Portugal Ministry of Health. 

Number of places 
31-12-2018

935

2674

4794

10

27

48

28

19

18

8553

to  2017, 

Compared 
the  number  of  medical 
inpatients facilities grew 5%, up to a total of 8,553, 
without  palliative  care.  This  growth  is  explained 
by the increase in the type of the Convalesce Care, 
Medium  term  and  rehabilitation  care  (UMDR  – 
Unidade  Média  Duração  e  Reabilitação)  and  long 
duration and maintenance units (ULDM – Unidade 
de  Longa  Duração  e  Manutenção)  and  Mental 
Health  .  Currently  ULDM  beds  represent  56%  of 
the beds available for admission. Institutional care 
services within RNCCI are provided by a range of 
agents: non-profit organisations (75.7% of the bed 
residential  care 
supply),  private  health  and 
facilities,  SNS  public  hospitals  and  other  health 
care units as shown on Table 2.22.5. All  must act 
within  common  technical  standards  and  their 
services are subsidised by the state. 

446 

Entities

31-12-2017

31-12-2018

Variation

N.º of 
agreem ents

N.º of beds

N.º of 
agreem ents

N.º of beds Agreem ents

Beds

National Health Service (SNS)

SCM

Other

Charities (IPSS)

TOTAL IPSS

Private sector

TOTAL

7

180

90

270

60

337

190

3 985

2 186

6 171

1721

8 082

9

183

92

275

63

347

219

4 112

2267

6 379

1825

8 423

28,6%

15,3%

1,7%

2,2%

1,9%

5,0%

3,0%

3,2%

3,7%

3,4%

6,0%

4,2%

Source: Portugal Ministry of Health. 

In  2018,  the  development  of  medical  inpatient 
responses  in  RNCCI,  including  Paediatric  care 
(inpatient and ambulatory care), based on services 
hired  with Private Institutions of Social Solidarity 
(IPSS  –  Instituições  Privadas  de  Solidariedade 
Social), 
represents  79%  of  all  agreements, 
representing  the  hiring  of  6,379  vacancies  ,  about 
76%  of  supply.  Within  the  private  institutions  of 
social solidarity (IPSS), the Holy Houses of Mercy 
(SCM  -  Santas  Casas  da  Misericórdia)  represent 
53%  of  all  agreements,  with  4,112  contracted 
vacancies, representing about 49% of the total. 

The development of medical inpatient responses in 
Mental Health Integrated Care (RNCCI SM), until 
now  are  based  on  services  hired  with  Private 
Institutions  of  Social  Solidarity 
(IPSS  – 
Instituições Privadas de Solidariedade Social). 

Table 2.22.5a:  Providers of institutional long term care – 

Mental health care 

31-12-2017

31-12-2018

Variation

Entities

N.º of 
agreem ents

Vacancies

N.º of 
agreem ents

Vacancies Agreem ents Vacancies

Charities (IPSS)

TOTAL IPSS

SCM

OUTRAS

0

16

16

0

189

189

1

20

21

24

255

279

-

25%

31%

-

34,9%

47,6%

Source: Portugal Ministry of Health. 

Within  the  private  institutions  of  social  solidarity 
(IPSS), the Holy Houses of Mercy (SCM - Santas 
Casas  da  Misericórdia)  represent  5%  of  all 
agreements  on  Mental  health  care  (covering  beds, 
ambulatory  and  home  care)  and  8.6%  of  the 
vacancies (0.6% of total contracted vacancies with 
this  type  of  institution).  Other  charity  institutions 
represent  95%  of  all  agreements,  with  255 
contracted  vacancies  (beds,  ambulatory  and  home 
care)  representing  about  91.4%  of  the  total  (see 
Table 2.22.5a). 

In hospitals, specialised teams (EGA – Equipas de 
Gestão  de  Altas)  prepare  patient  discharge  by 
referral to other settings.  

 
 
 
 
 
 
 
 
 
 
Home  Long-Term  Care  Multidisciplinary  Teams 
(ECCI 
-  Equipas  de  Cuidados  Continuados 
Integrados)  provide  local  primary  health  care  and 
social  support  to  patients  not  requiring  a  stay  in 
institutions,  and  are  coordinated  by  “community 
care”  units 
(UCC  –  Unidade  de  Cuidados 
Continuados) within the local health organisations 
(ACES  -  Agrupamentos  de  Centros  de  Saúde). 
Long-term Care at home is provided by ECCI.  

Referral  routes  are  defined  at  a  central  level  in 
order  to  enable  interdisciplinary  teams  to  operate 
consistently at regional and local level in referring 
patients  in  according  to  the  capacity  of  the  local 
network  as  well  as  with 
the  personal  and 
therapeutic  profiles  of  recipients.  Most  EGA 
(86%)  were  built  in  the  pilot  phase  (2006-2007), 
being  noted  as  one  of  the  key  factors  that 
contributed  to  the  success  of  RNCCI.  Now  all 
hospitals  have  EGA.  Since  hospitals  have  been 
aggregated  in  Hospital  Centers  (CH  –  Centros 
Hospitalares)  and  Local  Health  Units  (ULS  – 
Unidades  Locais  de  Saúde),  the  number  of  EGA 
are being adjusted to this reorganisation, but exist 
in all hospitals.  

The  reform  of  primary  health  care  initiated  the 
implementation of Health Centers referring teams, 
thus constituting a benchmark circuit, and now all 
Health Centers have referring teams.  

Table 2.22.6:  Number of ECCI and vacancies in 2018 

Region

Nº ECCI

Vacancies

North

Center

Lisbon and Tagus Valley (LVT)

Alentejo

Algarve

TOTAL

Source: Portugal Ministry of Health. 

92

68

59

37

26

282

1606

727

2092

553

750

5728

The number of vacancies as shown on Table 2.22.6 
depends  on  human  resource  allocation  to  the 
ECCI.  The  total  number  of  vacancies  in  RNCCI 
(Home  Care,  and  inpatient  units  related  to  adults) 
at the end of 2018 were 14,131 (without Palliative 
care), 
representing  729  places  per  100.000 
inhabitants  with  equal  or  more  than  65  years, 
shown in table. 

Long-term care systems 

3.22. Portugal 

Table 2.22.7:  Total number of vacancies in Adults RNCCI 

(Home Care and inpatient units) end of 2018  

Region

Inhabitants 
aged ≥ 65 
years

Nº Beds 

N.º 
Beds/100.000 
Inhabitants 
aged ≥ 65 
years

Nº Vacancies 
Hom e Care

Nº Vacancies 
Hom e Care/ 
100.000 
Inhabitants 
aged ≥ 65 
years

Total 
Vacancies

Total 
Vacancies/10^6 
Inhabitants 
aged ≥ 65 
years

North

Center

631 439

393 338

Lisbon and Tagus Valley (LVT)

696 815

Alentejo

Algarve

128 427

87 769

2 635

2 321

2 114

804

529

TOTAL

1 937 788

8 403

417

590

303

626

603

434

1 606

727

2 092

553

750

5 728

254

185

300

431

855

296

4 241

3 048

4 206

1 357

1 279

14 131

672

775

604

1 057

1 457

729

Source: Portugal Ministry of Health. 

The  total  places  of  home  care,  ambulatory  and 
inpatient  units,  in  the  three  areas  of  RNCCI  – 
adults,  Integrated  Paediatric  care  and  Mental 
Health  integrated  care  was  14,430.  "Home  Long 
Term Care Multidisciplinary Teams" were created 
in 2009, through the reform of primary health care. 
These teams depend directly from ACES.  

Eligibility  criteria:  dependency,  care  needs, 
income 

Long-term  benefits  are  means-tested.  Although 
there  is  an  assessment  of  need,  there  is  no 
minimum dependency criterion above which long-
term care is provided.  

Co-payments, out of the pocket expenses and 
private insurance 

is 

by 

determined 

The  financial  responsibilities  of  the  public  sector 
are shared between the Ministry of Health and the 
Ministry of Labour, Solidarity and Social Security. 
The  cost-sharing  required  by  the  Long-term  Care 
the 
National  Network 
government  (Decree  Law  No.  101/2006,  6  June 
2006,  Article  12)  and  co-financed  by  both  the 
health  and  social  security  sectors  (Portaria  No. 
994/2006,  19  September  2006)  according  to  the 
type  of  service.  Thus,  the  Ministry  of  Health 
finances  the  costs  of  health  care  provision,  while 
care  recipients  make  co-payments  for  the  social 
care  received.  The  care  recipient  will  have  to 
to 
contribute  a  co-payment  according 
the 
individual’s  or  his/her  family’s 
income  (see 
Despacho Normativo No. 34/2007, which specifies 
the  conditions  for  which  social  security  will  pay 
and the amount). 

From  the  beginning,  the  RNCCI  is  the  first 
response with full implementation of the financing 
model  based  on  family  differentiation  by  social 
security.  The  family  differentiation  financing, 
which involves the attribution of a contribution to 

447 

 
 
 
 
 
 
 
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Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

the  user  depending  on 
the 
household,  has  allowed  greater  equity  and  social 
fairness.  

income  of 

the 

In  2018,  the  amount  per  day  defined  as  the  cost 
with  social  support  for  care  of  medium  duration 
and  rehabilitation  units  (UMDR  –  Unidade  de 
Média Duração e Reabilitação) was EUR19.93 and 
for  the  long  duration  and  maintenance  units 
(ULDM  –  Unidade  de  Longa  Duração  e 
Manutenção)  was  EUR30.52.  Monitoring  and 
follow-up  made  showed  that  on  average,  in  2017, 
the  contribution  of  social  security  was  EUR10.79 
per day of hospitalisation by patient in UMDR and 
EUR15.41  in  ULDM,  i.e.  54.47  %  and  50.79%, 
respectively,  of  the  cost  was  paid  by  social 
security( 560). 

Prevention 
policies/measures 

and 

rehabilitation 

Prevention and rehabilitation are performed by the 
health care system. 

Recently 
reforms  

legislated  and/or  planned  policy 

Implementation of a contracting process 

in 

levels 

A  working  group  was  created  (Ministerial  Order 
No. 1981/2014 of 7 February) with the purpose of 
presenting a national strategy which contributes to 
the 
the  achievement  of  excellence 
response  that  is  given  to  users.  This  strategy 
should  encourage  the  adoption  of  procedures  that 
contribute  to  improved  levels  of  quality  of  care 
provide  and  to  foster  a  culture  of  commitment, 
responsibility  and  assessment  of  results  in  the 
RNCCI.  The 
implementation  of  contracting 
processes  with the  LTC providers should allow to 
match the adequacy of care to the needs of people 
who are dependent and to foster the consolidation 
of  the  RNCCI,  based  on  an  expansion  and 
sustainable  development  in  financial  terms  and 
also consistent with its mission. 

The working group presented a proposal with a set 
of  measures  on 
the 
contracting  process  with 
the  RNCCI  LTC 
providers; study the different methods of payment 
applied  to  LTC;  propose  initiatives  that  promote 

implementation  of 

the 

(560) ISS, IP data. 

448 

improved  quality  of  care  in  RNCCI  and  enhance 
the gains for users, and; promote the participation 
of various actors. 

Strengthening the outpatient component 

is  commitment 

to  push  forward 

There 
the 
outpatient  component  of  RNCCI  through  the 
implementation  of  "Day  and  Promotion  of 
Autonomy Units" (UDPA  -  Unidades de Dia e de 
Promoção  da  Autonomia)  and  strengthen  of 
"Home Long Term Care Multidisciplinary Teams" 
(ECCI),  making  them  effective,  as  opposed  to 
institutionalisation  of  patients  as  recommended 
internationally. Therefore, it is planned to return to 
the underlying intervention principles of the ECCI 
creation, i.e. focusing on the integration dimension 
/ joint health and social support, which will enable 
complementarity  with  a  more  effective  impatient 
response  as  the  already  existing  ones,  namely 
UMDR  and  ULDM,  as  well  as  promoting  higher 
mobility  of  users 
the  case  of  discharge 
in 
preparations, and ensuring continuity of care. 

Regarding  UDPA,  these  units  may  contribute  to 
maintaining  at  home  and  at 
their  usual 
environment  people  who  are  currently  referred  to 
other types of network. These units can also have a 
quality response to the needs of the population, if 
they  are  directed  towards  to  a  more  specialised 
support in the area of dementia. This is an issue of 
proximity,  so  its  implementation  should  be  based 
on knowledge of the territory, accessibility, issues 
of  economic  and  preferences  of  patients  and 
family. 

Quality and continuous improvement 

the 

specific 

techniques, 

that  ensures 

On  the  one  hand,  a  national  project  to  encourage 
quality, 
regional 
characteristics, is useful, using common indicators 
and  methodologies as a way  that  will increase the 
understanding  of  the  reality  of  LTC,  introducing 
benchmarking 
developing 
measures  of  continuous 
improvement,  among 
the  other  hand,  evaluation  and 
others.  On 
monitoring  of  quality  parameters  is  useful  as  it 
provides information to users and family, allowing 
putting  into  practice  the  principle  of  preference 
and also the informed choice principle, as  well as 
the development of strategies concerning the rights 
of long term care users. 

and 

 
                                                           
Long-term care systems 

3.22. Portugal 

Challenges 

The main challenges of the system appear to be:  

define 

•  Improving  the  governance  framework:  To 
establish  a  coherent  and  integrated  legal  and 
governance 
a 
framework;  To 
comprehensive approach covering both policies 
for  informal  (family  and  friends)  carers,  and 
policies  on  the  formal  provision  of  RNCCI 
services  and  its  financing;  To  establish  good 
information  platforms;  To  use  care  planning 
individualised  need 
processes,  based  on 
assessments, 
care 
involving  health 
providers  and  linking  need  assessment  to 
resource  allocation;  To  share  data  between 
improve 
government 
administrative  efficiency;  To  deal  with  cost-
shifting incentives across health and care. 

administrations;  To 

and 

earned 

•  Improving  financing  arrangements:  To  face 
the increased RNCCI costs in the future e.g. by 
tax-broadening, which means financing beyond 
revenues 
the  working-age 
by 
population;  To  foster  pre-funding  elements, 
which  implies  setting  aside  some  funds  to  pay 
for future obligations; To explore the potential 
of 
a 
supplementary financing tool; To determine the 
extent of user cost-sharing on RNCCI benefits.  

private  RNCCI 

insurance 

as 

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  RNCCI 
the  need-level 
coverage  schemes,  setting 
triggering  entitlement  to  coverage;  the  breadth 
of  coverage,  that  is,  setting  the  extent  of  user 
cost-sharing on RNCCI benefits; and the depth 
of  coverage,  that  is,  setting  the  types  of 
services included into the coverage; To reduce 
the  risk  of  impoverishment  of  recipients  and 
informal carers. 

•  Further  encouraging  independent  living:  To 
continue  providing  effective  home  care,  tele-
care  and  information  to  recipients,  as  well  as 
living 
home 
improving 
environment design. 

general 

and 

•  Ensuring  availability  of  formal  carers:  To 
for 
determine  current  and 
qualified  human  resources  and  facilities  for 
long-term care; To seek options to increase the 
productivity of LTC workers. 

future  needs 

•  Supporting 

family  carers:  To  establish 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

services  and 

•  Ensuring  coordination  and  continuity  of 
care:  Establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum;  To 
facilitate  appropriate  utilisation  across  health 
and  long-term  care;  To  arrange  for  adequate 
support  outside 
supply  of 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  RNCCI;  To  create  better  rules, 
improving  (and  securing)  safe  care  pathways 
and  information  delivered  to  chronically-ill 
people  or  circulated  through  the  system;  To 
steer  RNCCI  users 
towards  appropriate 
settings. 

•  Changing payment incentives for providers: 
To  consider  fee-for-service  to  pay  RNCCI 
workers  in  home-care  settings  and  capitation 
payments;  To  consider  a  focused  use  of 
budgets  negotiated  ex-ante  or  based  on  a  pre-
fixed share of high-need users.  

•  Improving  value  for  money:  To  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; To 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people  with  chronic  care;  To  employ 
prevention  and  health-promotion  policies  and 
identify  risk  groups  and  detect  morbidity 
patterns earlier. 

449 

 
4
5
0

Table 3.22.1:  Statistical Annex – Portugal 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

159
21.3
10.5

0.1
11.4
0.1

81.5
74.9
57.1
58.6
:
:

166
21.8
10.5

0.1
12.5
0.1

82.5
75.5
57.9
60.0
30.9
11.6

175
21.9
10.5

0.1
14.0
0.2

82.5
75.9
57.9
58.5
33.2
12.9

179
21.4
10.6

0.1
18.2
0.2

82.7
76.2
57.6
59.2
33.3
12.0

175
20.3
10.6

0.1
21.7
0.2

82.8
76.5
56.4
58.3
34.1
10.9

180
20.9
10.6

0.1
24.4
0.2

83.2
76.8
56.7
59.3
33.9
9.4

176
20.3
10.6

0.1
27.7
0.3

83.8
77.3
58.6
60.7
34.7
9.3

168
20.1
10.5

0.2
31.1
0.3

83.6
77.3
62.6
64.5
37.1
9.0

170
20.2
10.5

0.2
32.2
0.3

84.0
77.6
62.2
63.9
39.8
9.3

173
20.7
10.4

0.2
35.1
0.3

84.4
78.0
55.4
58.3
40.4
9.2

180
21.4
10.4

0.2
36.9
0.4

84.3
78.1
55.0
58.2
42.7
9.5

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

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2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

62
140
1.9

:
:

61
124
1.8

:
:

60
109
1.6

:
:

60
93
1.4

:
:

61
95
1.5

:
11

62
96
1.5

:
12

23
14
0.4

:
15

23
14
0.4

:
16

23
14
0.4

:
16

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.22.2:  Statistical Annex - continued – Portugal 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

10.3

0.86

8.3

0.5

0.5

33,227

15,933

283,732

3.2

38.6

99.8

0.2

13.4

86.6

22.6

304.1

0.0

2020

10.2

0.89

8.7

0.6

0.6

35,572

17,192

298,223

3.4

39.4

99.8

0.2

13.3

86.7

23.1

310.8

0.0

2030

9.9

0.96

9.7

0.7

0.9

41,242

20,242

332,628

4.0

41.2

99.8

0.2

13.1

86.9

22.9

308.9

0.0

2040

9.5

1.01

10.6

0.9

1.2

47,579

23,778

375,752

4.7

44.2

99.8

0.2

12.9

87.1

24.2

325.9

0.0

2050

9.1

1.03

11.3

1.2

1.8

52,891

26,957

415,273

5.4

48.0

99.8

0.2

12.7

87.3

25.6

345.0

0.0

2060

8.5

1.00

11.7

1.4

2.4

55,197

28,687

436,055

6.1

52.1

99.8

0.2

12.5

87.5

26.0

351.5

0.0

2070

8.0

0.92

11.5

1.4

3.2

52,417

27,806

417,302

6.2

54.0

99.8

0.2

12.2

87.8

26.2

354.0

0.0

MS Change 2016-
2070

EU Change 2016-
2070

-23%

7%

38%

159%

486%

58%

75%

47%

93%

40%

0%

-16%

-9%

1%

16%

16%

15%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

4
5
1

3
.
2
2
.

P
o

r
t
u
g
a

l

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
3.23. ROMANIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

In 2015, GDP per capita (13,900 PPS) in Romania 
was one of the lowest in the EU and far below the 
EU  average  of  26,600  PPS.  The  population  was 
estimated at 19.9 million in 2016 and is projected 
to decrease to 15.0 million until 2070.  

Health status 

Health  outcomes  in  Romania  are  lagging  behind 
EU  standards.  Life  expectancy  at  birth  is  71.5 
years for men and 78.7 years for women, far below 
the  EU  averages  (EU:  77.9  for  men  and  83.3  for 
women). Also healthy life years are below the EU 
averages for women (59.4 vs. 63.3 years), and for 
men  (59  vs.  62.6  years).  The  percentage  of  the 
Romanian  population  having  a  self-reported  long-
standing  illness  or  health  problem  is  considerably 
lower than in the Union (20.1% in Romania versus 
the  EU).  The  percentage  of 
34.2% 
the 
in 
population 
indicating  a  self-perceived  severe 
limitation in daily activities stands at 6.8%, which 
is lower than the EU-average (8.1%). 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living is projected to increase 
over  the  coming  50  years.  From  1.5  million 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  10%  is 
envisaged until 2070, to 1.7 million. That is a less 
steep  increase  than  in  the  EU  as  a  whole  (25%). 
However,  due  to  the  population  decline,  when 
measured  as  a  share  of  the  population,  the 
dependents  are  becoming  a  bigger  group,  from 
7.8%  to  11.2%,  an  increase  of  44%.  This  is  more 
than the EU-average increase of 21%. 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
"AWG  reference  scenario",  public 
long-term 
expenditure  is  driven  by  the  combination  of 
changes  in  the  population  structure  and  by  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is a projected increase in spending of about 0.9 pps 

of  GDP  by  2070  (561).  The  "AWG  risk  scenario", 
which  in  comparison  to  the  "AWG  reference 
scenario"  captures  the  impact  of  additional  cost 
drivers  to  demography  and  health  status,  i.e.  the 
possible effect of a cost and coverage convergence, 
projects an increase in spending of 2.1 pps of GDP 
by  2070.  This  reflects  the  fact  that  coverage  and 
unit  costs  of  care  are  comparatively  low  in 
Romania, and  may experience an upward trend in 
future, driven by demand side factors. 

Medium  fiscal  sustainability  risks  appear  for 
Romania  over  the  long  run.  These  risks  derive 
primarily  from  the  unfavourable  initial  budgetary 
position,  compounded  by  age-related  public 
spending (562). 

System Characteristics  

There  is  no  explicit  and  separate  long-term  care 
insurance  scheme  in  Romania.  Long-term  care  is 
fragmented  and  governed  by  several  laws  relating 
to  healthcare,  social  assistance,  pensions  and 
rehabilitation. In  most cases,  families take care of 
elderly  and  dependent  people.  Medical  long-term 
care needs are covered mostly in the formal health 
care sector.  

local  authorities.  Financing 

Most  formal  long-term  care  responsibilities  are 
assumed  by 
is 
provided  via  central  and  local  resources.  NGOs 
play  an  important  role  in  the  delivery  of  services. 
At the central level, financing is shared by the state 
budget  and  the  National  Health  Insurance  Fund 
(NHIF),  with  the  latter  providing  resources  for 
medical services. As from the second half of 2015, 
Romania  has  eliminated  the  restriction  of  social 
to  be  provided  by  profit-making 
services 
companies.  Consequently,  the  potential  of  the 
private social service suppliers, related to the long 
term  care  of  dependent  elderly,  is  likely  to 
increase.  Out-of-pocket-payments  complement 
public  resources;  their  level  is  set  by  the  local 
authorities. 

Depending  on  the  nature  of  the  benefit  provided, 
financing  is  ensured  from  the  public  pension 

(561) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

(562) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

452 

 
                                                           
budget  (pensions  -  only  disability  pensions),  the 
NHIF  (medical  services),  local  budgets  (home 
care), and the funds allocated from the state budget 
the  Ministry  of  Labour,  Family,  Social 
to 
Protection  and  Aged  Persons  (MLFSPAP)  (cash 
benefits and allowances).  

Public spending on long-term care (563) was at the 
level  of  0.3%  of  GDP  in  2015,  much  below  EU 
average  of  1.2%  of  GDP.  Virtually  100%  of  this 
expenditure  was  spent  on  in-kind  benefits  (EU: 
80%),  while  close  to  zero  spending  was  provided 
via cash-benefits (EU: 20%). This reflects the fact 
that, Romania does not use cash benefits.  

The expenditure for institutional (in-kind) services 
makes  up only 12% of public in-kind expenditure 
(EU: 61%). Thus, relative to other Member States, 
Romania has a very low focus on institutional care, 
which is basically reflecting the low coverage with 
formal institutional care benefits. However, a great 
deal  of  long-term  care  spending  may  not  be 
accounted  for  as  such,  as  it  will  be  provided  in 
acute  care 
thus  being  effectively 
registered as  health care expenditure. In this case, 
there is need to shift long-term care patients out of 
acute care to long-term care service providers. 

settings, 

Types of care 

According  to  Law  17/2000,  which  regulates  the 
social  care  for  elderly  persons,  long-term  care  for 
this  category  provides  three  types  of  community 
services:  temporary  or  permanent  home  care; 
temporary  or  permanent  care  in  a  residential 
centre;  and  care  in  daily  centres.  Home  care 
the  provision  of:  household  services 
implies 
and 
(prevention 
supporting 
and 
administrative  counselling,  payment  of  certain 
household  obligations,  catering,  etc.);  socio-
medical  services  (personal  hygiene,  socio-cultural 
activities, 
(medical 
consultations, medicine administration, etc.). 

social  marginalisation 
legal 

etc.);  medical 

of 
social 

reintegration, 

services 

According  to  the  Social  Assistance  Law  no. 
292/2011,  any  dependent  person  is  entitled  to 
personal  care  services,  provided  according  to 

(563) Long-term care benefits can be disaggregated into health 
related long-term care (including both nursing care and 
personal care services) and social long-term care (relating  
primarily to assistance with IADL tasks). 

Long-term care systems 

3.23. Romania 

his/her  individual  need  of  aid  to  accomplish  the 
daily  activities,  to  his/her  family  according  to  the 
socio-economic  situation  and  to  his/her  personal 
life  environment.  Long-term  care  represents  the 
personal  care 
than  60  days. 
lasting  more 
Beneficiaries  of  personal  care  are  the  elderly,  the 
disabled and those suffering from chronic disease. 
Personal  care  services  can  be  also  organised  and 
provided  in  an  integrated  form,  together  with 
medical  care,  rehabilitation  and  environment 
adaptation or other recovery services.  

The  home  care  services  are  presently  financed 
from  the  National  Health  Insurance  Fund,  while 
the  expenditures  incurred  with  the  social  services 
of  personal  care  are  ensured  from  the  local  or 
central  budget  (in  the  form  of  cash  benefit, 
payment  of  salaries  for  professional  formal  care 
givers,  and/or  financing  subsidies  for  the  services 
rendered by authorised providers), as well as from 
the  contributions  (out-of-pocket  payments)  made 
by the beneficiaries.   

of 

The 
is 
long-term  care  of  disabled  persons 
coordinated  by  the  National  Authority  for  the 
Protection 
Persons  with  Disabilities, 
coordinated  by  the  Ministry  of  Labour,  Family, 
Social  Protection  and  Aged  Persons  (MLFSPAP). 
Disabled  persons  are  entitled  to  cash  benefits 
(monthly  disability  indemnity,  additional  monthly 
personal budget, allowances and other indemnities 
and  facilities)  and  in-kind  services  of  social  and 
types  of  services  are 
medical  nature.  Two 
provided:  primary,  aimed  at  preventing  the  social 
exclusion,  and  specialised, 
the 
individual’s  physical  and  psychical  capacities. 
Concretely,  the  services  provided  to  disabled 
persons  are  the  same  as  those  delivered  to  aged 
people.  

to  ameliorate 

There  are  no  cash  benefits  for  informal  care  of 
elderly  people,  but  only  for  persons  who  are 
officially 
recognised  as  having  a  disability. 
However,  older  persons  who  are  chronically  or 
terminally  ill  or  have  multiple  comorbidities  may 
be assessed as presenting a degree of disability. In 
this  way,  they  can  benefit  from  care  allowances 
usually  granted  to  a  member  of  their  family.  The 
personal  care  involving  aid  for  accomplishing  the 
daily instrumental activities is provided by formal 
caregivers,  only 
if  no  informal  or  volunteer 
caregivers are available.  

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Eligibility 
user 
dependency, care needs, income 

criteria 

and 

choices: 

Benefits  and  services  for 
the  persons  with 
disability  are  granted  on  the  basis  of  a  certificate 
attesting  the  disability,  as  follows:  cash  benefits 
and  social  services  granted 
in 
residential/day  care  centres.  The  person  with  a 
severe disability, according to its nature and to the 
specific  care  needs  can  be  assisted  at  home  by  a 
family  member  or  another  person  employed  as  a 
personal  assistant.  The  recipient  of  care  can  also 
choose to receive a monthly cash benefit.  

in  home  or 

Local  budgets  can  grant  allowances  to  the  spouse 
or  a  relative  who  takes  care  of  a  dependent  older 
person, but this is subject to local initiative. If the 
carer is salaried and working part-time, she/he can 
apply  for  support  equal  to  the  remainder  of  the 
salary  -  equivalent  of  a  gross  monthly  salary  of  a 
an 
newly  qualified 
intermediate  level  of  training.  In  all  cases,  the 
allowance is granted on the basis of a means-tested 
assessment. 

assistant  with 

social 

Prevention and rehabilitation measures 

The  Strategy  for  Social  Inclusion  of  Persons  with 
Disabilities  2014-2020  continues  and 
further 
develops  the  approach  initiated  by  the  National 
Strategy  for  protection,  integration  and  social 
inclusion  of  people  with  disabilities  in  the  period 
2006 – 2013.  

The  Strategy  is  related  to  the  principles  and 
obligations arising from the ratification of the UN 
Convention  on 
the  Rights  of  Persons  with 
Disabilities.  The  UN  Convention  provides  a 
framework  for  developing  public  policy  and  for 
the  modernisation  of  practices,  tools  and  methods 
to support the community, leading to a barrier-free 
participation of persons with disabilities in society, 
to a dignified and fulfilled life in the community. 

The  Strategy  for  Social  Inclusion  of  Persons  with 
Disabilities  2014-2020  is  divided  into  nine  main 
areas of reference: 1. accessibility; 2. participation; 
3.  equality;  4.  quality  community  based  services; 
5. employment; 6. education and training; 7. social 
protection; 8. health; 9 international cooperation. 

established by the National Strategy for Promoting 
the  Active  Ageing  and  the  Protection  of  Elderly 
2015-2020 and by the Strategic Action Plan 2015-
2020.  This  project  stipulates,  among  others,  the 
establishment  within  the  Ministry  of  Labour  of  a 
long-term  care  Directorate,  responsible  for  the 
coordination,  planning  and  settlement  of  all  the 
LTC issues and for the joint development (together 
with the Ministry of Health) of a “Long-term Care 
Program”,  which  is  meant  to  integrate  all  the 
benefits  and  services  afferent  to  LTC,  under  a 
unified system.   

By implementing the 2014-2020 National Strategy 
for Promoting Active Ageing funds were allocated 
under  2014-2020  EFRD  and  the  State  Budget  in 
order  to  develop  infrastructure  for  social  home 
care  services  for  elderly  at  risk  of  poverty  or 
exposed  to  other  types  of  vulnerability.  Three 
projects  amounting  to  €1.87  million  (EFDR  and 
the  State  Budget)  have  been  contracted  by  March 
2018. 

Formal/informal caregiving 

Most of dependent elderly people benefit from the 
care services provided inside the family. 

in 

to 

in 

the 

some 

order 

prevent 

services 

the 
Moreover, 
institutionalisation  of  old  dependants,  the  State 
Budget  will  finance  two  programmes  delivered 
over two years that are dedicated to developing the 
public  network  of  community  household  services 
and  to  strengthening  the  capacity  of  public  social 
assistance 
territorial 
administrative  units.  The  first  programme  will 
support 
case 
implementation 
management and the social proximity principle for 
about  1,000  old  dependants.  The 
second 
programme will provide assistance for about 1,000 
local  public  administrative  authorities  in  order  to 
render  operational  support,  manage  and  provide 
social services. It will also finance the employment 
of  1,000  social  work  assistants  in  territorial 
administrative  units  (villages)  where  the  public 
service  was  not  created/ 
social  assistance 
accredited. 

the 

of 

Corruption 

There  is  a  medium-term  (2016-2018)  operational 
the  objectives 
action  plan,  devised 

to  fulfil 

Corruption  is  present  in  many  economic  sectors 
and  involves  appointed  and  elected  officials  at  all 
levels of government as  well  as civil servants and 

454 

 
employees of public institutions. This is borne out 
by  the  record  of  criminal  investigations  and 
convictions for corruption (564).  

Preventing corruption in public administration was 
one of the key priorities of the 2012-2015 National 
Anti-corruption  Strategy.  The  evaluation  of  the 
strategy  shows  some  progress  in  putting  in  place 
corruption  prevention  measures  at  the  level  of 
national administration. It concludes, however, that 
local administration structures are severely lagging 
behind  in  terms  of  building  up  the  necessary 
capacity  to  prevent  corruption  effectively.  The 
government  included  additional  measures  in  the 
to 
renewed  anticorruption  strategy  2016-2020 
remedy 
the 
evaluation. 

the  weaknesses 

identified 

in 

challenges 

some  progress, 

Despite 
remain 
regarding corruption in the LTC sector. Currently a 
major  review  is  underway  regarding  medical 
reimbursements  made  to  non-existent  patients  for 
home  care  services.  The  lack  of  transparency  in 
medical reimbursements affects the budget and the 
quality of services provided to dependents. 

Recently 
reforms  

legislated  and/or  planned  policy 

The National Health Strategy 2014-2020 outlines a 
specific  objective  on  increasing  access  to  quality 
services for rehabilitation, palliative and long-term 
ageing 
care 
phenomenon  and  epidemiological  profile  of 
morbidity: 

the  demographic 

adapted 

to 

1.  Development  of  a  National  Plan  for  medium 
term  on  rehabilitation  services, 

and 
palliative care and long-term including a 

long 

−  review  of  the  regulatory  framework  regarding 
the organisation, financing and delivery of long 
term; 

−  hospital  network  reorganisation  of  chronic 
diseases and medical and social assistance; 

−  classification  of  providing 

long-term  care 
according  to  levels  and  types  of  care,  with 
continued reduction for acute beds at more than 
4.5 per 1,000 population in 2020;  

(564) COM (2016) 41 final; SWD (2016) 16 final. 

Long-term care systems 

3.23. Romania 

funds 

−  diversification  of  funding  sources,  including 
repayable  grants  or  by 
in 
the 
facilities 

accessing 
supporting 
investment 
private 
construction  and  equipping  of 
providing long-term care. 

2.  The  implementation  of  the  National  Plan  on 
rehabilitation  services,  palliative  and  long-
term care: 

− 

− 

identification,  reorganisation  and  rehabilitation 
of infrastructure at county / regional /  national 
hospitals  for  chronic  diseases,  rehabilitation 
centres 
and 
morbidity profile; 

to  demographic 

according 

increasing  access  to  programs  of  continued 
medical  education  and  training  diversified  and 
focused on development needs and the needs of 
patients served; 

−  development  and  implementation  of  standards 
and  operation,  practice 
"therapeutic 
procedures 

of  organisation 
guidelines 
and 
pathway; 

−  developing  mechanisms, 

or 
institutional  work  procedures  that  ensure  an 
the 
integrated  and  effective  response  on 
rehabilitation  of  adults  and  children  with 
disabilities. 

standards 

Challenges 

Romania  has  a  relatively  fragmented  system  of 
long-term  care,  with  low  coverage  and  a  large 
is  privately 
provision  of 
financed.  The  main  challenges  of  the  system 
appear to be: 

informal  care 

that 

state 

responsibilities 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of 
authorities 
of 
concerning  the  provision  of  long-term  care 
services; to set the public and private financing 
mix  and  organise  formal  workforce  supply  to 
face  the  growing  number  of  dependents,  and 
provide  a  strategy  to  deliver  high-performing 
long-term  care  services  to  face  the  growing 
demand  for  LTC  services,  such  opening  the 
market for private providers of care services; to 

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•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  coordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  create  better 
improving  (and  securing)  safe  care 
rules, 
pathways 
to 
chronically-ill people or circulated through the 
system;  To 
towards 
appropriate settings. 

information  delivered 

steer  LTC  users 

and 

•  Improving  value  for  money:  to  invest  in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and  health-promotion  policies  and  to  identify 
risk  groups  and  detect  morbidity  patterns 
earlier. 

•  Corruption:  Tackle  corruption  in  the  LTC 

system.  

local 

strategically 
integrate  medical  and  social 
services via such a legal framework; to define a 
comprehensive approach covering both policies 
for  informal  (family  and  friends)  carers,  and 
policies  on  the  formal  provision  of  LTC 
services  and  its  financing;  to  establish  good 
information  platforms  for  LTC  users  and 
providers;  to  set  guidelines  to  steer  decision-
making  at 
level  or  by  practising 
providers;  to  use  care  planning  processes, 
based  on 
individualised  need  assessments, 
involving health and care providers and linking 
need assessment to resource allocation; to share 
to 
data  within  government  administrations 
facilitate 
potential 
the  management 
interactions  between  LTC  financing,  targeted 
personal-income  tax  measures  and  transfers 
(e.g.  pensions),  and  existing  social-assistance 
or  housing  subsidy  programmes;  to  deal  with 
cost-shifting incentives across health and care. 

of 

earned 

•  Improving  financing  arrangements:  to  face 
the  increased  LTC  costs  in  the  future  e.g.  by 
tax-broadening, which means financing beyond 
the  working-age 
by 
revenues 
population;  To  foster  pre-funding  elements, 
which  implies  setting  aside  some  funds  to  pay 
for future obligations; To explore the potential 
of  private  LTC  insurance  as  a  supplementary 
financing tool. 

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage; the depth of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits;  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included  into  the  coverage  as  stipulated  in  the 
actual  legislation.  To  provide  targeted  benefits 
to those with highest LTC needs; to reduce the 
impoverishment  of  recipients  and 
risk  of 
informal carers 

future  needs 

•  Ensuring  availability  of  formal  carers:  To 
for 
determine  current  and 
qualified  human  resources  and  facilities  for 
long-term care; to improve recruitment efforts, 
including 
the  migration  of  LTC 
workers and the extension of recruitment pools 
of workers.  

through 

456 

 
Table 3.23.1:  Statistical Annex – Romania 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

80
13.2
21.4

0.5
:
1.6

75.4
68.4
:
:
:
:

98
14.0
21.3

0.5
:
1.5

76.1
69.0
:
:
:
:

125
14.2
21.1

0.5
:
1.4

76.8
69.5
62.5
60.5
19.5
7.1

142
14.2
20.6

0.7
:
1.7

77.5
69.7
62.9
60.0
19.8
6.8

120
13.0
20.4

0.8
:
1.9

77.7
69.8
61.7
59.8
20.8
7.1

127
13.0
20.3

0.8
:
1.9

77.7
70.0
57.5
57.3
20.9
7.6

133
13.1
20.2

0.7
32.4
1.8

78.2
70.8
57.0
57.4
21.6
8.3

134
13.2
20.1

0.6
38.0
1.7

78.1
70.9
57.7
57.6
21.2
8.5

144
13.0
20.0

0.1
39.3
0.2

78.7
71.6
57.9
58.6
20.6
8.5

150
13.3
19.9

0.1
42.4
0.2

78.7
71.4
59.0
59.0
19.9
7.9

160
13.9
19.9

0.3
51.9
0.8

78.7
71.5
59.4
59.0
20.1
6.8

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
5
7

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

86
120
1.0

:
:

97
142
1.2

:
:

108
164
1.3

:
:

119
186
1.5

:
:

121
189
1.5

:
:

122
192
1.6

:
:

189
204
2.0

:
:

191
207
2.0

:
:

193
210
2.0

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
2
3
.

R
o
m
a
n
a

i

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
 
4
5
8

Table 3.23.2:  Statistical Annex - continued – Romania 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

19.7

1.53

7.8

0.3

0.3

2020

19.2

1.54

8.0

0.3

0.3

2030

18.0

1.63

9.1

0.4

0.5

2040

17.0

1.71

10.0

0.5

0.8

2050

16.3

1.73

10.6

0.5

1.4

2060

15.7

1.77

11.3

0.6

2.5

2070

15.0

1.67

11.2

0.6

4.6

222,768

205,896

228,246

211,281

244,363

225,809

269,034

250,443

280,064

263,977

298,727

287,115

291,485

283,832

0

2.2

28.0

100.0

0.0

3.3

96.7

0.9

27.7

:

0

2.3

28.5

100.0

0.0

3.3

96.7

0.9

27.5

:

0

2.6

28.8

100.0

0.0

3.3

96.7

0.9

28.7

:

0

3.1

30.5

100.0

0.0

3.4

96.6

1.0

30.3

:

0

3.3

31.4

100.0

0.0

3.3

96.7

1.0

31.5

:

0

3.7

33.2

100.0

0.0

3.3

96.7

1.0

31.2

:

0

3.8

34.3

100.0

0.0

3.3

96.7

1.0

30.7

:

MS Change 2016-
2070

EU Change 2016-
2070

-24%

10%

44%

100%

1441%

31%

38%

:

76%

23%

0%

:

-2%

0%

14%

11%

:

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

r

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
3.24. SLOVAKIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

GDP per capita in PPS is at 21,600 and below EU 
average of 29,600 in 2015. Slovakia currently  has 
a  population  of  5.4  million  inhabitants  and  is 
projected  to  reach  4.9  million  in  2070,  a decrease 
of 10%, in contrast with an increase in the EU as a 
whole of 2%. 

the "AWG reference scenario" captures the impact 
of  additional  cost  drivers  to  demography  and 
health  status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending up to 2.9 pps of GDP by 2070. Over the 
long  run,  medium  sustainability  risks  appear  for 
the  Slovak  Republic.  These  risks  derive  primarily 
from  the  projected  impact  of  age-related  public 
spending (notably healthcare and pensions) (566). 

Health status 

System Characteristics  

Life expectancy at birth for both  women and  men 
is  respectively  80.2  years  and  73.1  years  in  2015 
and is below the EU averages (83.3 and 77.9 years, 
respectively).  Healthy  life  years  at  birth  are  with 
55.1  years  (women)  and  54.8  years  (men)  far 
and  62.6, 
below 
(63.3 
the  EU-averages 
respectively).  The  percentage  of 
the  Slovak 
population  reporting  a  long-standing  illness  or 
health problem is slightly lower than in the Union 
(30.4% in Slovakia versus 34.2% in the EU). The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  its  daily  activities 
stands  at  9.3%,  which  is  higher  than  the  EU-
average (8.1%). 

Dependency trends 

Dependency  is  expected  to  increase  in  Slovakia. 
The number of people in dependency is forecasted 
to  increase  from  510  thousand  in  2015  to  770 
thousand  in  2070,  a  52%  change,  higher  than  the 
increase  in  the  EU  (25%).  Additionally,  the 
proportion  of  the  population  being  dependent  in 
terms  of  severe  limitations  in  daily  activities  is 
projected  to  increase  from  9.3  to  15.6%,  giving  a 
68%  increase,  compared  to  the  more  modest  EU 
trend of 21%. 

Expenditure projections and fiscal sustainability  

When it comes to public expenditure on long-term 
care  as  a  percentage  of  GDP,  rising  trends  are 
expected  (565).  In  the  "AWG  reference  scenario", 
encapsulating  health-status  and  demographic  cost 
drivers,  Slovakia's  public  expenditure  is  expected 
to increase from 0.9 to 1.5 pps of GDP until 2070. 
The "AWG risk scenario", which in comparison to 

(565) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip079_en.pdf. 

the  Ministry  of  Health 

Long term care (LTC) in Slovakia is regulated by 
separate  pieces  of  legislation.  LTC  is  in  the 
competence  of 
in 
cooperation  with  the  Ministry  of  Labour,  Social 
Affairs  and  Family.  The  Ministry  of  Labour, 
Social Affairs and Family is specifically in charge 
of:  1)  compensations  of  social  consequences  of 
a severe  disability  mainly  in  the  field  of  self-
tools,  providing 
service 
monetary 
and 
care-taking 
monetary  contribution  for  personal  assistance;  2) 
providing  or  ensuring  social  services  at  home, 
mainly  home  nursing  services.  In  institutions  – 
providing  social  services 
in  a social  service 
facility,  in  an  outpatient  or  hospitalised  form, 
weekly  or  yearly.  Developing  an  integrated  legal 
framework for LTC remains one of the key policy 
challenges in Slovakia.  

including  necessary 
for 

contribution 

For  the  moment,  there  is  a  poor  coordination 
between health and social long-term care, but lack 
of  coordination  is  perceptible  also  between  state 
administration  and  regional/local  administration. 
There is an acute demand for measures integrating 
health and social care into one institution. 

Based  on  the  2018  Ageing  Report,  total  public 
spending  on  LTC  (health  and  social  part) (567) 
reached  0.9%  of  GDP  in  2016  far  below  EU 
average of 1.6% of GDP. The low level of funding 
implies  that  a  considerable  part  of  current  LTC 
needs  are  not  covered  by  public  means.  This  is 
supported  by  the  fact,  that  in  2017,  approx.  4,000 
dependent  people  were  on  waiting  lists  for  social 

(566) European Commission, Fiscal Sustainability Report (2018), 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(567) Long-term  care  benefits  can  be  disaggregated  into  health-
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily to assistance with IADL tasks). 

459 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

institutions  places.  Thus, 

care 
informal  care 
provided by family members or close non-relatives 
plays a decisive role in Slovakia (568).  

In the EU, 50% of dependents are receiving formal 
in-kind  LTC  services  or  cash-benefits  for  LTC. 
This  share  is  with  56.3%  higher  in  Slovakia.  It 
means  that  approximately  1  out  of  2  individuals 
aged  15  or  more  and  declaring  themselves  as 
severely  dependent,  would  receive  some  kind  of 
formal care (at home or in institution, in-kind or in 
cash).  Slovakia  seems  to  have  below  the  average 
usage of cash benefits compared to the EU. In fact, 
11%  of  public  LTC  spending  is  done  via  cash 
benefits  (EU:  15.6%),  while  the  majority  of  the 
public expenditure on LTC are devoted to in-kind 
benefits (89%).  

The expenditure for institutional services makes up 
48.6.%  of  public  expenditure  on  LTC  in-kind 
benefits  (EU:  66%),  51.4%  being  spent  for  LTC 
in-kind  services  provided  at  home  (EU:  33%). 
Thus,  within its relatively low spending envelope, 
relative  to  other  Member  States  Slovakia  has  a 
focus on home care.  

Types  of  care,  eligibility  criteria  and  user 
choices: dependency, care needs, income 

LTC  in  the  area  of  health  is  provided  in  the  form 
of  geriatric  care 
in  outpatient  departments, 
specialised hospital departments, day care centres, 
home  nursing  agencies,  hospices  and  other 
facilities. Day care centres and nursing homes are 
financed  from  public  health  insurance  resources. 
Senior  and  specialised  homes  belong 
the 
competence  of  the  Ministry  of  Labour,  Social 
financed  by 
Affairs  and  Family  and  are 

to 

(568) As  explained  in  footnote  (3)  there  are  LTC  expenditures 
that  are  not  included  in  this  number,  and  which,  for  the 
purposes  of  Ageing  Report  2018  were  estimated  through 
building  a  proxy  from  separate  ESSPROS  (European 
System  of  integrated  Social  Protection  Statistics)  data.  In 
particular,  a  large  share  of  the  in-kind  benefits  of  the 
Ministry  of  Labour,  Social  Affairs  and  Family  or  the 
municipalities are not classified as expenditures on LTC in 
they  should  be  considered  LTC 
the  SHA, 
expenditure according to the definition bellow (page 1&2). 
However, there is no clear concept of LTC in Slovakia and 
therefore 
these 
expenditures  should  be  included  and  also  to  quantify  the 
impact  using  a  national  methodology.  For  example,  there 
are  homes  of  social  services  that  provide  other  kind  of 
services  apart  from  the  long-term  care  but  this  is  not 
distinguished in the statistics. 

to  define  which  of 

is  difficult 

though 

it 

municipalities,  payments 
and 
subsidies of the Ministry of Labour, Social Affairs 
and Family.  

clients 

from 

Social LTC benefits are provided in the form of in-
kind and cash benefits. Social services are financed 
by  local  and  regional  self-governments,  state 
subsidies,  and  payments  by  care  recipients.  Cash 
benefits  are  financed  by  the  State  and  provided 
through a network of local offices of labour, social 
affairs and family. 

Legislation  defines  the  minimum  duration  of  a 
functional  disease  and  the  minimum  degree  of 
dependence  for  the  provision  of  the  various 
benefits. The entitlement to cash benefits is means-
tested. The recipients' income and assets are taken 
into  account  in  the  eligibility  of  public  benefits. 
Co-payments  apply  for  recipients  of  benefits  in-
kind  usually  up  to  the  level  of  "economically 
justified"  costs.  The  entitlement  to  and  level  of 
cash benefits are subject to a person’s income and 
assets  not  exceeding  a  certain  ceiling.  Higher 
income  thresholds  are  applied  to  benefits  for 
children  needing  care.  Benefits  in-kind  (social 
service) are also subject to a means test, but under 
a  different  procedure.  The 
income  shall  be 
considered  as  the  total  income  excluding  one-off 
state  social  benefits,  child  benefit,  tax  bonuses, 
scholarships  etc.  Assets  are  not  counted  e.g.: 
property used for permanent housing, land for own 
use, or car used by severely disabled persons. The 
cash  benefit  is  reduced  as  income  increases  and 
when  income  is  over  5-times  the  subsistence 
minimum, the cash benefit is withhold. 

social 

services 

Payment  for  social  services  to  the  level  of 
economically  justified  costs  only  relates  to  the 
provision  of 
to 
compensations.  In  all-year  residential  facilities  of 
social  services,  the  law  regulates  an  income 
protection  up  to  25%  of  living  wage.  In  case  of 
home  nursing  service, 
is  a guaranteed  
income  balance  amounting  at  1.4  times  the  living 
wage. 

and  not 

there 

Social  services  in  Slovakia,  including  long-term 
care,  are  decentralised  and  are  financed  from  the 
budgets  of  municipalities  and  higher  territorial 
units. An amendment to the Act on Social Services 
which came into force on 1.3.2012 introduced also 
direct  state  participation 
the  financing  of 
particular  types  of  social  services  (mostly  long-

in 

460 

 
                                                           
term  care)  belonging  to  the  municipalities  and 
private  providers  of  social  services  at 
the 
municipal  level.  The  Ministry  of  Labour,  Social 
Affairs and Family gives to the providers of social 
services normative financial contribution in a fixed 
amount. The amount depends on the type of social 
services,  e.g.  contribution  for  a  client  in  a  facility 
for elderly persons is €320 per month; contribution 
for  a  client  in  a  facility-supported  living  is  €200 
per  month.  This  expenditure  only  has  partial 
impact on the LTC expenditure level according to 
the SHA classification. 

Prevention and rehabilitation measures 

focused  on 

The  system  of  social  services  encompasses 
social 
facilities  and  activities 
prevention  and  rehabilitation  and  support 
to 
independent  living  (e.g.  rehabilitation  centres, 
daily  care  stations,  specialised  activities  such  as 
ergo-therapy,  access  to  ICT  and  cultural  events, 
social  counselling).  Compensatory  cash  benefits 
enable  disabled  persons  to  adjust  their  housing  or 
improve  mobility  to  reduce  dependence  on  other 
person's  assistance.  However,  preventive  and 
rehabilitative activities comprise only a minor part 
of social LTC. 

Formal/informal caregiving 

There are four major classes of LTC carers: 

(1)  Informal  carers  -  nearly  60,000;  they  receive 
cash benefits for care, whereas only about 2% are 
working  at  the  same  time.  During  the  caregiving 
period,  the  health  and  pension  insurance  is  being 
paid by the state and they are entitled to use public 
supportive  services,  which  are  currently  used 
marginally.  Families  are  mostly  reluctant  to  use 
professional  LTC  services  if  they  are  able  to 
provide care "on their own". 

(2)  Home  nursing  -  done  by  approx.  6,300 
employees  of  municipalities  or  private  providers. 
The  extent  of  the  service  depends  on  the  client’s 
needs that are assessed by a medical expert. Home 
nursing is funded from the health insurances. 

(3) Personnel within residential care - circa 18,000 
in 
employees 
different  types  of  social  services  for  adults  and 

residential  care 

in  permanent 

Long-term care systems 

3.24. Slovakia 

seniors;  short-term  services  (care  on  a  daily  or 
weekly basis (569)) are used only occasionally. 

 (4)  Volunteers  –  only  registered  at  non-public 
residential 
they 
represented  nearly  30%  of  workers  working  for 
private providers of LTC. 

2008-2010 

providers, 

in 

Recently 
reforms  

legislated  and/or  planned  policy 

The  crucial  role  of  informal  (family)  care  for 
providing  long-term  care  services  in  Slovakia  is 
generally acknowledged. However, policy reforms 
in the past  years  were targeted almost exclusively 
on the formal sector of LTC, and improvement of 
informal  care  is  still  outstanding.  In  2018,  the 
Ministry  of  Health  introduced    additional  nursing 
services  in  social  residential  facilities  (such  as 
treatment  of  bedsores,  positioning  the  patient, 
application of drugs, nursing rehabilitation, etc.) to 
be reimbursed by the health insurances. However, 
the  reimbursement  for  nursery  care  in  residential 
homes  from  health  insurances  is  linked  to  a 
minimum level of bed capacities in municipalities, 
set  by  the  Ministry  of  Health  and  effective  from 
January 2018. 

The  Institute  of  Health  Policy  of  the  Ministry  of 
Health  currently  co-operates  with  the  Ministry  of 
Labour,  Social  Affairs  and  Family  to  prepare  a 
strategy  for  LTC.  The  strategy  aims  to  create  the 
integrated  model  of  LTC  care.  The 
optimal 
National  Programme  for  Active  Ageing  2014-
2020,  approved  by  a  government  resolution  in 
2013,  gives  the  possibility  to  introduce  insurance 
for LTC by 2020 by the Ministry of Labour, Social 
the 
Affairs  and  Family 
Ministry  of  Finance.  The  strategy  of  de-
institutionalisation 
and 
strengthening  of  care,  approved  by  a  government 
resolution end-2011, foresees a systemic transition 
from institutional to community-based care (570). It 

in  cooperation  with 

services 

social 

of 

(569) Providing  LTC  is  not  yet  based  on  a  comprehensive 
legislative  framework  (see  planned  policy  reforms),  such 
that the types of care are not precisely defined. This issue 
falls within the competence of the Ministry of Health. 
(570) Piloting de-institutionalisation is the main goal of a project 
called  “Supporting  the  process  of  de-institutionalisation 
and transformation of the social services system –NP DI”. 
The Ministry of Labour ran the project from 2013 to 2015. 
The project was successfully finished and will be followed 
by  two  other  projects  cofounded  by  the  EU  structural 
funds. 

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•  Ensuring  availability  of  formal  carers:  to 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term care. 

future  needs 

•  Supporting 

to  establish 
family  carers: 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Facilitating  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  LTC;  to  steer  LTC  users  towards 
appropriate settings. 

•  Improving value for money: to invest in ICT 
as  an  important  source  of  information,  care 
management and coordination. 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

includes  limits  on  capacity  of  institutions  and 
restrictions on the  year-round provision of care in 
certain  types  of  facilities  (e.g.  homes  of  social 
services  shall  provide  only  care  on  a  daily  or 
weekly  basis).  In  addition,  new  types  of  services 
aim to support independent living of persons  with 
disabilities  and  strengthen  social  prevention  and 
early intervention.  

Challenges 

The main challenges of the system appear to be: 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of  responsibilities  of  state  authorities  with 
respect  to  the  provision  of  long-term  care 
services; to set the public and private financing 
mix  and  organise  formal  workforce  supply  to 
face  the  growing  number  of  dependents,  and 
provide  a  strategy  to  deliver  high-performing 
long-term  care  services  to  face  the  growing 
demand  for  LTC  services;  to  strategically 
integrate medical and social services via such a 
legal  framework;  to  define  a  comprehensive 
approach  covering  both  policies  for  informal 
(family and friends) carers, and policies on the 
formal  provision  of  LTC  services  and  its 
financing; 
information 
to  establish  good 
platforms for LTC users and providers. 

earned 

•  Improving  financing  arrangements:  to  face 
the  increased  LTC  costs  in  the  future  e.g.  by 
tax-broadening, which means financing beyond 
revenues 
the  working-age 
by 
population;  to  foster  pre-funding  elements, 
which  implies  setting  aside  some  funds  to  pay 
for  future  obligations;  to  explore  the  potential 
of  private  LTC  insurance  as  a  supplementary 
financing tool.  

•  Encouraging  home 

to 

care 

care: 

legislative 

to 
new 

develop 
alternatives 
institutional  care  by  e.g. 
developing 
frameworks 
regulation 
encouraging  home 
controlling  admissions  to  institutional  care  or 
the establishment of additional payments, cash 
benefits  or  financial  incentives  to  encourage 
home care; to monitor and evaluate alternative 
services, 
incentives  for  use  of 
including 
alternative settings. 

and 

462 

 
Table 3.24.1:  Statistical Annex – Slovakia 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

39
15.0
5.4

0.0
:
0.1

78.1
70.2
56.6
55.2
:
:

46
16.1
5.4

0.0
:
0.1

78.4
70.4
54.6
54.5
27.5
11.1

56
17.7
5.4

0.0
:
0.1

78.4
70.6
56.1
55.6
27.3
10.4

66
18.5
5.4

0.0
:
0.1

79.0
70.9
52.5
52.1
29.6
11.2

64
17.5
5.4

0.0
:
0.1

79.1
71.4
52.6
52.4
29.5
10.8

68
19.0
5.4

0.0
:
0.1

79.3
71.8
52.0
52.4
30.7
10.4

71
19.2
5.4

0.0
:
0.0

79.8
72.3
52.3
52.1
31.6
10.2

73
19.6
5.4

0.0
5.3
0.1

79.9
72.5
53.1
53.4
29.8
10.0

74
19.8
5.4

0.0
5.2
0.1

80.1
72.9
54.3
54.5
30.7
9.6

76
20.6
5.4

0.0
5.1
0.0

80.5
73.3
54.6
55.5
30.3
9.9

79
21.6
5.4

0.0
5.3
0.1

80.2
73.1
55.1
54.8
30.4
9.3

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

49
:

44
:

:
:
:

:
:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
6
3

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

:
28
0.5

51
:

10
34
0.8

50
:

20
41
1.1

54
:

30
47
1.4

57
:

31
48
1.5

58
:

31
49
1.5

:
:

45
62
2.0

:
:

46
62
2.0

:
:

46
63
2.0

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
2
4
.

l

S
o
v
a
k
a

i

L
o
n
g

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4
6
4

Table 3.24.2:  Statistical Annex - continued – Slovakia 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

5.4

0.51

9.3

0.9

0.9

2020

5.5

0.53

9.7

0.9

1.0

49,586

67,645

167,390

52,623

69,155

176,660

5.2

56.3

88.9

11.1

48.6

51.4

42.8

33.2

3.3

5.5

56.1

88.6

11.4

49.5

50.5

42.5

32.9

3.3

2030

5.5

0.62

11.3

1.1

1.2

64,777

70,090

203,021

6.2

54.9

88.8

11.2

53.6

46.4

44.4

35.4

3.3

2040

5.4

0.69

12.9

1.2

1.5

2050

5.3

0.73

13.8

1.4

1.9

2060

5.1

0.76

15.0

1.5

2.4

2070

4.9

0.77

15.6

1.5

2.9

78,157

68,589

223,848

86,026

64,564

236,590

95,890

58,282

246,036

102,655

52,284

242,100

6.9

53.7

89.1

10.9

58.4

41.6

44.6

36.2

3.3

7.4

53.3

89.2

10.8

62.4

37.6

46.0

36.9

3.2

7.8

52.4

89.5

10.5

66.9

33.1

46.5

37.8

3.2

8.1

51.8

89.8

10.2

70.2

29.8

44.6

37.3

3.1

MS Change 2016-
2070

EU Change 2016-
2070

-10%

52%

68%

64%

222%

107%

-23%

45%

55%

-8%

1%

-8%

44%

-42%

4%

12%

-6%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.25. SLOVENIA 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

Slovenia  has  a  population  of  just  above  2  million 
inhabitants,  which  is  slightly  more  than  0.4%  of 
the  EU  population  in  2016  and  is  projected  to 
decrease  by  5%  by  2070.  With  a  GDP  of  39 
billion, or 22,600 PPS per capita in 2015 it scores 
lower  than  the  EU  weighted  average  (29,600). 
When looking at the unweighted average and at the 
median  level  though,  respectively  25,200  and 
22,100  PPS,  Slovenia  faces  a  significantly  lower 
gap, standing at 89.7% of the average, and closely 
resembling  the  median.  Based  on  the  Ageing 
Report 2018, total public expenditure on long-term 
care  (health  and  social  part)  (571)  is  with  0.9%  of 
GDP  in  2015  under  the  EU  average  in  the  same 
year (1.6%). 

Health status 

for  men 

and  women 

Life expectancy at birth for both  women and  men 
was  respectively  83.9  years  and  77.8  years  in 
2015,  similar  to  the  EU  average  (83.3  and  77.8 
respectively). 
years 
Nevertheless, in 2015 the healthy life years at birth 
for  both  sexes  were  significantly  lower  than  the 
EU  average,  with  57.7  years  for  women  and  58.5 
years for men (63.3 and 62.6 respectively in 2015). 
At the same time the percentage of the population 
having  a  long-standing  illness  or  health  problem 
was  in  2015  slightly  lower  than  in  the  EU  as  a 
whole  (33.1%  and  34.2%  respectively)  (572).  The 
percentage  of  the  population  indicating  a  self-
perceived  long-standing  severe  limitation  in  its 
daily activities has been fluctuating since 2006 (the 
highest  level  being  13%  in  2011),  but  despite 
remaining  above  the  EU-average  of  8.1%,  the 
trend seems to have changed in the last years with 
an overall decrease that reached 9.8  in 2015,  only 
slightly above the 2014 value (573). 

(571) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

(572) Source  Eurostat,  People  having  a  long-standing  illness  or 
status 

sex,  age  and 

labour 

health  problem,  by 
[hlth_silc_04]. 

(573) According 

(Eurostat  Database-
Population and Social Conditions- Health- Health Status). 

to  EU-SILC  Survey 

Dependency trends 

The number of people depending on others to carry 
out activities of daily living is projected to increase 
over  the  coming  50  years.  From  220  thousand 
residents  living  with  strong  limitations  due  to 
health  problems  in  2016,  an  increase  of  18%  is 
envisaged  until  2070  to  around  260  thousand, 
which  is  lower  that  the  EU  average  of  25%  over 
the  same  period.   According  to  this  scenario,  the 
dependents are becoming a bigger group also as a 
share of the population and an increase of 25% is 
to  13.2%),  which, 
projected 
conversely,  is  above  the  EU-average  increase  of 
21%. 

(from  10.6% 

Expenditure projections and fiscal sustainability  

is 

by 

driven 

expenditure 

is  projected 

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 
to  steadily 
percentage  of  GDP 
increase. In the "AWG reference scenario", public 
long-term 
the 
combination of changes in the population structure 
and  a  moderately  positive  evolution  of  the  health 
(non-disability)  status.  The  joint  impact  of  those 
factors  is  a  projected  increase  in  spending  of  0.9 
pps,  bringing  Slovenia  from  0.9  (574)  to  1.8%  of 
GDP  spent  on  long-term  care  in  the  period  2016-
2070, with a steeper increase than for EU average 
(93% and 73% respectively) (575). The "AWG risk 
scenario",  which  in  comparison  to  the  "AWG 
reference  scenario"  captures 
impact  of 
additional  cost  drivers  to  demography  and  health 
status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending  of  3.5  pps  of  GDP  by  2070.  Overall, 
projected  long-term  care  expenditure  increase  is 
expected to add to budgetary  pressure on  medium 
and  long  run.  Medium  fiscal  sustainability  risks 
appear  over  the  medium  and  the  long  run  due, 
especially  for the long-term risk categorisation, to 
in  age-related  public 
the  projected 

increase 

the 

(574) Including  public  expenditure  on  LTC  (1%  of  GDP) 
according to SHA (health and social part) and cash-benefits 
for  economic  integration  for handicapped  from  ESSPROS 
disability function (0.4% of GDP).  
2018 

(575) The 

Report: 

Ageing 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

465 

 
                                                           
                                                           
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spending,  notably  deriving  from  long-term  care, 
healthcare and pensions (576). 

System Characteristics  

Administrative organisation 

Currently, there is no uniform system of long-term 
care  (LTC)  in  Slovenia.  There  is  no  definition  of 
long-term care and therefore no unified entry point 
or  a  standard  model  for  assessing  care  needs  for 
health  and  social  services  which  could  be 
classified  as  long-term  care  services.  This  creates 
risks  of  inefficiencies  and  makes  it  more  difficult 
for  the  user  to  obtain  comparable  services  for 
comparable  needs  and  to  navigate  the  system. 
Different  forms  of  services  and  benefits  which 
could  be  classified  as  LTC  services  are  provided 
within  the  health  care  system,  social  and  parental 
protection  system,  pension  and  disability  system 
and  the  system  of  care  for  the  disabled,  and  are 
regulated  by  different  acts  from  these  areas.  The 
provision  of  community  based 
social  and 
healthcare services is not well coordinated between 
providers of health and social care services and the 
financing of  the  system is  fragmented. Until  now, 
Slovenia  has  focused  its  limited  spending  on 
institutional  care  rather  than  home  care.  Over  the 
the  government  has  been 
last  fifteen  years 
preparing a new umbrella regulation, which would 
bring all the different recipients and benefits under 
one rule.  A new draft  legislative proposal aims to 
establish a fiscally sustainable and accessible LTC 
system  which  combines  the  health  and  social 
aspects of care with integrated LTC services, with 
emphasis  on  prevention  and  strengthening  the 
capabilities  of  the  user,  with  the  aim  of  later 
transition into higher categories of dependence on 
the assistance of another person. At the same time 
it is necessary to strengthen e-care and reduce the 
administrative  burden  (with  the  aim  of  directing 
human resources to working with users rather than 
bureaucracy).  The 
the 
legislation  was  in  public  discussion  and  inter-
ministerial  coordination  in  2017  and  awaits  the 
new  government  which  will  proceed  with  the  law 
drafting.  However  it  seems  that  the  revised  draft 
will  have 
to  undergo  an  additional  public 
consultation  as  currently  there  is  no  consensus  on 

last  draft  version  of 

(576) European Commission (2018), Fiscal Sustainability Report 
https://ec.europa.eu/info/sites/info/files/economy-

(2018) 
finance/ip094_en_vol_2.pdf. 

466 

how the element of financing should be solved. In 
the  spring  of  2015,  a  comprehensive  analysis  of 
the Slovenian health care system has started, in the 
context of which an analysis of long-term care was 
also  carried  out.  The  analysis  was  completed  in 
December  2015.  Key 
findings  are  hereby 
presented (577). 

Long-term care expenditure in Slovenia represents 
only  a  small  component  of  GDP,  and  is  much 
lower  than  health  care  spending,  but  is  growing 
much  more 
  Even  on  optimistic 
assumptions  about  the  levels  of  disability,  the 
effects of demographic change  will be to increase 
expenditure  on  long-term  care  by  more  than  50% 
by 2035. 

rapidly. 

There  are  four  main  public  funding  sources  for 
long-term care, but nearly half of the public long-
term  care  spending  is  by  the  Health  Insurance 
Institute. 

in 

The Health Insurance Institute  will see the largest 
absolute  growth 
long-term  care  spending 
because  of  its  focus  on  long-term  care  for  older 
people.    The  Ministry  of  Labour  will  see  only  a 
smaller increase given the focus on long-term care 
for non-elderly people. 

Private  spending  on  long-term  care  is  almost  all 
out-of-pocket  spending  by  recipients  and  this  has 
been growing significantly.  On current policy and 
practice this would increase rapidly (given that the 
services  paid  for  privately  are  likely  to  grow 
rapidly) and this might not be sustainable. 

There  is  unnecessary  complexity  in  the  current 
public  funding  of  long-term  care  that  leads  to 
confusion 
in 
brokering  access  to  combinations  of  services 
needed  by  users,  and  this  may  be  a  factor  in  the 
over reliance on residential care. 

entitlements,  difficulty 

about 

Consideration  should  be  given  to  reducing  the 
complexity  of  (particularly  the  public)  funding  of 
long-term care.  This  might be achieved either by 
shifting  responsibility  to  a  single  government 

(577) Analysis  of  Health  Care  System  in  Slovenia.  European 
Observatory  for  Health  Care  Systems,  WHO  and  the 
: 
Ministry  of  Health  of 
http://www.mz.gov.si/fileadmin/mz.gov.si/pageuploads/An
aliza/24_11_2015/Long_Term_Care_in_Slovenia_Charles
_Normand.pdf. 

the  RS.  Available  at 

 
                                                           
                                                           
Long-term care systems 

3.25. Slovenia 

department  and/or  agency,  or  by  mechanisms  that 
aim  to  co-ordinate  the  spending  and  entitlements 
between the different funding organisations. 

Consistently  with  the  findings  of  the  Ageing 
Report,  this  study  shows  that  long-term  care 
spending is likely to grow rapidly. In addition, the 
rate  of  growth  will  vary  hugely  between  the 
different  public  funders  of  care.    With  a  much 
longer  time  scale  it  would  be  possible  to  derive 
more precise estimates of the changing costs to the 
different  drivers,  but  the  current  calculations 
display clearly the patterns of likely change. 

As  mentioned  above,  different  forms  of  services 
and  benefits,  which  could  be  classified  as  LTC 
services  are  provided  by  different  systems 
(healthcare, pension, social and parental protection 
etc) and are regulated by different acts from these 
areas.  

Long-term care in Slovenia includes cash benefits 
and  benefits  in  kind  (health  care  and/or  social 
services  for  institutional  care  and  only  social 
services  for  home  care).  Health  care  services 
which could be classified as long-term care are not 
available  in  home  care  settings.  The  provision  of 
community based social and healthcare services is 
not  well  coordinated  between  providers  of  health 
and  social  care  services  and  the  financing  of  the 
system  is  fragmented.  Until  now,  Slovenia  has 
focused  its  limited  spending  on  institutional  care 
than  home  care.  Cash  benefits  and 
rather 
institutional  care  are  organised  centrally  whereas 
home care services are provided on a local level.  

beneficiaries  of  minimum  income)  (579).  Cash 
benefits  which are directed to persons  with  health 
care  needs  or  with  limitation  in  performing  basic 
activities of daily living (ADL) ( 580), are financed 
from the Pension and Disability Fund and partially 
by  the  state  budget  (Ministry  of  Labour,  Family, 
Social Affairs and Equal Opportunities) (581).  

Social  services  which  could  be  classified  as  long-
term care are partially financed from the state and 
the  municipalities’  budgets,  and  partially  paid  by 
the  users  (recipients).  Out-of-pocket  payments  for 
social  care  services  depend  on  the  financial 
situation of a person in need. In case a person has 
insufficient  financial  means,  the  relatives  and/or 
the  municipality  cover  expenses  of  residential  or 
home care services. Health and social care services 
which  can  be  classified  as  long-term  care  for 
disabled  children  and  disabled  youth  in  full-time 
education are entirely (in the case of youngsters in 
full-time tertiary education only partially) covered 
by the health care insurance and the state budget. 

Providers  guaranteeing  different  services  within 
the  scope  of  institutional  forms  of  assistance 
integrate  health  care  and  social  areas,  while  the 
assistance has not been integrated in the context of 
forms provided in the living home environment.  

At the beginning of 2016, the National Parliament 
adopted the Personal Assistance Act, which will be 
implemented  in  2019.  The  law  regulates  the  right 
for  active  working 
to  a  personal  assistant 
population with disabilities who need more than 30 

and 

services) 

community 

Funding  for  long-term  care  expenditure  comes 
from  several  sources.  Health  care  benefits  in  kind 
(institutional 
are 
financed  from  the  compulsory  (99%)  and  the 
complementary  (1%)  health  care  insurance  (578). 
Currently,  the  regulation  of  obligatory  social 
insurances is made in a way that contributions are 
paid by both employers and employees (including 
self-employed). Inactive persons are insured either 
through  their  active  close  relatives  (children  and 
youngsters  in  full-time  education)  or  the  reduced 
contributions for them are paid from the state and 
municipalities’  budgets  (pensioners,  unemployed, 

(578) Yearly  data  on  national  health  expenditure  prepared  in 
accordance  with  System  of  Health  Accounts  2011 
methodology; also available in OECD Stat 2018. 

(579) For  example,  in  Slovenia  there  are  more  than  600,000 
pensioners,  and  they  do  not pay  directly  any  public  social 
insurance  contributions 
(part  of  compulsory  health 
insurance  for  them  is  covered  from  the  state  budget)  and 
are  nearly  100% 
the  voluntary  private 
additional health care insurance. 

included 

in 

(580) Basic  Activities  of  Daily  Living  (ADL)  include  bathing, 
dressing, eating, getting in and getting into and out of bed 
or  chair,  moving  around  and  using  the  bathroom.  Often 
they  are  referred  to  as  “personal  care”  (Colombo  et  al. 
2011).  According  to  the  System  of  Health  Accounts 
methodology  (OECD,  WHO,  Eurostat,  2011)  expenditure 
related to provide help to people with ADL limitations are 
classified  under  code  HC.3  as  LTC  health  expenditure 
which  means  that  are  included  also  in  health  expenditure. 
However,  expenditure  for  LTC  social  services  (related  to 
IADL limitation – Instrumental Activities of Daily Living) 
are  classified under  code  HC.R.1.  LTC  social  expenditure 
are included in total LTC expenditure (HC.3 plus HC.R.1), 
but excluded from health expenditure.  

(581) Pension  insurance  contributions  would  represent  as  much 

as 2.4% of health care financing. 

467 

 
                                                           
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

hours of assistance per week (ADL and IADL) and 
are not treated in the institutional care. 

care was provided for 5.9% of population aged 65 
years and over (585). 

Types of care 

then, 

For  systematic  statistics  and  monitoring  of 
performance and development of long-term care an 
inter-institutional  working  group  for  statistical 
monitoring of the system was set up in 2012 (582). 
The results of the working group were published in 
2014  (583).  Since 
the  Inter-institutional 
Working  Group  for  statistical  monitoring  at  the 
Statistical Office of RS has no longer been active, 
and has been replaced by a newly established inter-
institutional  working  group  for  the  monitoring  of 
long-term  care (584).  The  working  group  members 
are  representatives  of  the  relevant  government 
departments, representatives of the professions and 
academics. 

Four  modes  of  long-term  care  provision  are 
included  in  the  current  system  of  long-term  care: 
in-patient  care  (institutions),  day-case  care,  home 
care  and  cash  benefits  (according  to  the  SHA 
framework).  

Inpatient  long-term  care  (institutional  care)  is 
organised  by  homes  for  the  elderly,  special  social 
institutions,  centres  for  training,  occupation  and 
care  and  centres  for  education  of  children  with 
special needs. There were 22,415 people altogether 
residing  in  these  institutions  at  the  end  of  2015; 
mainly  in  homes  for  elderly.  Inpatient  long-term 

(582) Appointed  by  the  Statistical  Office  of  the  Republic  of 
Slovenia  and  led  by  Social  Protection  Institute  of  the 
Republic  of  Slovenia.  The  working  group,  which  is  no 
longer  active,  included  representatives  of  all  main  actors 
providing  data  on  services  and  benefits  which  could  be 
classified  as  LTC  services  and  benefits  (in  addition  to 
already  mentioned 
of 
institutions, 
Macroeconomic  Analysis  and  Development,  the  Ministry 
of Labour, Family Social Affairs and Equal Opportunities, 
the Ministry of Health, the Slovenian Community of Social 
Institutions,  the  National  Institute  of  Public  Health,  the 
Pension  an  Disability  Insurance  Institute,  the  Institute  for 
Economic  Research  and  the  Health  Insurance  Institute  of 
Slovenia). 

Institute 

the 

(583) Source:  Nagode,  Mateja,  Eva  Zver,  Stane  Marn,  Anita 
Jacović,  Davor  Dominkuš.  Long-term  care  –  use  of 
international  definition  in  Slovenia.  Working  paper  No. 
2/2014 XXIII. Ljubljana: IMAD.  

(584) Decision of the Minister no. 0241-2 / 2017 from 11.4.2018. 

468 

There  were  less  than  500  users  of  organised  day 
care,  which accounts  for 0.1% of population aged 
65  years  and  over.  They  were  mainly  included  in 
day care organised by homes for elderly. 

Home-based  care  is  organised  by  community 
nursing care, home help, family assistant, personal 
assistance  and  housing  groups.  More  than  21,600 
people  received  this  kind  of  care  at  the  end  of 
2015;  mostly  community  nursing  care  and  home 
help.  Home-based  care  was  provided  to  5.7%  of 
population aged 65 years and over. 

Regarding  the  total  number  of  cash  benefits 
recipients  in  2015  there  were  almost  42,000 
recipients  of  cash  benefits  (Attendance  and 
Allowance Supplement based on 6 different acts), 
of which around 62% were aged 65 years and over 
and  40%  were  aged  more  than  80  years;  about 
60%  were  women  and  40%  men.  However,  if  we 
are  taking  into  account  overlapping  between  cash 
benefits  and  services  in  kind,  there  were  only 
16,570  recipients  of  cash  benefits  who  only 
received cash benefit and were not included in any 
other  service  classifiable  as  long-term  care.  Cash 
benefits  only  were  received  by  4.4%  of  the 
population aged 65 years and over.  

that 

institutions) 

is  estimated 

It 
there  were  altogether 
approximately  sixty  thousand  recipients  of  formal 
services  classifiable  as  long-term  care  and  cash 
benefits  at  the  end  of  2015;  this  accounts  for 
16.1%  of  population  aged  65  years  and  over. 
Inpatient  care  (in 
is  very  well 
developed  and  spread  in  Slovenia.  It  has  a  long 
tradition.  Community  nursing  care  is  also  well 
spread  and  developed.  On  the  other  hand,  home-
based social care started to develop approximately 
twenty years ago and it is still not well developed. 
Even  though  the  number  of  people  receiving 
home-based  services  which  can  be  classified  as 
long-term care is relatively high, the care is not as 
intensive  and  comprehensive  as  in  the  case  of 
institutional care and services of health and social 
care are not integrated. 

(585) Source: 

the 
https://www.stat.si/StatWeb/en/News/Index/7116. 

Statistical 

Office 

of 

RS;   

 
                                                           
                                                           
Eligibility criteria 

There is no definition of long-term care, no unified 
entry  point  nor  a  model  of  long-term  care  needs 
assessment.  The  eligibility  for  a  health  or  social 
service  which  could  qualify  as  long-term  care  is 
linked to the service in question and is  made by a 
team  of  professional  workers  (in  the  case  of 
institutional care) or by an individual professional 
worker  (in  the  case  of  home  care).  Cash  benefits 
are  granted  upon  application  and  approval  of  the 
expert team (assessing the care needs). 

Co-payments, out of the pocket expenses and 
private insurance  

Benefits  in  kind  are  income  tested,  taking  into 
account recipient, spouse and children. 

Out-of-pocket  payments  depend  on  the  financial 
ability  of  a  person  entitled.  In  case  a  person 
entitled 
financial  means, 
municipalities  cover  expenses  of  residential  or 
home care services. 

insufficient 

has 

Based on the rules set by the government (Decree 
on criteria for defining exemptions in the payment 
of the services, OG RS 110/04,124/04,114/06) the 
competent local "Centre for Social Work" decides 
on partial or complete exemption of the user from 
the payment of the services. The decree defines the 
social  security  threshold,  set  as  an  amount  of 
money  that  has  to  remain  at  disposal  of  the  user 
after  the  payment  of  the  services.  Further,  the 
decree  defines  the  ability  to  pay  as  the  maximum 
amount  up to  which the  user  is able to participate 
in  the  payment  of  these  services.  The  payment 
contribution is the amount that needs to be paid to 
the provider of the services and the exemption from 
the  payment  is  defined  as  the  amount  which  the 
user of the service is not able to pay according to 
his/her calculated ability to pay. 

The exemption from the payment is defined as the 
difference  between  the  value  of  the  service  and 
user's  contribution,  whereas  the  exemption  of  the 
one, who is liable to pay for the services, is defined 
as  the  difference  between  the  amount  of  the 
exemption  of  the  payment  of  the  user  of  the 
services  and  the  payment  contribution.  The  one 
being liable for the payment is a physical or legal 
entity that is not a family member and is obliged to 
pay the costs of the services. If the contributions of 

Long-term care systems 

3.25. Slovenia 

the  user  and  the  liable  person  do  not  cover  the 
costs  of  the  services,  the  difference  between  the 
value of the services and both contributions is paid 
by  the  local  community  or  the  state.  In  this  case 
the user must ask the competent "Centre for Social 
Work"  for  the  exempt  from  payment  of  all  the 
costs. 

to 

the  criteria  defined 

Additionally 
the 
aforementioned decree, the local communities can 
decide  on  additional  exemptions  from  payment  of 
the costs of home care services. 

in 

If  the  user  of  the  service  who  is  asking  for  the 
exemption  from  payment  of  the  services  is  the 
owner  of  a  real  estate  property,  the  issuing  of  the 
written order on exemption from payment contains 
the prohibition from alienation or burdening of this 
real  estate  to  the  credit  of  the  municipality  which 
finances  the  institutional  care  of  the  user.  If  the 
user  asks  for  the  exemption  from  the  payment  of 
home care services, the prohibition from alienation 
or  burdening  is  issued  only  for  real  estate  in  the 
property  of  the  user  which  is  not  used  as  the 
permanent residence of the user. 

A  family  assistant  has  a  right  to  the  partial 
coverage  of  the  lost  income  on  the  level  of  the 
minimal  wage  or  to  the  proportional  coverage  of 
the lost income if he/she stays in a shorter than full 
time  employment.  The  family  assistant  has  full 
pension and disability insurance contributions paid 
the  case  of 
as  well  as  contribution 
unemployment and parental leave. The time  spent 
for  providing  the  services  as  family  assistant  is 
included  into  the  pensionable  period  (which  is  a 
condition  for  receiving  old  age  pension  after 
retirement). 

for 

Total  (public  and  private)  expenditure  on  long-
term  care  in  2015  amounted  to  roughly  1.26%  of 
GDP  (in  2016  1.24%  of  GDP)  (586).  The 
expenditure for long-term care has been increasing 
over the years, from 1.08% GDP recorded in 2005. 
This  is  mainly  due  to  an  increased  number  of 
users.  In  addition,  private  expenditure  has  been 
increasing  much  faster  than  public  expenditure. 
Hence, in terms of financing sources, the share of 
total  long-term  care  accounted  for  by  private 
expenditure  increased  in  the  period  2005-2013 

(586) Source: 

the 
https://www.stat.si/StatWeb/en/News/Index/7478. 

Statistical 

Office 

of 

RS; 

469 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

(587),  which  has  important  implications  from  the 
social  point  of  view,  i.e.  affordability  of  formal 
care and quality monitoring of informal care (588). 

Role of the private sector  

The providers of services can be public or private 
entities.  Private  providers  are  selected  through 
public  tenders  and  are  granted  concession  with 
limited  duration;  they  have  to  fulfil  the  same 
conditions  as  public  providers.  The  standards  for 
provision of services are quite strict (regarding the 
staff,  qualifications,  procedures, 
number  of 
technical equipment and premises) and are defined 
by the state in the case of social care services (both 
institutional  and  home-based  care),  and  by  the 
Health Insurance Institute in the case of health care 
(institutional and community) services.  

Institutional  care  is  organised  within  the  network 
of  institutions  for  elderly,  disabled  adults  and 
severely  disabled  children.  Persons  staying  in 
residential care are provided with integrated health 
and 
costs  of 
services.  The 
care 
institutional 
accommodation  are  also  part  of 
service. 

social 

Community  nursing  and  home  help  are  regulated 
within  different  regulatory  systems.  Therefore 
providers  are  not  the  same  and  operate  separately 
under  different  regulatory  systems.  Community 
health  services  including  services  that  qualify  as 
long-term care are provided by community nurses 
who  are  employed  by  local  health  centres  or  are 
given  a  concession.  They  perform  preventive  and 
health education services, health-related services at 
home  and  to  a  certain  extent  also  home  help 
services.  They  are  one  of  the  first  professional 
workers  to  identify  health  and  social  hardship  as 
well  as  the  needs  of  individual  persons  and  their 
families for home and long-term care.  

Home help is adjusted to the needs of an individual 
and 
(IADL); 
assistance  in  essential  daily  activities  (ADL)  and 

includes  housework  assistance 

(587) From  22.2%  to  26.3%,  respectively.  Source:  Statistical 
RS; 

office 
https://www.stat.si/StatWeb/en/News/Index/7478.  

the 

of 

(588) Note that at-risk-of-poverty rates among elderly people are 
over-average and the average monthly pensions are relative 
low (around € 560 in 2015). In this context the increase in 
the  out-of-the-pocket  contributions  can  lead  to  social 
problems in the future as it puts affordability of formal care 
at risk. 

470 

assistance  in  maintaining  social  contacts.  The 
"Social  Protection  Institute"  carried  out  a  few 
analysis of the situation of home care in Slovenia. 
The  last  analysis  (Lebar  et  al,  2015  (589)  showed 
that  home  help  is  provided  mainly  by  public 
agencies  (i.e.  centres  for  social  work  and  homes 
for  older  people)  and  only  few  were  private 
organisations with concessions. 

Formal/informal caregiving 

Formal  long-term  care  caregivers  (590)  must  meet 
to  education  and  other  working 
in  relation 
conditions  strict  rules.  Some  non-professional 
providers  (family  assistant  or  personal  assistant) 
must  already 
in  special  education 
their 
programs.  Educational  programs 
frequency  are  defined  by  the  "Social  Chamber" 
and  approved  by 
the  "National  Professional 
Council".  

take  part 

and 

Until  a  few  years  ago,  Slovenia  had  no  national 
policy that would deal with informal family carers 
(591)  directly.  There  were  some  acts,  which 

za 

varstvo. 

socialno 

Available 

(589) Lebar, L., Kovač,N., Nagode, M. (2015) Izvajanje pomoči 
na  domu.  Analiza  stanja  za  leto  2014.  Ljubljana:  Inštitut 
RS 
at: 
https://www.irssv.si/upload2/pnd/IRSSV%20Izvajanje%20
pomoci%20na%20domu%20-
%20analiza%20stanja%20v%20letu2014_koncno.pdf.  
(590) Carers  in  inpatient  LTC  (in  institutions):  Latest  available 
data  of  Associations  of  social  institutions  of  Slovenia 
indicate  that  there  were  9,943  people  employed  in  homes 
for  elderly  and  special  social  institutions  in  December 
2012.  Out  of  these,  there  were  4,823  people  employed  in 
social care and 4,776 people in health care (344 in others). 
According to the data of Statistical Office of the Republic 
of Slovenia there were 1,036 carers employed in centres for 
protection and training – 907 in social services, 61 in health 
care services and 68 in training services (employment).  
Carers in home-based LTC: According to the data of Social 
Protection Institute of the Republic of Slovenia there were 
62.4  coordinators  of  home help at  the  end  of 2012.  Home 
help  was  carried  out  by  911  carers,  92.7%  of  them  were 
regularly  employed.  In  10.6%  local  municipalities  there 
was a shortage of carers. According to the data of National 
Institute  of  Public  Health  there  were  altogether  821 
community nurses in Slovenia at the end of 2012 (covering 
the  whole  field  of  community  nursing  and  home  care  not 
only LTC). Ministry of Labour, Family, Social Affairs and 
Equal  Opportunities  reports  that  there  were  745  family 
assistants in 2012 and around 800 personal assistants. 
(591) Informal  carers:  The  results  of  SHARE  survey  for  2013 
show  that  in  Slovenia  around  48,000  people  aged  50  or 
more  provided  personal  care  or  home  help  to  a  person 
outside  their  own  household  (6.5  %  of  respondents)  and 
around 37,000 people aged 50 and over provided personal 
care  within  their  own  household  (6.1%  of  respondents). 
Similar  share  of  respondents  was  for  countries 
in 
in  Scandinavian 
(5-8%), 
Continental  Europe 

lower 

 
                                                           
                                                           
 
informal 

indirectly  concerned 
family  carers: 
Pension and Disability Insurance Act mentions the 
right  to  attendance  allowance;  Health  Care  and 
Health Insurance Act the right to compensation for 
care-giving to a close family member, with whom 
the insured lives in a common household and  Act 
Amending  the  Social  Security  Act  that  enables 
family  carers  as  family  assistants  to  get,  under 
specific  rules,  a  financial  compensation.  Since 
2006  several  strategic  documents  were  adopted 
that  emphasize  the  importance  of  informal  carers, 
mainly  to  give  adequate  training  and  services  on 
the  local  level  (day  care,  respite  care)  to  the 
families  who  care  for  a  disabled  elderly  family 
member  and  to  support  measures  allowing  more 
flexible  working  arrangements  (the  right  for  part-
time work without the danger that the carer would 
lose social security).  

Prevention 
policies/measures 

and 

rehabilitation 

In 2011, Slovenia started to develop the network of 
model  practices  within 
the  family  medicine 
practice  where  the  preventive  activities  for  the 
chronically  ill  or  users  of  long-term  care  in  the 
home  environment  are  exercised.  More  than  340 
model practices are already operating. 

Rehabilitation  programs  related  to  long-term  care 
are systematically carried out in the framework of 
the  activities  of  homes  for  the  elderly  and  are 
funded  by  health  insurance  institute.  There  is  a 
lack of such programs in local communities. 

Recently 
reforms  

legislated  and/or  planned  policy 

Over the last 15 years there were several attempts 
to  prepare  the  long-term  care  system  reform. 
Several  drafts  of  the  act  that  would  regulate  the 

countries  (3.5%)  and  higher 
in  Southern  European 
countries  (9-11%).  (Nagode,  M.  in  Srakar,  A,  2015. 
Značilnosti  starejšega  prebivalstva  v  Sloveniji  –  prvi 
rezultati raziskave Share, Institut za ekonomske raziskave, 
2015).  Research  done  by  Anton  Trstenjak  Institute  of 
gerontology  and  intergenerational  relations  show  similar 
situation that in Slovenia more than 55,000 people aged 50 
or  more  is  taking  care  of  their  parents    and  more  than 
50,000 of their frail partner (Ramovš, J., Lipar,T., Ramovš, 
M.  (2014)  Oskrba  v  onemoglosti.  V:  Ramovš,  Jože  (ur) 
Staranje v Sloveniji – raziskava o potrebah, zmožnostih in 
stališčih nad 50 let starih prebivalcev Slovenije. Ljubljana: 
Inštitut Antona Trstenjaka). 

Long-term care systems 

3.25. Slovenia 

whole  system  of  long-term  care  and  the  potential 
(new)  compulsory  insurance  for  long-term  care 
were  prepared  by  different  stakeholders  (Ministry 
of  Labour,  Family,  Social  Affairs  and  Equal 
Opportunities,  Health  Ministry,  Association  of 
Providers  of  Institutional  Care,  NGO  Pensioner’s 
Association).  The  differences  between  draft  acts 
prepared  by  different  stakeholders  were  not  so 
much in the content (arrangements of the system), 
but  mostly  in  the  approach  to  financing  the  long-
term care system.  

The  need  for  long-term  care  system  reform  and 
plans  for 
it  also  became  part  of  strategic 
documents, such as the main national development 
strategy  in  the  area  of  social  protection,  the 
"Resolution  on  the  National  Programme  of  Social 
Protection  for  the  period  2013-2020"  and  the 
strategic  document  for 
the 
“Resolution on the National Healthcare Plan 2016 
-2025: Together  for  the  society  of  health”,  passed 
in the parliament in March 2016 and envisaging: 

the  health  care, 

1)  the  integration  of  health  and  social  services  in 
the area of long-term care; 

2)  strengthening  of  rehabilitation,  reintegration, 
and prevention for all age groups;  

3)  securing  sufficient  funds  for  health  and  long-
term care based on solidarity principles. 

Besides  the  plan  for  long-term  care  reform  both 
documents  emphasises 
the  development  of 
community  based  services  and  unification  of 
health  and  social  home  care  services.  In  the  draft 
operational programme for the use of structural EU 
the 
funds 
emphasis  is  also  on  de-institutionalisation  and 
support  for  development  of  community  based 
services  (such  as  day  centres,  smaller  residential 
units, etc.).  

the  new  financial  perspective, 

in 

Since  2012,  the  long-term  care  reform  is  high  on 
the  political  agenda.  A  working  group  for  the 
methodological,  statistical  and  financial  issues 
regarding  LTC  was  established  in  2012  (592).  At 
the  end  of  2013,  the  government  adopted  the 
starting  points  of  the  reform  of  LTC  system, 
including  the  calendar  for  the  reform.  It  was 
agreed that the  first  step of the reform  will be the 

(592) See reference 9. 

471 

 
                                                                                   
 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

preparation  and  adoption  of  new 
legislation 
covering the whole LTC system and thus unifying 
it. A working group for the preparation of the new 
legislative  act  was  established,  composed  by 
representatives  of  three  ministries  (covering  areas 
of health, social affairs and finances), associations 
of  users,  associations  of  service  providers,  the 
Health  Insurance  Institute,  the  Pension  Insurance 
Institute  and 
the  Institute  of  Macroeconomic 
Analysis and Development.  

However,  for  several  reasons  (also  conflicting 
interests and lack of political agreement) the health 
care  reform  was  stopped  and  is  again  planned  in 
the  coalition  agreement  to  be  carried  out  by  the 
current  government.  In  the  spring  of  2015,  a 
comprehensive  analysis  of  the  health  care  system 
has started, in the context of  which an analysis of 
long-term  care  was  carried  out.  The  analysis  was 
completed  in  December  2015.  One  of  the  main 
conclusions  of  the  analysis  of  the  health  care 
system  was  that  the  reform  of  the  health  system 
and  the  system  of  long-term  care  should  be 
prepared  in  a  coordinated  manner  and  that  the 
activities  in  this  regard  should  be  carried  out  in 
2016. Drafting of a new law on long-term care has 
been  one  of 
the  present 
the  priorities  of 
government since 2016. Key actors in this area are, 
the 
in  addition 
ministry  responsible  for  social  affairs  and  the 
ministry responsible for health.  

to  many  other  stakeholders, 

the  new 

legislation,  Slovenia  plans 

to 
With 
introduce  solidarity-based  financing  of  long-term 
care,  based  on 
the  principles  of  social-risk 
insurance. The main aim of the reform is to ensure 
fiscal  sustainability  of  the  long-term  care  system, 
on the one hand, and to increase social security and 
quality  of  life  of  persons  depending  on  care  and 
assistance of other people for performing basic and 
supportive  life  activities,  on  the  other  hand.  The 
the 
(reformed)  system  should  provide 
new 
availability and access to quality services that will 
enable  care  and  support  to  individuals  in  need, 
especially 
community 
environment. 

at  home 

local 

and 

The  reformed  long-term  care  system  should  also 
have  a  positive  effect  on  the  reduction  of  poverty 
among  elderly  people  (which  is  above  average 
now).  As  pensions  are  relatively  low,  and  the 
extent of out-of-pocket payments of people in need 
has been increasing, this currently puts pressure on 

472 

the budgets of elderly and their families. With the 
planned  system  of  long-term  care  financing,  the 
out-of-pocket  contributions  would  be  reduced  and 
economically 
for 
even 
disadvantaged. 

eliminated 

the 

By  the  end  of  the  year  2016,  the  government 
decided  to  transfer  the  responsibility  for  the 
preparation  of  the  Long-Term  Care  Act  from  the 
ministry  responsible  for  social  affairs  to  the 
Ministry of Health, where the Directorate for long-
term  care  was  established  on  1st  January  2017. 
With  this  transfer,  also  the  coordination  of  the 
integrated  providers’  network  development  and 
coordination  of  pilot  projects  in  the  area  of  long-
term  care  was  transferred  to  the  Ministry  of 
Health. The preparation of the Long-term care Act 
was intensified and submitted into public debate in 
autumn  in  2017,  and  currently  awaits  the  new 
government  which  will  proceed  with  legislative 
procedure. 

The  draft  act  is  based  on  the  agreement  that  the 
need  for  long-term  care  is  a  new  social  risk  for 
which the residents of Slovenia have to be insured 
within  the  system  of  public  social  insurances  and 
on  the  universal  right  to  long-term  care.  The  new 
act will also try to ensure that users have the access 
to  quality  integrated  services,  mainly  in  the  local 
environment 
and  home  based 
services) or cash benefits. 

(community 

The new act  will be titled "Act on long-term care 
and compulsory insurance for long-term care" and 
will regulate both the provision of services and the 
financing  of  the  system:  with  introduction  of 
public  compulsory 
insurance,  and  additional 
possibility  of  voluntary  private  insurance  for  non-
standard  services  and  accommodation  costs  in 
institutional care facilities.   

Thus the Act will regulate: 

•  LTC insurance and financing of activities; 

•  definition of beneficiaries and rights (services); 

•  procedure  of  claiming  the  rights  (including 

needs assessment); 

•  provision of LTC services; 

 
•  providers  of  LTC  services  and  public  network 

of providers; 

•  quality and safety; 

•  monitoring and information system; 

•  connection  with  the  health  and  social  care 

system. 

The  draft  act  envisages  a  single  entry  point  and  a 
uniform procedure for eligibility assessments. The 
person  in  need  will  take  part  in  the  assessment 
procedure and will at the end decide for the type of 
care and support needed and preferred (services or 
cash-benefit or personal assistant).  

The  Social  Protection  Institute  of  RS  conducted 
with  the  partners  a  pre-pilot  project  to  test  and 
adapt the chosen assessment tool and procedure for 
the  eligibility  criteria  and  the  personal  planning 
procedure in 2017. 

If  the  person  in  need  decides  for  cash-benefits  to 
be  used  for  informal  domestic  care  or  for  a 
personal assistant, the user is entitled to 14 days of 
respite care and the informal carer has the right to 
appropriate  training  and  advice.  Other  planned 
elements of the system are the supervision over the 
domestic  care,  the  final  decision  on  the  threshold 
of  the  need  of  ADL  services,  the  scope  and  the 
content of the rights and provisions. 

The  new  system  should  encourage  independent 
living,  user  engagement  and  the  use  of  ICT  in 
long-term care.  

care 

Merging of different sources of financing of long-
term 
provide  more 
transparency and effectiveness of financing of this 
area.  

system 

should 

Individual  planning,  participation  of  users  in  the 
process  of  preparation  of  personal  care  plans  and 
the  responsibility  of  providers  for  realisation  of 
individual  care  plans  are  the  planned  mechanisms 
that  should  also  ensure  more  effective  use  of 
funds.  

reorientation 

from  currently  prevailing 
The 
institutional  (residential)  care  to  more  community 
based  and  home  based  care  should  as  well  have 

Long-term care systems 

3.25. Slovenia 

positive  financial  effects  on  the  budget  (less  new 
investments  for  institutional  infrastructure  and 
redirection of funds to new jobs in community and 
home  based  services).  However  this  option  is  at 
this  stage  explicitly  not  among 
future 
intentions  of  the  government,  who  does  not 
envisage  any  restriction  to  institutional  care  (593). 
Strengthening  of  preventive  activities  (healthy 
ageing),  rehabilitation  and  the  use  of  ICT  should 
additionally decrease the costs of long-term care. 

the 

However,  one  of  the  crucial  issues  related  to  the 
reform  is  still  how  to  separate  the  costs  of  long-
term care system from the costs of the health care 
system  and  how  to  ensure  an  additional  stable 
source  which  would  contain  the  rapid  increase  in 
annual household expenditures for long-term care.  

The  calculation  of  the  financial  impact  of  the 
proposed  solutions  in  the  new  Long-Term  Care 
Act  aims  to  also  take  into  account  the  increase  in 
labour  costs  due  to  recent  agreement  between  the 
government and trade unions presenting the public 
sector. 

As part of preparations for the introduction of the 
new  legislation,  the  educational  curriculum  for 
various  profiles  at 
level  was 
supplemented,  in  order  to  integrate  the  health  and 
social  content  of  the  educational  programs  on  the 
one  side  and  to  provide  integrated  delivery  of 
services at the other side. 

the  secondary 

Challenges 

Slovenia  has  a  relatively  fragmented  system  of 
long-term care, with future sustainability concerns, 
especially in light of high out-of-pocket payments. 
The main challenges of the system appear to be: 

•  Improving  the  governance  framework:  to 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of responsibilities of state authorities wrt to the 
provision of long-term care services; to set the 
public  and  private  financing  mix  and  organise 
formal  workforce  supply  to  face  the  growing 
number  of  dependents,  and  provide  a  strategy 

(593) According to article 5 of the Social Security Act, “rights to 
services  and  financial  social  assistance  in  Slovenia  are 
exercised  on 
the  principles  of  equal 
accessibility  and  free  choice  of  forms  for  all  beneficiaries 
under the conditions laid down by law”. 

the  basis  of 

473 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

to  deliver  high-performing 
long-term  care 
services  to  face  the  growing  demand  for  LTC 
services also by adopting and implementing the 
necessary legislative acts to reform the current 
long-term care system; to strategically integrate 
health  and  social  services  via  such  a  legal 
framework; 
information 
to  establish  good 
platforms  for LTC users and  providers, setting 
up a system of records to  monitor the existing 
situation  and  improve  planning;  to  share  data 
within government administrations  to facilitate 
the  management  of  potential 
interactions 
between  LTC  financing,  targeted  personal-
income 
(e.g. 
pensions),  and  existing  social-assistance  or 
housing subsidy programmes. 

tax  measures  and 

transfers 

•  Improving financing arrangements: to foster 
pre-funding  elements,  which  implies  setting 
aside some funds to pay for future obligations; 
to  define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC services and its financing. 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage; the depth of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits;  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage; to reduce the risk of 
impoverishment  of  recipients  and  informal 
carers. 

to 

new 

legislative 

•  Encouraging  home  care  and  independent 
living:  to  develop  alternatives  and  improve 
institutional  care  by  e.g. 
eligibility 
developing 
frameworks 
encouraging  home  care,  cash  benefits  or 
financial  incentives  to  encourage  home  care; 
developing  services  in  community  care  which 
are  currently  not  accessible  and  would  reduce 
the  pressure  on  institutions;  to  monitor  and 
to  provide 
evaluate  alternative 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

services, 

through 

including 

and future needs for qualified human resources 
and  facilities  for  long-term  care;  to  improve 
recruitment  efforts, 
the 
migration of LTC workers and the extension of 
recruitment  pools  of  workers;  in  addition,  to 
continue  supporting  informal  carers,  such  as 
through  flexible  working  conditions,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons. 

the 

•  Ensuring  coordination  and  continuity  of 
care:  to  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
the  allocation  of  care  co-
information, 
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health and long-term care: to steer LTC users 
towards appropriate settings. 

•  Changing payment incentives for providers: 
to  consider  a  new  payment  model  and  a 
focused use of budgets. 

•  Improving  value  for  money:  to  encourage 
competition across  LTC providers to stimulate 
productivity enhancements and digitalisation if 
based  on  cost-effective  solutions;  to  invest  in 
assistive devices,  which for example,  facilitate 
co-
self-care,  patient 
ordination between health and care services.  

centeredness, 

and 

•  Prevention: to further the efforts in promoting 
healthy  ageing  and  preventing  physical  and 
mental  deterioration  of  people  with  chronic 
care; 
to  employ  prevention  and  health-
promotion policies and identify risk groups and 
detect morbidity patterns earlier. 

•  Improving 

efficiency 
administrative 
including  by  simplifying  the  procedures  and 
employing 
IT  solutions  based  on  cost-
efficiency considerations. 

•  Ensuring  availability  of  formal  carers  and 
support to family carers: to determine current 

474 

 
 
Table 3.25.1:  Statistical Annex – Slovenia 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

29
23.2
2.0

0.7
:
1.5

80.9
73.9
60.1
56.4
:
:

32
23.7
2.0

0.6
:
1.4

82.0
74.5
61.0
57.7
36.5
8.4

35
24.3
2.0

0.6
:
1.4

82.0
74.6
62.3
58.7
37.7
7.9

38
23.9
2.0

0.7
:
1.5

82.6
75.5
60.9
59.4
39.3
9.7

36
20.7
2.0

0.7
:
1.5

82.7
75.9
61.5
60.6
30.9
10.5

36
21.2
2.0

0.7
:
1.5

83.1
76.4
54.6
53.4
36.1
12.1

37
21.5
2.1

0.7
:
1.5

83.3
76.8
53.8
54.0
36.3
13.0

36
21.5
2.1

0.9
:
1.8

83.3
77.1
55.6
56.5
35.3
11.5

36
21.2
2.1

0.8
:
1.4

83.6
77.2
59.5
57.6
31.6
9.5

38
21.9
2.1

0.9
188.0
1.7

84.1
78.2
59.6
57.8
32.3
9.3

39
22.6
2.1

0.8
189.8
1.7

83.9
77.8
57.7
58.5
33.1
9.8

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
7
5

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

8
12
1.0

:
:

14
12
1.3

:
:

19
13
1.6

:
:

24
14
1.9

:
:

21
40
3.0

:
:

21
38
2.9

:
:

22
38
2.9

:
:

22
40
3.0

:
:

22
41
3.1

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
2
5
.

l

S
o
v
e
n
a

i

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
 
4
7
6

Table 3.25.2:  Statistical Annex - continued – Slovenia 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

2.1

0.22

10.6

0.9

0.9

35,217

34,135

42,136

5.4

51.1

73.2

26.8

71.2

28.8

28.8

12.0

12.4

2020

2.1

0.23

10.9

1.0

1.0

38,050

37,014

45,109

5.8

53.0

74.8

25.2

71.2

28.8

28.2

11.8

11.3

2030

2.1

0.25

11.9

1.1

1.4

44,842

44,242

52,122

6.8

57.1

77.9

22.1

70.8

29.2

29.1

12.1

10.0

2040

2.1

0.27

12.8

1.4

2.1

54,500

54,275

61,492

8.2

64.2

79.7

20.3

70.7

29.3

30.5

12.7

9.7

2050

2.0

0.27

13.1

1.7

2.9

60,976

60,730

68,388

9.3

70.8

81.2

18.8

70.9

29.1

32.3

13.3

9.4

2060

2.0

0.26

13.3

1.8

3.7

63,718

63,755

71,524

10.0

75.1

81.5

18.5

70.8

29.2

32.4

13.4

9.3

2070

2.0

0.26

13.2

1.8

4.4

64,801

64,598

72,772

10.3

78.6

81.6

18.4

70.8

29.2

31.7

13.1

9.0

MS Change 2016-
2070

EU Change 2016-2070

-5%

18%

25%

93%

369%

84%

89%

73%

92%

54%

12%

-31%

-1%

1%

10%

9%

-27%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.26. SPAIN 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

in  2016 

(according 
the  next  decades, 

Spain  had  a  population  of  almost  46.4  million 
to  Eurostat 
inhabitants 
projections).  Over 
is 
this 
expected to increase to 49.9  million by 2070. With 
a  GDP  of  €26.1  thousand  PPS  per  capita  it  is 
below  the  EU  average  GDP  per  capita  of  €29.6 
thousand.  

Health Status 

(63.3  and  62.6 

In  2015,  life  expectancy  at  birth  for  men  and 
women  was,  respectively,  80.1  years  and  85.8 
years  and  above  the  EU  average  (77.9  and  83.3 
years respectively). Similarly, healthy life years at 
birth  for  both  sexes  are  64.1  years  (women)  and 
63.9  years  (men)  significantly  above  the  EU-
average 
respectively).  The 
percentage  of  the  Spanish  population  having  a 
long-standing  illness  or  health  problem  is  lower 
than  in  the  EU  as  a  whole  (In  2015,  32.9%  and 
34.2% 
the 
indicating  a  self-perceived  severe 
population 
limitation in its daily activities has decreased since 
2006,  and  is  significantly  lower  than  the  EU-
average (5.2% against 8.1% in 2015). 

respectively).  The  percentage  of 

Dependency trends 

The share of dependents in Spain is set to increase 
from 5.3% in 2016 to 7.2% of the total population 
in  2070,  an  increase  of  36%.  This  is  higher  than 
the  EU-average  increase  of  21%.  From  less  than 
2.5 million residents living with strong limitations 
due to health problems in 2016, an increase of 46% 
is  envisaged  until  2070  to  3.58  million.  That  is  a 
much  steeper  increase  than  in  the  EU  as  a  whole 
(25%).  

Expenditure projections and fiscal sustainability  

reference 

With  the  demographic  changes,  the  projected 
public  expenditure  on 
long-term  care  as  a 
percentage  of  GDP  is  steadily  increasing.  In  the 
AWG 
long-term 
expenditure  is  driven  by  the  combination  of 
changes 
the  population  structure  and  a 
moderately  positive  evolution  of  the  health  (non-
disability) status. The joint impact of those factors 
is  a  projected  increase  in  spending  of  1.3  pps  of 

scenario,  public 

in 

GDP  to  about  2.2  pps  of  GDP  by  2070  (594). The 
"AWG risk scenario", which  in comparison to the 
"AWG  reference  scenario"  captures  the  impact  of 
additional  cost  drivers  to  demography  and  health 
status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending  of  3.5  pps  taking  expenditure  to  4.4  pps 
of GDP by 2070.  

Overall,  for  Spain,  no  significant  short-term  risks 
of fiscal stress arise. Risks appear, on the contrary, 
to  be  high  in  the  medium  term  from  a  debt 
sustainability analysis perspective due to the stock 
of  debt  being  still  high  at  the  end  of  projection 
(2028). High fiscal risks are expected in the long-
run ( 595). 

System Characteristics (596) 

It is arguable that the first long-term care system as 
a  such  in  Spain  was  established  in  2007,  with  the 
approval of the Law 39/2006 Ley de Promoción de 
la  Autonomía  Personal  y  Atención  a  las  Personas 
en situación de Dependencia (Law of Promotion of 
the Autonomy and Care of People in a Dependent 
Situation, LAPAD),  which established the  System 
for Autonomy and Care for Dependency (SAAD). 

Prior  to  Law  39/2006  of  December  2006,  LTC 
care was provided through the basic social services 
of regions and municipalities, and by programmes 
towards  people  with  disability  benefits.    This 
provision  only  partly  met  the  LTC  needs  of  the 
population.  The  Social  Security  system  provided 
benefits  for  individuals  with  severe  levels  of 
disability  as  well  as  allowances  through  the  non-
contributory disability pension and family benefits 
for parents of disabled children.  

It  is  estimated  that  only  around  12%  of  elderly 
dependants  received  any  kind  of  support  that  was 
publicly  financed  in  2000.  The  role  of  the  public 
sector  was  secondary,  provided  only  in  cases 
where 
informal  care  was  not  possible  or 
insufficient  and  the  level  of  support  depended  on 
recipient. 
the 
Furthermore,  competences  for  social  services  had 

economic 

capacity 

the 

of 

(594) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf . 

(595) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(596) This section draws on OECD (2011b) and ASISP (2014). 

477 

 
                                                           
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been  decentralised  to  regional  and  local  level,  so 
important differences existed across territories. 

The  SAAD  was  created  in  2007  in  line  with  the 
LAPAD  with  the  objective  of  promoting  personal 
autonomy and ensuring the necessary attention and 
protection  of  all  dependants  in  Spain,  through  the 
necessary collaboration of all public administration 
levels.  A  gradual  calendar  of  implementation  to 
cover all existing dependants was established with 
an original end-date of 2015, later to be delayed. 

II  – 

severity.  During 

Within  the  SAAD,  dependency  is  split  into  three 
different  degrees  of  dependency:  Degree  I  – 
moderate  dependency;  Degree 
severe 
dependency;  and  Degree  III  –  high  dependency.  
Each  degree  is  in  turn  divided  into  two  levels  of 
increasing 
the  progressive 
implementation  period,  only  Degree  III  could 
apply during the 2007 (the first year), then Degree 
II level 2 in 2008, Degree II level 1 in 2009-2010 
and  finally  moderate  dependants  (Degree  I)  in 
2011-2012  (level  2)  and  2013-2014  (level  1) 
would  follow.  However,  as  explained  above,  this 
plan was delayed later. 

Managing  the  SAAD  is,  as  for  the  previous  LTC 
service  provision,  the  competence  of  the  regional 
Governments. As a consequence, many differences 
in  its  application  can  be  observed  across  the 
different  regions.  Whereas  2.0%  of  population  is 
recognised  as  being  dependent  in  Spain,  the  ratio 
across regions varies from 2.7% in Andalucía and 
Cantabria,  to  only  1.4%  in  Navarra,  1.3%  in  the 
Comunitat Valenciana and only 1.1% in Canarias. 

According  to  SAAD  statistics,  in  July  2016  in 
there  were  1.21  million  dependants. 
Spain 
Specifically,  366,764  people  were  recognised  as 
high  dependents 
(30%),  454,751  as  severe 
dependents  (37%)  and  the  rest  (391,407,  32%)  as 
total,  837,321  are 
moderate  dependents. 
receiving  benefits,  while  the  other  375,601  (31%) 
are on the waiting list.  

In 

On average each beneficiary receives 1.24 benefits 
(including in-kind and cash benefits), although this 
figure varies across regions. In terms of provision, 
the  most  important  benefit  is  the  cash  benefit  for 
home  care.  According  to  the  July  2016  SAAD 
statistics, 357,984 recipients (34.6% of the services 
provided) are receiving it. The incidence of in-kind 
benefits  is  relatively  lower:  residential  care  made 

478 

up  14.4%  of  services  provided,  home  care 
represented  15.8%,  tele-care  was  14.6%  and  day 
care centres 8.45%. 

Public spending on LTC (597) reached 0.9% (598) of 
GDP in 20165 in Spain, below the EU average of 
1.6  %  of  GDP.  21.1%  of  public  LTC  spending  is 
done via cash benefits, close to the EU average of 
20%.  

In Spain, 63.2% of the estimated total dependents 
are receiving formal in-kind LTC services or cash 
benefits  for  LTC,  above  the  EU  average  of  50%. 
Overall, 3.3% of the population (aged 15+) receive 
formal  LTC  in-kind  and/or  cash  benefits  (EU: 
4.6%).  On  the  one  hand,  low  shares  of  coverage 
may indicate a situation of under-provision of LTC 
services. On the other hand, higher coverage rates 
may 
increased  fiscal  pressure  on 
government  budgets,  possibly  calling  for  greater 
needs of policy reform. 

imply  an 

The expenditure for institutional (in-kind) services 
makes  up  81.7%  of  public  in-kind  expenditure 
(EU:  61%),  10.9%  being  spent  for  LTC  services 
provided  at  home  (EU:  33.7%).  Thus,  relative  to 
other  Member  States  Spain  has  a  focus  on 
institutional  care,  which  may  be  inefficient,  as 
institutional care is relatively costly with respect to 
other types of care. 

Administrative organisation 

through 

is  funded 

The  system 
taxation  and 
financed by funds from the central government and 
regions.  The  central  government  then  allocates 
funds  to  each  region  based  on  the  number  of 
dependents, their degree of disability and the level 
of  assistance  they  require.  Regions  can  decide 
whether  to  allocate  additional  funding  to  provide 
additional services.  

Types of care 

As mentioned in the previous section, the benefits 
provided  include  a  range  of  in-kind  and  cash 

(597) Long-term  care  benefits  can  be  disaggregated 

into 
healthrelated  long-term  care  (including  both  nursing  care 
and  personal  care  services)  and  social  long-term  care 
(relating primarily to assistance with IADL tasks). 

(598) It  should  be  noted  that  the  definition  of  LTC  expenditure 
used  for  these  expenditure  variables  differs  from  the 
definition used for the Ageing Report 2015. 

 
                                                           
benefits.  A  list  is  provided  in  Chapter  15  of  the 
LAPAD, which details a wide range of services to 
be  carried  out  through  a  social  services  public 
network  of  social  services  under  the  control 
controlled  of  the  regional  governments  to  be 
subsidised by the public sector.  

Services  include  tele-care,  home  care,  personal 
care help, residential care and day as well as night 
residential services. These services are provided by 
a  network  of  public 
institutions  of  regional 
governments,  local  organisations,  state  reference 
licensed  private  providers.  Cash 
centres  and 
benefits are granted based on the recipient's degree 
of  dependency  and 
their  economic  means. 
According  to  the  LAPAD,  they  include  a  home 
care  cash  benefit  and  a  cash  benefit  for  personal 
assistance.  

1) Allowance for the care recipient to hire services. 
This  allowance  enables  the  care  recipient  to 
contract  services  from  private  licensed  providers 
when the public sector is not able to provide this. 
Benefit levels range from €400/month for degree II 
level 1, to €831 for degree III, level 2, in 2012 for 
those  who  already  have  an  assessed  degree  and 
level, and for  new recipients  from  August 2012 it 
goes from €300.00 for grade I to €715.07 for grade 
III. 

2) Allowance for informal care. The informal carer 
needs  to  be  a  relative  of  the  care  recipient, 
although  if  services  are  not  available  in  the  area, 
the informal carer can be a resident of the same (or 
neighbouring)  municipality.  The 
allowance 
compensates  to  some  extent  the  service  provided 
by  the  informal  carer.  Benefit  levels  range  from 
255.77  Euros/month  for  degree  II  level  1,  to 
€442.59 for degree III, level 2, in 2012 those who 
already have a recognised degree and level, and for 
new recipients from August 2012 is from €153.00 
for grade I to €387.64 for grade III. 

3)  Allowance 
for  personal  assistance.  This 
allowance  enables  recipients  individuals  with  a 
high  degree  of  disability  (Group  III)  to  hire 
personal help to improve their personal autonomy, 
access  to  work/  education  as  well  as  to  provide 
help  with  daily  activities.  A  contract  has  to  be 
provided  and  the  carer  needs  to  have  appropriate 
professional  qualifications.  Benefit  levels  range 
from €609 /month for degree III level 1, to 812 for 
degree III level 2, in 2012 those who already have 

Long-term care systems 

3.26. Spain 

a  recognised  degree  and  level,  and  for  new 
recipients  from  August  2012  is  from  €300.00  for 
grade I to €715.07 for grade III. 

Home-care  provision 
includes  prevention  and 
promotion  of  personal  autonomy,  help  with 
personal  care  and  with  instrumental  activities  of 
daily  living.  All  persons  below  the  minimum 
income  threshold  are  automatically  guaranteed 
home care.  

service  providers 

Institutional  LTC 
include 
regional  and  municipal  centres  as  well  as  private 
sector  institutions.  Providers  are  required  to  have 
minimum  ratios  of  workers  per  care  recipient  and 
by  type  of  worker  for  carers  and  geriatricians. 
Most  institutions  are  private  with  only  24%  of 
residences  being  publicly-owned  (although  22% 
additional residents receive a public subsidy to be 
placed in a private centre). Providers often receive 
substantial government subsidies in order to make 
their service  more affordable for recipients. There 
are  large  regional  disparities  in  the  distribution  of 
beds and services offered as well as in term of their 
prices.  

Day care centres are also largely private (65%) but 
are publicly subsidised at 60% and have seen large 
increases in the past (there were 36,000 new places 
between 2002 and 2007). 

Eligibility criteria 

Spain  applies  means-tested  criteria,  for  both  in-
kind  and  cash  benefits.  In  addition,  users  are  not 
given  a  choice  between  cash  and  in-kind  benefits 
nor  can  they  accumulate  them,  and  they  do  not 
have a discretionary use of cash benefits.  

Benefits  are  universal  and  cover  all  Spanish 
nationals  or  those  who  have  been  residents  of 
Spain for at least 5 years (of which at least the last 
2 before filing the claim need to have been spent in 
Spain).  Eligibility 
through  an 
assessment of the degree of dependency, evaluated 
the  Scale  of  Dependency 
on 
(Established  in  the  Royal  Decree  740/2011).  As 
mentioned  before,  there  are  three  degrees  of 
disability,  with  2  sub-levels  within  each  grade. 
They are defined as follows:  

is  determined 

the  basis  of 

−  Degree  I  (Moderate  Disability):  the  individual 
requires  help  for  several  basic  activities  of 

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daily  living  at  least  once  a  day,  or  needs  help 
on  a  sporadic  basis  or  limited  to  personal 
autonomy.  

although often benefitting from subsidies meant to 
increase the affordability of services to recipients. 

−  Degree  II  (Severe  Disability):  the  individual 
needs help for several activities of daily living, 
two  or  three  times  a  day  but  does  not  need 
permanent help from a carer nor extensive help 
to ensure personal autonomy.  

−  Degree  III  (High  dependency):  the  individual 
needs help for several activities of daily living 
several times per day, and because of total loss 
of  physical,  mental,  intellectual  or  sensorial 
autonomy,  s/he  needs  permanent  help  from  a 
carer  or  needs  generalised  help  to  ensure 
personal autonomy.  

The  assessment  is  expressed  as  a  numerical  score 
according  to  the  eligibility  scale,  and  individuals 
with  a  score  below  25  are  not  entitled  to  public 
services or allowances. 

the  responsibility  for 

Again, 
the  assessment 
belongs  to  the  regions.  Once  an  individual  has 
been  assessed  as  being  in  need  of  care,  an 
individual  plan  is  prepared  by  the  social  services, 
including a list of appropriate services for the level 
of  disability  and  dependency,  as  well  as 
entitlement 
the 
legislation (Royal decree 1051/2013). 

to  allowances, 

line  with 

in 

Formal/informal caregiving 

At  present  there  is  no  allowance  directly  directed 
to  family  carers  as  the  care  allowance  that  exists 
currently is provided to the care recipient. Informal 
carers  can  benefit  from  pension  rights  and  other 
social  contributions  if  they  subscribe  a  special 
agreement with the Social Security body. Assisting 
informal  carers  through  training  and  provision  of 
information is one of the objectives of the SAAD, 
and common standards were adopted in 2009.  

All  formal  workers  are  required  to  hold  relevant 
in 
professional  qualifications 
residential 
institutions,  home  carers,  personal 
assistants as well as the directors of institutions.  

including  carers 

Since 2015 professional profiles are determined as 
well  as  the  duties  to  be  performed  and  they  are 
based  on  qualifications 
to  be 
that  need 
demonstrated  by 
the  appropriate  Vocational 
Training Diplomas or Professional Certificate. 

Since  this  Resolution  there  have  been  some  calls 
by  the  regional  authorities  for  guarantees  on  the 
expertise of these professionals, in order to certify 
that 
the  necessary 
requirements. 

their  qualifications 

fulfil 

Co-payments, out of the pocket expenses and 
private insurance 

All  the  potential  recipients  below  a  specified 
minimum  income  are  guaranteed  provision  home 
care.  Cost-sharing  by  recipients  for  the  benefits 
they  receive  is  determined  according  to  their 
economic  status  up  to  a  maximum  of  90%  of  the 
service cost. 

For all other services allowances are means-tested 
and  the  remainder  needs  to  be  paid  by  the  care 
recipient or their relatives.   

Role of the private sector  

As  explained  in  previous  sections,  the  private 
sector is involved in the provision of several types 
of care. In institutional care it is the main provider, 

480 

From the beginning of 2007 to the end of 2013, the 
number  of  long  term  care  formal  workers  has 
increased  by  approximately  50.9%,  with  116,507 
new  members  being  registered  as  working  in  the 
Social Security records. 

Prevention 
policies/measures 

and 

rehabilitation 

Some  prevention  services  do  exist  and  are 
subsidised.  Home-care  services  also 
include 
prevention and promotion of personal autonomy. 

Recently 
reforms 

legislated  and/or  planned  policy 

The  Territorial  Council  of  Social  Services  and  of 
the  System  for  the  Autonomy  and  Care  of 
Dependent Persons (SAAD) is a cooperation body 
where  the  Central  Government,  the  Autonomous 
are 
Regions 

the  Local  Government 

and 

 
its  current  and 

represented. In its session of 10 July 2012, it  has 
approved  measures  to  improve  the  System  and 
make  it  more  transparent,  with  better  quality, 
improved  care  of  dependent  persons,  and  also  to 
guarantee 
financial 
sustainability,  with criteria that guarantee equality 
in  the  granting  of  the  benefits  throughout  Spain, 
and  with  impact  on  employment,  respecting  the 
principles set down in the Dependency Act. These 
measures  are  applicable 
the  Autonomous 
Regions. 

future 

in 

The  Resolutions  of  said Territorial  Council  where 
measures  were  approved  have  been  expressed  by 
the  Government 
following  general 
legislation  for  the  whole  of  Spain  and  applicable 
by  the  Autonomous  Regions  in  each  one  of  its 
territories: 

the 

in 

•  Royal  Decree-Law  20/2012,  modifying  Act 
39/2006, of 14 December, on the Promotion of 
Personal  Autonomy  and  Care  of  people  in 
situation  of  dependency.  This 
regulation 
abolishes  the  classification  by  levels  within 
each degree of dependency, since it lengthened 
the  procedure  and  consumed  added  resources 
without  giving  rise  to  any  differentiation  in 
terms  of  the  benefits  acknowledged.  It  also 
established  a  calendar  for  grade  I  to  1  July 
2015,  to  give  priority  care  to  people  with 
greater degree of dependency and it established 
the maximum amounts of the financial benefits 
for each of the degrees of dependency. 

•  Decision  of  23  April  2013,  of  the  State 
Secretariat  for  Social  Services  and  Equality, 
publishes  the  Resolution  of  the  Territorial 
Council  of  Social  Services  and  of  the  System 
for  the  Autonomy  and  Care  of  Dependent 
Persons  regarding  criteria,  recommendations 
and minimum conditions for the preparation of 
for  Prevention  of  Situations  of 
Plans 
Dependency  and  the  Promotion  of  Personal 
Autonomy,  which  includes  a  Catalogue  of 
reference  of  social  services.  With  the  purpose 
of  preventing  the  appearance  or  worsening  of 
diseases  or  disabilities  and  their  after-effects, 
the  coordinated  development,  between 
by 
social  and  health  services,  of  actions 
to 
promote  healthy  living  conditions,  specific 
preventive  and  rehabilitation  programs  aimed 
at  the  elderly  and  disabled  people  and  those 

Long-term care systems 

3.26. Spain 

who  are  affected  by  complex  hospitalisation 
processes. 

•  Decision  of  25  July  2013,  of 

three 

the  age  of 

the  State 
Secretariat  for  Social  Services  and  Equality, 
publishes  the  Resolution  on  common  criteria, 
recommendations  and  minimum  conditions  of 
the  comprehensive  care  plans  for  children 
under 
in  situations  of 
dependency  or  at  risk  in  application  of  Act 
39/2006, of 14 December, on the Promotion of 
Personal  Autonomy  and  Care  of  people  in 
situation  of  dependency.  The  aim  and  purpose 
of  this  resolution  is  to  promote  their  personal 
autonomy,  so  that  they  can  enhance  their 
capacity 
for  development  and  wellbeing, 
enabling  their  inclusion  in  the  family,  school 
and social spheres. These Comprehensive Plans 
shall be developed by the Autonomous Regions 
and are aimed at children under the age of three 
certified to be in situation of dependency or at 
risk  of  developing  it.  They  also  consider  the 
necessary  strategies  aimed  at  facilitating  the 
support  and  participation  of 
family, 
guardians and/or carers, as well as the specific 
characteristics of the environment.  

the 

the  minimum 

•  Royal  Decree  1050/2013,  of  27  December 
level  of 
2013,  governing 
protection established in Promotion of Personal 
Autonomy  and  Care  of  Persons  in  a  Situation 
of  Dependence  Act  39/2006,  of  14  December 
2006. 

•  Royal  Decree  1051/2013,  of  27  December 
2013,  governing  the  provisions  of  the  System 
for  the  Autonomy  and  Care  of  Dependent 
Persons,  as  established  in  the  Promotion  of 
Personal  Autonomy  and  Care  of  Persons  in  a 
Situation  of  Dependence  Act  39/2006,  of  14 
December 2006. 

the  Information  System  of 

•  Order  SSI/2371/2013,  of  17  December, 
the 
regulating 
System  for 
the  Autonomy  and  Care  of 
Dependent  Persons  (SISAAD),  which  defines 
the set of data necessary for the payment of the 
minimum  level  in  addition  to  those  that  are 
necessary 
for  management,  statistics  and 
studies. 

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transparent 

the  Information  System, 

All  this  new  legislation  seeks  to  clarify,  make 
more 
to 
ensure  their  safety  and  to  check  and  compare  the 
the  system  by  Regional 
data  entered 
Communities,  and  that  these  data  are  equal  and 
homogeneous. 

into 

On  the  other  hand,  the  above  regulations  and 
commitments  culminate  and  consolidate 
the 
measures adopted by the Territorial Council. Other 
improvements  are  not  foreseen  in  the  dependency 
system,  making  possible  to  keep  the  SAAD  with 
higher quality and a better professional care.  

Challenges 

Spain  has  taken  significant  steps  to  establish  a 
social  care  system  that  provides  coverage  to  the 
population.  The  main  challenges  of  the  system 
appear to be:  

to 

face 

•  Improving  the  governance  framework:  To 
establish  a  coherent  and  integrated  legal  and 
governance  framework  for  a  clear  delineation 
of  responsibilities  of  state  authorities  with 
respect  to  the  provision  of  long-term  care 
services;  To  set 
the  public  and  private 
financing  mix  and  organise  formal  workforce 
the  growing  number  of 
supply 
dependents,  and  provide  a  strategy  to  deliver 
high-performing long-term care services to face 
the  growing  demand  for  LTC  services;  To 
integrate  medical  and  social 
strategically 
services via such a legal framework; To define 
a  comprehensive  approach  covering  both 
policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  To  establish 
good information platforms for LTC users and 
providers;  To  set  guidelines  to  steer  decision-
making  at 
level  or  by  practising 
providers;  To  share  data  within  government 
administrations to facilitate the management of 
potential  interactions  between  LTC  financing, 
targeted  personal-income  tax  measures  and 
transfers  (e.g.  pensions),  and  existing  social-
assistance or housing subsidy programmes.  

local 

LTC  insurance  as  a  supplementary  financing 
tool;  To  determine  the  extent  of  user  cost-
sharing on LTC benefits.  

•  Providing adequate levels of care to those in 
need  of  care:  To  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  need-level 
triggering entitlement to coverage;  the breadth 
of  coverage,  that  is,  setting  the  extent  of  user 
cost-sharing on LTC benefits; and the depth of 
coverage,  that  is,  setting  the  types  of  services 
included  into  the  coverage;  To  reduce  the  risk 
of  impoverishment  of  recipients  and  informal 
carers. 

•  Encouraging  home 

care 

legislative 

to 
new 

care:  To  develop 
institutional  care  by  e.g. 
alternatives 
frameworks 
developing 
encouraging  home 
regulation 
controlling  admissions  to  institutional  care  or 
the establishment of additional payments, cash 
benefits  or  financial  incentives  to  encourage 
home care; To monitor and evaluate alternative 
services, 
incentives  for  use  of 
including 
alternative settings. 

and 

•  Encouraging  independent  living:  To  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

•  Ensuring  availability  of  formal  carers:  To 
for 
determine  current  and 
qualified  human  resources  and  facilities  for 
long-term care.  

future  needs 

•  Supporting 

family  carers:  To  establish 
policies for supporting informal carers, such as 
through  flexible  working  conditions,  respite 
care, carer’s allowances replacing lost wages or 
covering expenses incurred due to caring, cash 
benefits  paid  to  the  care  recipients,  while 
ensuring  that  incentives  for  employment  of 
carers  are  not  diminished  and  women  are  not 
encouraged 
labour 
to  withdraw  from 
market for caring reasons.  

the 

•  Improving 

financing  arrangements:  To 
foster  pre-funding  elements,  which  implies 
setting  aside  some  funds  to  pay  for  future 
obligations; To explore the potential of private 

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
the  allocation  of  care  co-
information, 

482 

 
Long-term care systems 

3.26. Spain 

ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  Facilitating  appropriate  utilisation  across 
health  and  long-term  care:  To  create  better 
improving  (and  securing)  safe  care 
rules, 
pathways 
to 
chronically-ill people or circulated through the 
system; to steer LTC users towards appropriate 
settings. 

information  delivered 

and 

•  Changing payment incentives for providers: 
To  consider  a 
focused  use  of  budgets 
negotiated  ex-ante  or  based  on  a  pre-fixed 
share of high-need users.  

•  Improving  value  for  money:  To  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
and 
information, 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

483 

 
 
 
 
4
8
4

Table 3.26.1:  Statistical Annex – Spain 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

931
25.9
43.3

0.5
114.0
1.3

83.6
77.0
63.4
63.3
:
:

1,008
27.1
44.0

0.5
131.1
1.4

84.4
77.8
63.5
63.9
23.7
8.5

1,081
27.5
44.8

0.5
138.6
1.4

84.4
77.9
63.2
63.5
25.1
9.1

1,116
26.5
45.7

0.6
140.9
1.3

84.6
78.3
63.7
64.0
29.8
5.4

1,079
24.7
46.2

0.7
157.4
1.4

85.0
78.8
62.1
63.1
30.3
5.7

1,081
24.4
46.5

0.7
169.4
1.6

85.5
79.2
63.8
64.5
29.5
5.4

1,070
24.2
46.7

0.7
162.3
1.5

85.6
79.5
65.6
65.4
23.0
4.7

1,040
24.2
46.8

0.7
161.1
1.4

85.5
79.5
65.8
64.8
26.2
5.1

1,026
23.9
46.7

0.7
156.1
1.5

86.1
80.2
63.9
64.7
31.6
5.4

1,038
24.8
46.5

0.7
159.1
1.5

86.2
80.4
65.0
65.0
29.8
5.4

1,080
26.1
46.4

0.7
178.4
1.6

85.8
80.1
64.1
63.9
32.9
5.2

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

r

E
u
o
p
e
a
n
C
o
m
m

i
s
s
i
o
n

i

J
o
n
t
R
e
p
o
r
t
o
n
H
e
a

r

l
t
h
C
a
e
a
n
d
L
o
n
g

r

-
T
e
m
C
a
e
S
y
s
t
e
m

r

s
a
n
d
F
i
s
c
a

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

180
181
0.8

:
:

208
258
1.0

:
322

235
334
1.2

280
340

262
411
1.4

385
338

267
419
1.5

423
336

272
427
1.5

427
346

307
693
2.1

:
357

315
715
2.2

:
374

322
736
2.3

:
392

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

l

S
u
s
t
a
n
a
b

i

i
l
i
t
y
-

C
o
u
n
t
r
y
D
o
c
u
m
e
n
t
s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Table 3.26.2:  Statistical Annex - continued – Spain 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

46.4

2.45

5.3

0.9

0.9

2020

46.6

2.58

5.5

1.0

1.1

2030

47.2

2.89

6.1

1.2

1.4

2040

48.3

3.28

6.8

1.5

2.0

2050

49.3

3.65

7.4

1.9

2.9

328,249

737,020

483,844

357,938

825,520

535,970

402,335

971,897

619,983

490,157

1,248,164

774,274

609,580

1,616,774

976,656

3.3

63.2

79.5

20.5

77.0

23.0

81.7

10.9

18.5

3.7

66.7

79.5

20.5

76.7

23.3

82.7

10.9

18.6

4.2

69.1

79.0

21.0

76.0

24.0

82.9

10.8

18.8

5.2

76.6

79.6

20.4

75.3

24.7

88.0

11.3

18.9

6.5

87.7

80.3

19.7

74.9

25.1

92.9

11.7

19.0

2060

49.6

3.81

7.7

2.2

3.8

726,096

1,944,626

1,166,259

7.7

100.0

79.7

20.3

74.9

25.1

90.7

11.3

19.2

2070

49.9

3.58

7.2

2.2

4.4

758,963

1,986,735

1,216,095

7.9

100.0

78.9

21.1

75.5

24.5

86.8

10.8

19.2

MS Change 2016-
2070

EU Change 2016-
2070

7%

46%

36%

135%

368%

131%

170%

151%

138%

58%

-1%

3%

-2%

6%

6%

-1%

4%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

4
8
5

3
.
2
6
.

S
p
a
n

i

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
3.27. SWEDEN 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

Sweden  had  a  population  of  almost  9.9  million 
inhabitants  in  2016,  which  is  expected  to  reach 
13.9 million in 2070. This is a 40% increase that is 
contrast  with  the  2%  overall  increase  in  the  EU 
over  this  period.  With  a  GDP  of  33,700  PPS  per 
capita  in  2015,  it  is  above  the  EU  average  of 
29,600 PPS per capita.  

Health status 

In 2015, life expectancy at birth for both men and 
women was respectively 80.4 years and 84.1 years, 
above  the  EU  average  (77.9  and  83.3  years, 
respectively). Even more so, the healthy life years 
at  birth  for  both  sexes  were  74.0  years  (women) 
and 73.8 years (men) and substantially higher than 
the  EU-average  (63.3  and  62.6,  respectively).  At 
the  same  time  the  percentage  of  the  Swedish 
population having a long-standing illness or health 
problem  was  slightly  higher  than  in  the  EU  as  a 
whole  (35.9%  and  34.2%,  respectively).  The 
percentage  of  the  population  indicating  a  self-
perceived  severe  limitation  in  its  daily  activities 
has been decreasing in the last few years, and was 
far  lower  than  the  EU-average  (3.7%  against 
8.1%). 

Dependency trends 

living 

The  amount  of  people  that  depend  on  others  to 
carry  out  activities  of  daily 
increases 
significantly over the coming 50 years ( 599). From 
around  510  thousand  residents  living  with  strong 
limitations  due  to  health  problems  in  2016,  an 
increase  of  63%  is  envisaged  until  2070  to  840 
thousand. That is a steeper increase than in the EU 
as  a  whole  (25%).  Also  as  a  share  of  the 
population,  the  dependents  are  becoming  a  bigger 
group,  from  5.2%  to  6.0%,  an  increase  of  17%. 
This  is  nevertheless  less  than  the  EU-average 
increase of 21%. 

Expenditure projections and fiscal sustainability  

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 

(599) The 

2018 

Ageing 

Report: 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip065_en.pdf. 

486 

percentage of GDP is steadily increasing, from 3.2 
percent  in  2016,  to  4.9  percent  in  2070  in  the 
"AWG  reference  scenario",  corresponding  to  a 
63%  increase,  about  double  the  same  increase  as 
the EU. In the "AWG risk scenario", expenditure is 
projected  to  grow  from  3.2  to  5.7,  attaining  a 
differential of 77%, lower than the EU average of 
170%. 

Fiscal  sustainability  risks  appear  to  be  low  in 
Sweden over the low, medium and long-term (600). 

System Characteristics (601) 

local 

is  mainly  financed  from 

According  to  the  Social  Services  Act  (1982), 
Swedish  older  people  have  the  right  to  claim 
public  service  and  help  to  support  themselves  in 
their day-to-day existence “if their needs cannot be 
met  in  any  other  way”.  The  Swedish  system  of 
LTC  is  under  the  responsibility  of  municipalities 
taxation. 
and 
According to 2016 Eurostat data, some 7% of  the 
total cost of LTC (including both social and health-
related LTC) is financed through co-payments and 
charges, while the rest is covered by public funds, 
mainly  through  local  taxes.  Around  10%  of  the 
local  authorities'  total  funding  (not  only  LTC) 
comes  from  central  government  grants.  Some  5% 
of  the  total  cost  of  LTC  is  financed  through  co-
payments and charges, while the rest is covered by 
public funds, mainly through local taxes with some 
10-12%  funding  coming  from  central  government 
grants to municipalities.  

Public  spending  on  LTC  ( 602)  reached  3.2%  of 
GDP in 2016, above the average EU level of 1.6% 
of GDP. 99.9% of the benefits were in-kind, while 
0.1% were cash-benefits (EU: 84.4 vs 15.6%).  

In the EU, 50% of dependents are receiving formal 
in-kind  LTC  services  or  cash-benefits  for  LTC. 
This  share  is  with  100%  much  higher  in  Sweden. 
Overall, 5.4% of the population (aged 15+) receive 
formal  LTC  in-kind  and/or  cash  benefits  (EU: 
4.6%).  On  the  one  hand,  low  shares  of  coverage 

(600) Fiscal sustainability Report (2018), Institutional Paper 094, 

January 2019, European Commission. 

(601) This section draws on WHO/Europe (2012), Fukushima et 

al (2010), OECD (2011b) and ASISP (2014). 

(602) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily to assistance with IADL tasks). 

 
                                                           
                                                           
may indicate a situation of under-provision of LTC 
services. On the other hand, higher coverage rates 
may 
increased  fiscal  pressure  on 
government  budgets,  possibly  calling  for  greater 
needs of policy reform. 

imply  an 

The expenditure for institutional (in-kind) services 
makes  up  66.1%  of  public  in-kind  expenditure 
(EU: 66.3%), 33.9% being spent for LTC services 
provided at home (EU: 33.7%).  

Administrative organisation 

At  central  government  level,  the  Ministry  of 
Health and Social Affairs (Socialdepartementet) is 
responsible  for  developing  legislation  on  health 
care, social insurance and social issues. These laws 
and  regulations  are  the  basis  for  the  planning, 
funding and provision of LTC services through the 
cooperation  of  20  county  councils  and  290 
in 
municipalities.  The  central  government 
constant dialogue with the Swedish Association of 
Local  Authorities  and  Regions  (SALAR),  a  co-
operative  national  organisation  that  represents  all 
county councils and municipalities.  

is 

County  councils  and  municipalities  are  highly 
autonomous  with  respect  to  central  government. 
Both have elected assemblies and have the right to 
levy  and  collect  taxes.  County  councils  and 
municipalities can, within the limits established in 
legislation,  decide  what  level  of  priority  they  will 
assign to the elderly  versus other age groups. The 
fact  that  LTC  is  mainly  funded  by  local  taxation 
underlines 
local 
independence  of 
authorities from national government. 

the 

the 

through 

(whether 

County  councils  are  responsible  for  providing 
healthcare 
family  doctors, 
hospitals,  health  centres,  or  other  providers). 
Municipalities offer a number of social services to 
assist elderly living at home, including home help 
services,  daytime  community  activities,  etc.  With 
the  1992  reform  municipalities  were  also  handed 
responsibility  over  local  nursing  homes  and  other 
the 
forms  of 
responsibility for health care belongs to the county 
councils. In local nursing homes the municipalities 
are  by  law  responsible  for  providing  home  health 
care  including  all  medical  staff  and  excluding 
doctors  only.  Over  the  years,  all  county  councils 
and  municipalities,  except 
the  municipalities 
within Stockholm county, have formed agreements 

institutional  LTC.  In  contrast, 

Long-term care systems 

3.27. Sweden 

on  transferring  the  responsibility  for  home  health 
care  also  in  all  ordinary  homes  from  the  county 
councils  to  the  municipalities.  This  has  led  to  a 
more  coherent  organisation.  However,  county 
councils are still responsible for patients until they 
are discharged from hospital. The responsibility of 
medical  care  and  rehabilitation  for  elderly  in 
ordinary  homes  is  shared  between  municipalities 
and county councils. This places high demands on 
the  coordination  of  care  between  municipalities 
and  county  councils.  Lack  of  coordination  may 
lead to an inefficient use of resources, cooperation 
issues and lack of continuity as well as attempts by 
county councils and municipalities to transfer both 
responsibilities and costs to one another.  

From  1  January  2010,  local  authorities  have  to 
draw  up  an  individualised  care  plan  for  each 
recipient. The care plan states clearly each step of 
the required services and treatment. The plan also 
identifies  the  official  in  charge  of  the  case  and 
specifies  which  authority  is  responsible  for  which 
component of the services and care provided.  

Types of care 

The primary LTC service is home care, comprising 
help  with  daily  activities  such  as  shopping, 
cooking,  cleaning  and  laundry.  It  also  includes 
personal care, such as  help  with bathing, going to 
the toilet, getting dressed and getting in and out of 
bed.  

As well as home care, the following LTC services 
are also available in Sweden: institutional care, day 
care,  home  nursing  care,  meal  services,  home 
adaptation  and  personal  safety  alarms.  There  are 
also transportation services for care recipients who 
are unable to use public transport. In addition, the 
local  authorities  also  provide  non-means  tested 
grants  to  assist  the  disabled  to  use  their  homes  in 
an efficient manner (Fukushima, 2010). 

Eligibility criteria 

Permanent residents who suffer from some degree 
of  dependency  are  eligible  for  care,  determined 
only by an assessment of their need for care. There 
is  therefore  no  means-testing  criterion  applied  to 
the  provision  of  long-term  care.  Need  for  care  is 
either assessed by a general practitioner or through 
a  request  for  assessment  by  the  relevant  local 
authority.  For  direct  requests  to  the  authority,  the 

487 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

potential  recipient  as  well  any  eventual  relatives 
are  interviewed  by  an  evaluator  in  order  to 
determine  the  extent  of  support  required,  and 
whether  the  care  can  be  provided  in  recipient’s 
own home or not.  

Nowadays,  even  relatively  severe  dependency 
cases  needing  extensive  medical  care  can  be 
treated in the home of the recipient. Home help is 
offered  in  flexible  hours,  in  some  cases  including 
up to seven visits per day or more. In some cases, 
however,  home  care  will  not  be  advisable  (for 
instance  due  to  the  inadequacy  of  the  home)  and 
institutional care will be considered as a last resort 
policy. In June 2018 the Government passed a new 
legislation  on  Assisted  Security  Housing  to  the 
parliament.  The  purpose  of  the  new  legislation  is 
to encourage local municipalities to design special 
housing for elderly so it will better meet the needs 
of elderly people who need only lighter support but 
who no longer feel safe to stay in their own homes. 
The  National  Board  of  Health  and  Welfare 
(NBHW) introduced a standardised instrument for 
needs  assessment  in  2012.  The  tool  for  needs 
International 
assessment 
Classification  of  Functioning,  Disability  and 
Health  (ICF)  standard.  The  government  have 
commissioned  the  NBHW  to  implement  the  new 
tool  and  financially  supported  activities  such  as 
training of process-leaders. In cases where citizens 
disagree  with  the  care-manager's  decisions,  they 
can appeal to an administrative court. The number 
of  successful  appeals  is  very  low,  but  the  right  to 
appeal  is  perceived  as  providing  personal  security 
to individuals. 

is  based  on 

the 

Co-payments, out of the pocket expenses and 
private insurance 

Cost-sharing  for  LTC  services  is  set  according  to 
the Social Services Act with the aim of protecting 
recipients from excessive fees. A ceiling fee is set 
annually  by  the  government,  representing  the 
maximum amount that a recipient can be charged. 
This  ceiling 
in 
principle,  although  it  may  be  reduced  if  the 
recipient's monthly income is below the minimum 
cost  of  living  as  defined  by  the  government  (also 
on an annual basis).  

is  set  without  means-testing 

Within 
rules,  each  municipality  will 
determine  their  own  schedule  of  cost-sharing  fees 

these 

488 

for  recipients.  In  2006 (603),  around  19%  of 
recipients  of  home  care  did  not  pay  any  fees,  as 
their income was below the threshold. 

There are no private insurances for the cost of LTC 
in  Sweden,  so  care  is  financed  exclusively  from 
taxation,  cost-sharing  and  other  out-of-pocket 
payments.  

Role of the private sector  

Municipalities  and  county  councils  can  decide  on 
how  to  organise  the  provision  of  LTC,  including 
collaboration with different providers. Institutional 
and  home  care  may  be  provided  either  by  a 
municipality  or  a  private  provider  (which  can 
include  private  companies  but  also  trusts  and  co-
operatives).  However,  even  when  care  is  actually 
provided  by  the  private  sector,  municipalities  and 
country 
exclusive 
responsibility for ensuring financing, provision and 
ensuring an adequate level of quality. 

still  have 

councils 

the 

The introduction of choice for the individual is by 
far the main driving force behind the expansion of 
privately  run  (but  publicly  financed)  institutions. 
Another  reason  has  been  the  assumption  that 
competition will be good for quality, effectiveness 
and  the  career  possibilities  for  the  mainly  female 
staff in elderly care.  

Formal/informal caregiving 

to 

Municipalities  are  required  by  law  (since  1  July 
2009)  to  provide  support  to  informal  carers. 
According 
the  Social  Services  Act, 
municipalities  need  to  respect  and  cooperate  with 
informal  carers,  offering  support  tailored  to  their 
needs.  The  aim  is  to  alleviate  the  workload  of 
carers and its impact on their health status, as well 
as providing them with necessary information and 
to  provide 
knowledge.  The  Act  also  aims 
recognition  of  the  work  provided  by  carers  and 
acknowledge its importance.  

In accordance with the above, support for informal 
carers  takes  different  forms.  Carers  have  the  right 
in  some  circumstances  to  take  leave  from  their 
work  in  order  to  provide  care  for  a  terminally  ill 
relative.   

(603) Fukushima et al, 2010. 

 
                                                           
Long-term care systems 

3.27. Sweden 

Municipalities  also  provide  support  groups  or 
centres for carers, which can be a source of mutual 
support.  Municipalities  can  provide  "Respite 
leave",  giving  carers  temporary  leave  from  their 
caring  responsibilities,  with  the  latter  being  taken 
over by home care providers or charities over that 
period  (provided  for  free 
in  about  50%  of 
municipalities, in others a small charge is required) 
or by institutional providers on a temporary basis.  

purpose  in  2016,  SEK  300  million  in  2017  and 
from  2018  SEK  400  million  is  allocated  on  a 
yearly basis. The Parliament decided in April 2018 
to  adopt  the  government's  proposal  for  a  new  law 
on  Housing  adjustment  contributions.  The  new 
legislation entered into force in July 2018 and aims 
at  providing  housing  for  disabled  people  giving 
them the opportunity to live an independent life in 
their own housing. 

In addition, there are different services that provide 
informal carers  with advice,  including one-on-one 
sessions,  websites  and  assistance  from  volunteers. 
Some  municipalities  also  organise  services  for 
carers,  including  spa  treatments,  massage  and 
health consultations ( 604). 

Prevention 
policies/measures 

and 

rehabilitation 

Prevention  is  dealt  with  by  the  public  health 
system in Sweden. 

Recently 
reforms  

legislated  and/or  planned  policy 

The  Act  on  System  of  Choice  in  the  Public 
Sector 

In  order  to  stimulate  a  greater  variety  of  LTC 
providers  and  increase  the  quality  of  services 
provided, the government introduced a new law in 
2009,  the  "Act  of  System  of  Choice  in  the  Public 
Sector". Its aim is  to make it easier for a variety of 
commercial  providers  to  enter  the  market  of 
service and care for the elderly. The law works as 
a voluntary tool for those municipalities who want 
to  let  recipients  choose  suppliers,  and  to  expose 
public  sector  providers  to  competition  from  the 
private  sector.  The  law  is  an  alternative  to  the 
Swedish Public Procurement Act (2007:1091). 

July  2016, 

the  Government 

In 
introduced 
government  grants  for  arranging  and  providing 
housing for older people. The purpose of the grants 
is  to  encourage  renovation  of  existing  residential 
properties  for  elderly  people  and  the  construction 
of new ones, as  well as covering  modifications to 
properties in order to enable older people to remain 
in their homes through improved accessibility and 
safety.  SEK  150  million  was  allocated  for  this 

The  government  has  introduced  increased  license 
requirements  and  special  rules  for  procurement  in 
the  welfare  sector,  including  home  help  services 
for  elderly.  The  legislation  aims  at  ensuring  that 
private performers have sufficient prerequisites for 
conducting business with good quality and another 
goal  is  to  strengthen  the  confidence  in  the  sector. 
The proposals are also considered to simplify both 
procuring  authorities  and  suppliers  and  promoting 
NGO’s  participation  in  procurement.  The  new 
legislation will enter into force in January 2019. 

A new provision has been introduced in the Social 
Services  Act  which  makes  it  possible  for  local 
Social Services Committee to offer home services 
to  older  people  without  an 
individual  need 
assessment.  The  purpose  is  to  provide  local 
municipalities  with  the  opportunity  to  grant  older 
women  and  men  home  help  services  in  an  easier 
way  and  with  greater  scope  for  participation  and 
self-determination from the user’s perspective. 

Dignity – National set of values for elderly care  

The  national  set  of  values  for  the  elderly  is 
expressed  in  the  Social  Services  Act  (2001:453) 
since  2010.  The  Social  Services  Act  also  clarifies 
increased 
that 
opportunities for influence on the social services. 

the  elderly  should  be  given 

The national set of values basically means that care 
services  for  the  elderly  should  focus  on  enabling 
elderly to live with dignity and to experience well-
being.  This  means  among  other  things  that  the 
elderly  care  services  should  uphold  and  respect 
everyone's  right  to  privacy  and  bodily  integrity, 
autonomy, participation and personalisation.  

Health and social care should help the individual to 
feel  safe and experience  meaningfulness.  Services 
within elderly care must be of good quality. 

(604) Fukushima et al. (2010). 

489 

 
                                                           
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

•  Encouraging  independent  living:  To  provide 
effective  home  care,  ITC  and  information  to 
recipients,  as  well  as  improving  home  and 
general living environment design. 

•  Ensuring  availability  of  formal  carers:  To 
determine  current  and 
for 
qualified  human  resources  and  facilities  for 
long-term  care;  to  seek  options  to  increase  the 
productivity of LTC workers. 

future  needs 

•  Ensuring  coordination  and  continuity  of 
care:  To  establish  better  co-ordination  of  care 
pathways  and  along  the  care  continuum,  such 
as 
to 
through  a  single  point  of  access 
information, 
the  allocation  of  care  co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

and 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  To  arrange  for 
adequate supply of services and support outside 
hospitals, 
to 
financial 
discourage  acute  care  use  for  LTC;  to  create 
better rules, improving (and securing) safe care 
to 
pathways 
chronically-ill people or circulated through the 
system; to steer LTC users towards appropriate 
settings. 

information  delivered 

incentives 

and 

•  Improving  value  for  money:  To  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  To  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

Older people should have influence over when and 
how services should be carried out. 

The  right  for  older  couples  to  continue  to  live 
together  

Today  spouses  can  choose  to  continue  to  live 
together  even  when  only  one  of  the  spouses  is  in 
need  of  care  in  special  housing.  The  right  came 
into  force  in  2012  after  an  amendment  to  the 
Social Services Act.  

Government  grant 
staffing  

to 

support 

increased 

A  sufficient  level  of  staffing  is  recognised  by  the 
government  as  a  crucial  part  of  quality  in  elderly 
care. It is important to create safety and quality to 
the elderly, as well as good working conditions for 
the staff. A government grant to the municipalities 
of seven  billion SEK under the period 2015-2018, 
has  increased the number of staff working closest 
to  the  elderly.  The  staff  is  supposed  to  have 
relevant 
should  be  offered 
introduction and at work education. The grant will 
be  offered  provided  that  this  is  approved  by  the 
Parliament.  

education  or 

Possible future changes 

In  June  2018  the  Government  reported  to  the 
Parliament  its  view  on  elderly  care  in  Sweden 
(SKr.  2017/18:  280)  and  the  work  done  to  adapt 
to  demographic  and 
the  ageing  population 
technological  development.  The 
report  also 
specifies the areas that should be prioritised during 
the forthcoming mandate period: A wider range of 
and 
housing 
rehabilitation  efforts,  better  interaction  between 
health  care,  to  create  more  attractive  workplaces 
within  social  care  for  elderly  with  stronger 
professional  proficiency,  increased  use  of  welfare 
technology  and  e-health,  and  the  importance  of 
gender equality and equal care. 

prevention 

elderly, 

the 

for 

Challenges 

•  Improving  the  governance  framework:  To 
face  the  growing  number  of  dependents,  and 
provide  a  strategy  to  deliver  high-performing 
long-term  care  services  to  face  the  growing 
demand  for  LTC  services;  To  strategically 
integrate medical and social services.   

490 

 
Table 3.27.1:  Statistical Annex – Sweden 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

313
32.3
9.0

0.6
178.3
1.2

82.9
78.5
63.2
64.5
:
:

335
34.0
9.0

0.6
192.5
1.2

83.1
78.8
67.5
67.3
35.2
8.2

356
35.7
9.1

0.6
202.5
1.2

83.1
79.0
66.8
67.7
34.8
7.8

352
34.2
9.2

0.6
201.7
1.2

83.3
79.2
69.0
69.4
33.9
9.0

310
30.5
9.3

0.7
197.9
1.2

83.5
79.4
69.6
70.7
32.8
8.0

369
31.8
9.3

0.6
195.3
1.2

83.6
79.6
66.4
67.0
31.5
8.4

405
32.6
9.4

2.6
845.5
5.1

83.8
79.9
65.5
67.0
32.9
8.1

423
33.0
9.5

2.7
883.3
5.2

83.6
79.9
:
:
34.7
:

436
32.5
9.6

2.7
872.3
5.2

83.8
80.2
66.0
66.9
36.0
7.7

433
32.6
9.6

2.7
895.9
5.2

84.2
80.4
73.6
73.6
36.1
3.8

449
33.7
9.7

2.7
936.8
5.4

84.1
80.4
73.8
74.0
35.9
3.7

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

200
224

:
224

:
:
:

:
:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
9
1

2007

2008

2009

2010

2011

2012

2013

2014

2015

EU 2009

EU 2011

EU 2013

EU 2015

97
222
3.5

:
222

140
223
4.0

:
217

184
224
4.4

:
221

227
225
4.8

:
222

230
227
4.8

:
224

232
229
4.9

:
226

87
206
3.1

:
232

88
208
3.1

:
238

88
210
3.1

:
:

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

:
:

:
:

:
:

:
:

3
.
2
7
.

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4
9
2

Table 3.27.2:  Statistical Annex - continued – Sweden 

PROJECTIONS

Population

Population projection in millions

Dependency

Number of dependents in millions

Share of dependents, in %

Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits

Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

9.9

0.51

5.2

3.2

3.2

103,250

198,257

237,142

5.4

100.0

99.9

0.1

66.1

33.9

204.3

54.7

0.2

2020

10.3

0.54

5.2

3.3

3.3

108,902

210,468

251,338

5.5

100.0

99.9

0.1

66.0

34.0

204.5

54.6

0.2

2030

11.3

0.63

5.6

3.8

3.9

138,178

262,970

312,939

6.3

100.0

99.9

0.1

66.2

33.8

205.2

55.1

0.2

2040

12.0

0.69

5.7

4.1

4.3

162,395

298,636

357,550

6.8

100.0

99.9

0.1

66.9

33.1

204.3

54.9

0.2

2050

12.7

0.74

5.8

4.3

4.6

180,020

328,861

391,771

7.1

100.0

99.9

0.1

67.0

33.0

204.9

55.2

0.2

2060

13.3

0.79

5.9

4.7

5.2

202,835

363,352

436,048

7.5

100.0

99.9

0.1

67.4

32.6

207.9

56.1

0.2

2070

13.9

0.84

6.0

4.9

5.7

221,755

395,261

472,961

7.9

100.0

99.9

0.1

67.5

32.5

208.4

56.2

0.2

MS Change 2016-
2070

EU Change 2016-
2070

40%

63%

17%

53%

77%

115%

99%

99%

45%

:

0%

8%

2%

-4%

2%

3%

16%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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s

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Long-term care systems 

3.27. Sweden 

493 

 
 
3.28. UNITED KINGDOM 

General 
Expenditure, 
sustainability and demographic trends 

context: 

fiscal 

an  increase  of  19%,  which  is  however  lower  than 
the EU average of 21% over the same period. 

Expenditure projections and fiscal sustainability  

In 2016, the United Kingdom had a population of 
around  65.6  million  inhabitants,  which  is  roughly 
13.0% of  the  EU  population (605).  With  a  GDP  of 
around €2,602 billion, or 29,112 PPS per capita, it 
is slightly below the EU average GDP per capita of 
€29,610.  Public  expenditure  on  long-term  care 
(health) (606) is 1.2% GDP, slightly higher than EU 
average in the previous years (around 1% in 2012). 
During  the  coming  decades  the  population  of  the 
UK is set to increase, from 65.6 million inhabitants 
in  2016  to  81  million  inhabitants  in  2070.  This 
24% increase is well above the EU average change 
of                                                                                                                         
2%.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

is  projected 

is  driven  by 

With  the  demographic  changes,  the  projected 
long-term  care  as  a 
public  expenditure  on 
to  steadily 
percentage  of  GDP 
increase. In the "AWG reference scenario", public 
long-term  care  expenditure 
the 
combination of changes in the population structure 
and  a  moderately  positive  evolution  of  the  health 
(non-disability)  status.  The  joint  impact  of  those 
factors is a projected increase in spending of about 
1.3  pps  of  GDP  by  2070  (607).  The  "AWG  risk 
scenario",  which  also  captures  the  impact  of 
additional  cost  drivers  to  demography  and  health 
status,  i.e.  the  possible  effect  of  a  cost  and 
coverage  convergence,  projects  an  increase  in 
spending of 1.8 pps of GDP by 2070. Overall, the 
projected  long-term  care  expenditure  increase  is 
expected  to  add  to  budgetary  pressure.  Fiscal 
sustainability  risks  as  captured  by  S1  are  medium 
over  the  medium  term,  linked  to  the  current  high 
level  of  government  debt  and  projected  ageing 
costs.  Overall,  given  the  high  risks  to  debt 
sustainability,  fiscal  sustainability  risks  over  the 
medium-term  are  high.  In  the  long  term,  the  UK 
appears to face high fiscal sustainability risks, also 
related to projected ageing costs (608). 

System Characteristics  

Public  spending  on  long-term  care  in  the  UK 
reached 1.2% of GDP in 2015, in line with the EU 
average for the same year (1.2%). Around 75% of 
total long-term care public  spending  was spent on 
in-kind benefits in 2016 (EU average 84.4%) with 
25%%  being  spent  on  cash-benefits  (EU  average 
15.6%) (609).  

In  the  United  Kingdom,  52.3%  of  dependents  are 
receiving formal in-kind long-term care services or 
cash benefits for long-term care (EU average 50% 
in  2016).  Overall,  5.3%  of  the  population  receive 

(607) The 2018 Ageing Report: 

https://ec.europa.eu/info/publications/economy-
finance/2018-ageing-report-economic-and-budgetary-
projections-eu-member-states-2016-2070_en. 

(608) European Commission, Fiscal Sustainability Report (2018) 

https://ec.europa.eu/info/sites/info/files/economy-
finance/ip094_en_vol_2.pdf. 

(609) The 2018 Ageing Report. 

Health status 

Life expectancy at birth for both  women and  men 
was,  in  2015,  82.8  and  79.2  years,  respectively 
below  and  above  the  EU  average  (83.3  and  77.9 
years  for  women  and  men).  Healthy  life  years  at 
birth were 63.3 years for women and 63.7 years for 
men, again above  the EU-average for  males (63.3 
and 62.6 respectively  in 2015). The percentage of 
the  UK  population  having  a  long-standing  illness 
or  health  problem  is  above  the  EU  average  with 
35.3%  vs.  34.2%  in  2015.  Also  the  percentage  of 
the  population  indicating  a  self-perceived  severe 
limitation  in  its  daily  activities  is  above  the  EU-
average (10.6% against 8.1% in 2015). 

The number of people depending on others to carry 
out activities of daily living increases significantly 
over  the  coming  decades.  From  6.67  million 
residents  living  with  strong  limitations  due  to 
health  problems  in  2015,  an  increase  of  47%  is 
envisaged until 2070 to around 9.84 million. That 
is a steeper increase than in the EU as a whole (EU 
25%).  Also  as  a  share  of  the  population,  the 
dependents  are  projected  to  become  a  bigger 
group, going  from 10.2% to 12.1% by 2070, with 

(605) Based on Eurostat projections. 
(606) Long-term  care  benefits  can  be  disaggregated  into  health 
related  long-term  care  (including  both  nursing  care  and 
personal  care  services)  and  social  long-term  care  (relating 
primarily  to  assistance  with  tasks  linked  with  Activities 
with Daily Living). 

494 

Dependency trends                                                                                                                         

 
                                                           
                                                           
 
formal long-term care in-kind and/or cash benefits, 
which  is  above  the  EU  average  of  4.6%  ( 610). 
However  higher  coverage  rates  may  imply  an 
increased  fiscal  pressure  on  government  budgets, 
possibly calling for greater needs of policy reform. 

The expenditure for institutional services makes up 
56.8%  of  public  in-kind  expenditure  (EU:  66.3% 
in  2016),  43.2%  being  spent  for  long-term  care 
services  provided  at  home  in  the  same  year.  The 
United  Kingdom  appears  to  be  more  focussed  on 
home  care  than  the  average  (EU  33.7%),  which 
may  be  more  efficient,  as  institutional  care  is 
relatively costly with respect to other types of care. 
While the share of expenditure on institutional care 
is  relatively  low,  unit  costs  of  this  type  of 
provision, measured as a share of GDP per capita, 
appear  to  be  above  average,  pointing  to  scope  to 
further  rationalise  spending  in  this  area.  Lower 
than  average  unit  costs  for  the  provision  of  cash 
benefits  also  suggest  that  this  area  could  be 
strengthened  with  potential  gains  from  a  cost-
efficiency  perspective,  subject 
rational 
allocation  and  well-regulated  use  of  additional 
resources. 

to  a 

The  United  Kingdom  has  a  devolved  long-term 
care  system  where  Wales,  England,  Scotland  and 
Northern Ireland manage their systems separately. 
Considering  that  83%  of  the  United  Kingdom’s 
elderly  reside  in  England,  the  majority  of  service 
use  and  expenditure  relates  to  England,  even 
though the elderly are not the only source of long-
term  care  expenditure  (611).  A  large  part  of  the 
fiscal  responsibility  for  long-term  care  used  to  lie 
with  the  individual,  but  there  is  also  considerable 
public support for the  financing of long-term care 
and  the  provision  of  services  (612).  In  Scotland,  a 
contribution  of  £177  a  week  to  a  care  provider  is 
available  to  anyone  assessed  as  needing  personal 
care  services,  and  is  not  means  tested.  Additional 
payments  are  available  to  people  needing  nursing 
care. This is known as ‘free personal care’, though 
doesn’t cover the full cost of care for most and is 
only  available  in  certain  circumstances  (613).  The 

(610) The 2018 Ageing Report. 
(611) Working age population with chronic conditions, including 
learning disabilities, represent an important source of non-
age-related spending. 

additional 

(612) OECD Fact Sheet, (May 2011). 
(613) For 
details 
thhttps://www2.gov.scot/Topics/Health/Support-Social-
Care/Support/Adult-Social-Care/Free-Personal-Nursing-
Care, accessed May 3, 2019. 

topic 

this 

on 

see 

Long-term care systems 

3.28. United Kingdom 

Department  of  Health,  Social  Services  and  Public 
Safety in Northern Ireland has recently carried out 
a consultation on adult social care reform (614). 

Administrative organisation 

is  strictly  means-tested  by 

Unlike  health  care  in  England  and  Wales,  adult 
local 
social  care 
authorities.  In  Scotland  care  is  provided  free  to 
everyone  in  need ( 615),  while  Northern  Ireland  is 
considering the introduction of free care. 

Types of care 

Home  care:  Domiciliary  care  otherwise  known  as 
home care helps people who are frail or who have 
support  needs  live  independently  in  their  own 
homes.  Personal  assistants  visit  people  to  provide 
practical support with tasks including washing and 
getting  dressed.  People  may  also  need  other  help 
with  other  practical  household  tasks.  Those  who 
believe they have care needs are entitled to a care 
assessment from their local authority If the person 
has  eligible  needs  the  council  will  carry  out  a 
financial  assessment  to  establish  whether  the 
person is entitled to help with the cost of their care. 

Residential  care  homes:  Most  care  homes,  are 
privately  run.  Local  authorities  can  commission 
care  from  either  private  care  homes  or  their  own 
facilities There are three types of institutional care 
in  the  United  Kingdom,  residential  care  homes, 
nursing homes and reablement beds in a hospital.  

Private Sector 

According  to  the  OECD  Fact  Sheet,  May  2011 
most  services  are  provided  by  the  private  sector 
however, in the private services have clients which 
are  separated  in  two  distinct  categories.  Publicly 
funded  clients  and  privately  funded  clients.  Since 
the majority of the clients are classified as publicly 
funded clients this means that the private sector is 
financed to a great extent by the public sector. 

(614) For 

further 

see 
http://www.dhsspsni.gov.uk/showconsultations?txtid=5850
1, accessed Oct. 18, 2013. 

details 

(615) Further  information  about  the  Scottish  system  is  available 
at 
http://www.scotland.gov.uk/Topics/Health/Support-
Social-Care/Support/Older-People/Free-Personal-Nursing-
Care, accessed October 18, 2013. 

495 

 
                                                           
 
                                                                                   
 
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Eligibility  criteria,  co-payments,  out  of  the 
pocket expenses and private insurance 

provided.  In  the  United  Kingdom,  private  long-
term care insurance is minimal (616).   

Local  authorities  receive  a  finite  amount  of 
funding  from  central  Government  but  may  also 
raise their own revenue through business rates and 
council tax. They determine how to distribute and 
set  budgets  for  expenditure  on  adult  social  care. 
Funding  comes  from  a  combination  of  central 
taxation  (formula  and  specific  grant  to  local 
authorities-block  grants),  local  taxation  (council 
tax  and  business  rates)  and  depending  on  local 
authority  means  test  user  charges  for  social  care 
services.  The  majority  of  central  government 
grants  received  are  not  earmarked  for  particular 
services  and  local  authorities  can  decide  how  to 
allocate  the  overall  budget  to  various  public 
services including social care services.  

Health services provided under the National Health 
Service  (NHS)  are  free  at  the  point  of  delivery, 
irrespective of the financial means of the user. As 
mentioned above, social care services arranged by 
local authorities attract user charges depending on 
the  user’s  financial  means.  Whether  or  not  a 
person  qualifies  for  any  financial  support  towards 
their care costs depends on the level of their assets. 
Local  authorities  provide  means-tested  financial 
help  to  pay  for  care  and  support  where  a  person 
cannot  afford  the  cost  themselves.  The  financial 
assessment  takes  into  account  what  a  person  can 
afford from both their income and their assets, for 
example savings or property. If a person has above 
the capital limit of £23,250 they pay the full costs 
of their care and support. If their assets are below 
the  lower  capital  limit  of  £14,250,  they  pay  what 
they  can  afford  from  income  only.  Anyone  who 
falls between the capital limits will be expected to 
pay  what  they  can  afford  from  income  plus  a 
means  tested  contribution  from  assets.  The  value 
of  a  person’s  house  is  not  included  in  the  means 
test if they receive care at home, or if they enter a 
care home but a  spouse or qualifying relative  still 
lives  at  the  house.  These  terms  are  known  as 
means test disregards.  

to 

In  response 
the 
Government funds a part of the nursing home fees 
that is meant to reflect the nursing input in the care 

the  Royal  Commission, 

496 

Some  people  over  the  age  of  18  with  a  ‘primary 
health  need’  may  be  eligible  for  NHS  Continuing 
Healthcare  (CHC),  a  package  of  care  that  is 
arranged and funded solely by the NHS for people 
not in hospital.  

CHC eligibility is not determined by age or clinical 
condition, but  we  know  that the  majority of those 
qualifying  are 
society  with 
debilitating  conditions  such  as  dementia,  or 
younger people with serious debilitating conditions 
such as spinal injury.  

the  oldest 

in 

Individuals  may  receive  CHC  funding  for  any 
setting, including their own home or a care home.  

If found to be eligible for CHC in an individual’s 
own  home,  the  NHS  will  pay  for  healthcare  (e.g. 
services  from  a  community  nurse  or  specialist 
therapist)  and  associated  social  care  needs  (e.g. 
personal  care  and  domestic  tasks  -  help  with 
bathing, dressing, food preparation and shopping). 

In a care home, the NHS also pays for care home 
fees, including board and accommodation. 

If an individual is not assessed as eligible for CHC 
but  does  have  some  nursing  needs,  and  resides  or 
needs  to  reside  in  a  care  home  with  nursing,  they 
may  be  eligible  for  NHS-funded  Nursing  Care 
(FNC). If assessed as eligible, the relevant Clinical 
Commissioning Group will pay a flat rate payment 
to  the  care  home  to  cover  the  reasonable  costs  of 
providing  registered  nursing  care  to  FNC  eligible 
residents. 

Institutional care 

In the United Kingdom, local authorities negotiate 
the  fees  that  are  paid  to  the  providers  of  publicly 
subsidised residential care and home-care services. 
As  local  authorities  are  in  many  areas  the  main 
purchaser  of  care  from  local  providers,  they  have 
considerable  market  power  to  negotiate  fees  at 
relatively 
levels.  Traditional  models  of 
residential  and  domiciliary  care  still  dominate 
today’s  market.  However  over  the  last  30  years, 
the market has shifted from a focus on care homes 

low 

(616) OECD Fact Sheet, May 2011. 

 
                                                           
in 

to  more  care  provided  at  home.  This  is  partly 
driven  by  a  policy  shift  towards  maintaining 
people’s 
the 
independence  at  home  and 
  The  Competition  and  Markets 
community. 
Authority  (CMA)  published  its  market  study  into 
residential  care  homes  for  over  65s  in  the  UK  in 
November  2017.    The  scope  of  the  market  study 
was to understand ‘why the care home market may 
not be working well for residents and their families 
and  to  develop  proposals  to  make  it  better’.  The 
report estimated that fees paid by local authorities 
to care home providers could be on average up to 
10% below total cost, on the basis of historical fees 
data  and  analysis.  The  report  concluded  that  this 
could  present  challenges 
term 
stability  of 
the  care  market.  Prevention  and 
rehabilitation policies/measures. 

longer 

the 

to 

Some 
services  which  are  preventative  or 
rehabilitative  in  nature  are  fully  funded  by  the 
state. 

Recently 
reforms  

legislated  and/or  planned  policy 

the  UK  passed 

In  2014 
legislation  which 
consolidated existing law in England into a single, 
unified, modern statute. The legislation focuses on 
promoting people’s well-being by enabling them to 
prevent  and  postpone  the  need  for  long  term  care 
and  to  pursue  education,  employment  and  other 
opportunities to realise their potential. The changes 
made include: 

− 

− 

introduction  of  a  new  national  minimum 
eligibility criteria,  which defines the  minimum 
level  of  need  for  support  an  individual  should 
be  assessed  as  having  before  they  are  entitled 
to  publicly  funded  care,  rather  than  allowing 
this  to  be  set  at  the  discretion  of  local 
government; (from April 2015); 

informal  carers  will  be  treated  as  equal  to  the 
person they care for, including the same rights 
to  assessment  and  broadened  entitlements  to 
publicly funded support (from April 2015); 

−  rebalancing  the  focus  of  services  to  promote 
wellbeing and prevention or  delaying of  needs 
in order to reduce dependency, rather than only 
intervening at crisis point; (from April 2015); 

Long-term care systems 

3.28. United Kingdom 

−  a new offer that the state will defer the costs of 
residential  care  in  return  for  a  charge  against 
the  person’s  house,  so  that  no-one  will  be 
forced to sell their home in their lifetime to pay 
for residential care (from April 2015). 

The  Government  has  committed  to  consult  on 
options for reform of the social care sector, to put 
it  on  a  more  sustainable  footing  for  the  longer 
term.  

Challenges 

The  UK  has  a  relatively  fragmented  system  of 
LTC,  with  above-average  unit  costs  and  average 
reliance  on  informal  care.  As  it  stands,  the  main 
challenges of the system appear to be: 

•  Improving  the  governance  framework:  to 
define  a  comprehensive  approach  covering 
both  policies  for  informal  (family  and  friends) 
carers, and policies on  the  formal provision of 
LTC  services  and  its  financing;  to  establish 
good information platforms for LTC users and 
providers;  to  use  care  planning  processes, 
based  on 
individualised  need  assessments, 
involving health and care providers and linking 
need assessment to resource allocation; to share 
to 
data  within  government  administrations 
facilitate 
potential 
the  management 
interactions  between  LTC  financing,  targeted 
personal-income  tax  measures  and  transfers 
(e.g.  pensions),  and  existing  social-assistance 
or  housing  subsidy  programmes;  to  deal  with 
cost-shifting incentives across health and care. 

of 

•  Improving financing arrangements: to foster 
pre-funding  elements,  which  implies  setting 
aside some funds to pay for future obligations. 

•  Providing adequate levels of care to those in 
need  of  care:  to  adapt  and  improve  LTC 
coverage  schemes,  setting 
the  depth  of 
coverage, that is, setting the extent of user cost-
sharing  on  LTC  benefits;  and  the  scope  of 
coverage,  that  is,  setting  the  types  of  services 
included into the coverage, to reduce the risk of 
impoverishment  of  recipients  and  informal 
carers. 

•  Ensuring  availability  of  formal  carers:  to 
for 

determine  current  and 

future  needs 

497 

 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

or circulated through the system; to steer  LTC 
users towards appropriate settings. 

•  Improving  value  for  money:  to  invest  in 
assistive devices,  which for example,  facilitate 
self-care,  patient 
co-
ordination between health and care services; to 
invest  in  ICT  as  an  important  source  of 
information, 
and 
coordination. 

centeredness, 

management 

care 

and 

•  Prevention:  to  promote  healthy  ageing  and 
preventing physical and mental deterioration of 
people with chronic care; to employ prevention 
and health-promotion policies and identify risk 
groups and detect morbidity patterns earlier. 

to 

through 

qualified  human  resources  and  facilities  for 
long-term care; to improve recruitment efforts, 
including 
the  migration  of  LTC 
workers and the extension of recruitment pools 
of  workers; 
the  retention  of 
increase 
successfully recruited LTC workers, by further 
improving  the  pay  and  working  conditions  of 
the  LTC  workforce  building  on  the  horizontal 
improvements  brought  about  for  all  categories 
by 
training 
opportunities,  more  responsibilities  on-the-job, 
feedback  support  and  supervision,  to  seek 
options  to  increase  the  productivity  of  LTC 
workers. 

the  National  Living  Wage, 

•  Supporting  family  carers:  to  further  the 
efforts  on  establishing  policies  for  supporting 
informal  carers,  as  envisaged  by  the  future 
carers  strategy,  such  as 
through  flexible 
working  conditions, 
respite  care,  carer’s 
allowances  replacing  lost  wages  or  covering 
expenses  incurred  due  to  caring,  cash  benefits 
paid to the care recipients,  while ensuring  that 
incentives  for  employment  of  carers  are  not 
diminished  and  women  are  not  encouraged  to 
withdraw  from  the  labour  market  for  caring 
reasons. 

•  Encouraging  independent  living:  to  provide 
effective  home  care,  tele-care  and  information 
to  recipients,  as  well  as  improving  home  and 
general living environment design. 

•  Ensuring  coordination  and  continuity  of 
care:  to  further  the  efforts  towards  better  co-
ordination of care pathways and along the care 
continuum,  such  as  through  a  single  point  of 
access to information, the allocation of care co-
ordination  responsibilities  to  providers  or  to 
care  managers,  via  dedicated  governance 
structures  for  care  co-ordination  and 
the 
integration  of  health  and  care  to  facilitate  care 
co-ordination. 

•  To  facilitate  appropriate  utilisation  across 
health  and  long-term  care:  to  arrange  for 
adequate supply of services and support outside 
hospitals,  changing  payment  systems  and 
financial  incentives  to  discourage  acute  care 
use  for  LTC;  to  create  better  rules,  improving 
(and 
safe  care  pathways  and 
information  delivered  to  chronically-ill  people 

securing) 

498 

 
Table 3.28.1:  Statistical Annex –United Kingdom 

GENERAL CONTEXT

GDP and Population
GDP, in billion euro, current prices
GDP per capita, PPS
Population, in millions
Public expenditure on long-term care (health)
As % of GDP
Per capita PPS
As % of total government expenditure
Note: Based on OECD, Eurostat - System of Health Accounts 
Health status
Life expectancy at birth for females
Life expectancy at birth for males
Healthy life years at birth for females
Healthy life years at birth for males
People having a long-standing illness or health problem, in % of pop.
People having self-perceived severe limitations in daily activities (% of pop.)

SYSTEM CHARACTERISTICS

2005

2,027
30.9
60.2

:
:
:

81.3
77.0
65.5
64.2
:
:

2006

2,147
31.1
60.6

:
:
:

81.6
77.3
64.9
64.8
38.0
9.2

2007

2,245
30.8
61.1

:
:
:

81.8
77.6
66.0
64.6
35.8
9.0

2008

1,975
29.5
61.6

:
:
:

81.8
77.7
66.3
65.0
33.9
8.8

2009

1,717
26.7
62.0

:
:
:

82.4
78.3
66.1
65.0
35.8
9.6

2007

2008

2009

259
951
2.0

318
847
1.9

:
:

288
899
1.9

:
:

Coverage (Based on data from Ageing Reports)
Number of people receiving care in an institution, in thousands
Number of people receiving care at home, in thousands
% of pop. receiving formal LTC in-kind 
Note: Break in series in 2010 and 2013 due to methodological changes in estimating number of care recipients
Providers
Number of informal carers, in thousands
Number of formal carers, in thousands

:
:
:

:
:
:

:
:

:
:

2005

2006

Source: EUROSTAT, OECD and WHO. 

4
9
9

2010

1,842
27.4
62.5

:
:
:

82.6
78.6
65.6
64.9
34.5
9.2

2010

230
1,003
2.0

2011

1,884
27.1
63.0

:
:
:

83.0
79.0
65.2
65.2
36.0
9.1

2011

234
1,017
2.0

2012

2,078
27.5
63.5

:
:
:

82.8
79.1
64.5
64.6
32.9
10.6

2012

238
1,032
2.0

2013

2,064
27.4
63.9

1.2
334.5
2.8

82.9
79.2
64.8
64.4
32.5
10.2

2013

243
1,020
2.0

2014

2,279
27.9
64.4

1.2
339.5
2.7

83.2
79.5
64.2
63.4
34.4
10.5

2014

246
1,030
2.0

2015

EU 2009

EU 2011

EU 2013

EU 2015

2,602
29.1
64.9

1.2
355.0
2.8

82.8
79.2
63.3
63.7
35.3
10.6

12,451
26.8
502

1.1
264.1
1.6

82.6
76.6
62.0
61.3
31.3
8.3

13,213
28.1
503

1.2
283.2
1.8

83.1
77.3
62.1
61.7
31.7
8.3

13,559
28.0
505

1.2
352.1
2.5

83.3
77.7
61.5
61.4
32.5
8.7

14,447
29.6
509

1.2
373.6
2.5

83.3
77.9
63.3
62.6
34.2
8.1

2015

EU 2009

EU 2011

EU 2013

EU 2015

249
1,040
2.0

3,433
6,442
2.0

3,851
7,444
2.2

4,183
6,700
2.2

4,313
6,905
2.2

5,550
:

:
:

:
:

:
:

:
:

:
:

:
:

:
:

:
:

:
:

:
:

3
.
2
8
.

U
n
i
t
e
d
K
n
g
d
o
m

i

L
o
n
g

r

-
t
e
m
c
a
e
s
y
s
t
e
m

r

s

 
 
 
 
 
 
 
 
 
 
 
 
5
0
0

Table 3.28.2:  Statistical Annex - continued – United Kingdom 

PROJECTIONS

Population

Population projection in millions
Dependency

Number of dependents in millions

Share of dependents, in %
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario

Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Public spending on formal LTC in-kind ( % of tot. publ. spending LTC)

Public spending on LTC related cash benefits ( % of tot. publ. spending LTC)

Public spending on institutional care ( % of tot. publ. spending LTC in-kind)

Public spending on home care ( % of tot. publ. spending LTC in-kind)

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

2016

65.6

6.67

10.2

1.5

1.5

2020

67.5

6.97

10.3

1.6

1.6

2030

71.8

7.78

10.8

1.8

1.9

2040

75.2

8.49

11.3

2.1

2.2

2050

77.7

9.09

11.7

2.4

2.6

2060

79.4

9.45

11.9

2.6

3.0

2070

81.0

9.84

12.1

2.8

3.3

644,163

1,242,964

1,604,522

685,067

1,321,712

1,699,848

831,859

1,584,020

2,015,483

1,008,108

1,859,854

2,349,049

1,182,738

2,122,156

2,664,252

1,302,625

2,284,079

2,869,875

1,389,748

2,437,852

3,049,085

5.3

52.3

97.7

2.3

56.8

43.2

85.1

33.5

1.4

5.5

53.2

97.7

2.3

56.8

43.2

85.0

33.5

1.4

6.2

56.9

97.7

2.3

57.1

42.9

87.4

34.6

1.5

6.9

61.5

97.8

2.2

57.8

42.2

89.2

35.3

1.5

7.7

65.7

97.8

2.2

58.3

41.7

89.4

35.6

1.5

8.1

68.3

97.9

2.1

58.9

41.1

91.0

36.2

1.5

8.5

69.9

97.9

2.1

58.9

41.1

92.7

36.9

1.5

MS Change 2016-
2070

EU Change 2016-2070

24%

47%

19%

83%

120%

116%

96%

90%

59%

34%

0%

-10%

4%

-5%

9%

10%

8%

2%

25%

21%

73%

170%

72%

86%

52%

61%

33%

5%

-27%

0%

-1%

10%

1%

-14%

Source: EUROSTAT, OECD, WHO and European Commission (DG ECFIN)-EPC (AWG) 2018 Ageing Report projections (2016-2070). 

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ANNEX 

Health care – data sources by indicator 

GDP

GDP, in billion Euro, current prices

GDP per capita PPS (thousands)

Real GDP growth (% year-on-year) per capita

Real total health expenditure growth (% year-on-year) per capita

Expenditure on health*

Total as % of GDP

Total current as % of GDP

Total capital investment as % of GDP

Total current per capita PPS

Public as % of GDP

Public current as % of GDP

Public current per capita PPS

Public capital investment as % of GDP

Public as % total expenditure on health

Public expenditure on health in % of total government expenditure

Proportion of the population covered by public or primary private health insurance

Out-of-pocket expenditure on health as % of total expenditure on health

Note: *Including also expenditure on medical long-term care component, as reported in standard internation databases, 
such as in the System of Health Accounts.

Population and health status

Population, current (millions)

Life expectancy at birth for females

Life expectancy at birth for males

Healthy life years at birth females

Healthy life years at birth males

Amenable mortality rates per 100 000 inhabitants*

Infant mortality rate per 1 000 life births

System characteristics

Data sources

Eurostat

Ameco

Eurostat

Eurostat

Data sources

Eurostat and WHO

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Eurostat, OECD, WHO and AMECO

Eurostat, OECD and WHO

Eurostat and OECD

Eurostat, OECD and AMECO

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Eurostat

OECD

Eurostat and WHO

Data sources

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Composition of total or public current expenditure as % of GDP and as % of total current health expenditure

Data sources

Inpatient curative and rehabilitative care

Day cases   curative and rehabilitative care

Out-patient curative and rehabilitative care

Pharmaceuticals and other medical non-durables

Therapeutic appliances and other medical durables

Prevention and public health services

Health administration and health insurance 

Expenditure drivers (technology, life style)

MRI units per 100 000 inhabitants

Angiography units per 100 000 inhabitants

CTS per 100 000 inhabitants

PET scanners per 100 000 inhabitants 

Proportion of the population that is obese

Proportion of the population that is a regular smoker

Alcohol consumption litres per capita 

Providers

Practising physicians per 100 000 inhabitants

Practising nurses per 100 000 inhabitants

General practitioners per 100 000 inhabitants

Acute hospital beds per 100 000 inhabitants

Outputs

Doctors consultations per capita

Hospital inpatient discharges per 100 inhabitants

Day cases discharges per 100 000 inhabitants

Acute care bed occupancy rates

Hospital curative average length of stay

Day cases as % of all hospital discharges

Population and Expenditure projections

Projected public expenditure on healthcare as % of GDP*

AWG reference scenario

AWG risk scenario

Note: *Excluding expenditure on medical long-term care component.

Population projections

Population projections until 2070 (millions)

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Eurostat, OECD and WHO

Data sources

Eurostat

Eurostat

Eurostat

Eurostat

OECD

Eurostat and OECD

OECD and WHO

Data sources

Eurostat and OECD

Eurostat and OECD

Eurostat and OECD

Eurostat, OECD and AMECO

Data sources

Eurostat and OECD

Eurostat

Eurostat

Eurostat and WHO

Eurostat

Eurostat and AMECO

Data sources

Ageing report 2018

Ageing report 2018

Ageing report 2018

501 

 
 
European Commission 

Joint Report on Health Care and Long-Term Care Systems and Fiscal Sustainability- Country Documents 

Long-term care – data sources by indicator 

Indicator

GDP and Population

GDP, in billion euro, current prices

GDP per capita, PPS

Population, in millions

Public expenditure on long-term care

As % of GDP

Per capita PPS

As % of total government expenditure

Health status

Life expectancy at birth, females

Life expectancy at birth, males

Healthy life years at birth, females

Healthy life years at birth, males

People having a long-standing illness or health problem, in % of pop.

People having self-perceived severe limitations in daily activities (% of pop.)

Coverage (Based on data from Ageing Reports)

Number of people receiving care in an institution (thousands) 

Number of people receiving care at home (thousands)

% of pop. receiving formal LTC in-kind 
Providers

Number of informal carers (thousands) (OECD)

Number of formal carers (thousands) (OECD)
Population

Population projection in millions (Europop2013)
Dependency

Number of dependents in millions (2015 Ageing Report)

Share of dependents (%, 2015 Ageing Report)
Projected public expenditure on LTC as % of GDP

AWG reference scenario

AWG risk scenario
Coverage

Number of people receiving care in an institution

Number of people receiving care at home

Number of people receiving cash benefits

% of pop. receiving formal LTC in-kind and/or cash benefits

% of dependents receiving formal LTC in-kind and/or cash benefits
Composition of public expenditure and unit costs

Data source

Eurostat

Ameco

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Eurostat

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018 and Eurostat

OECD

OECD

Eurostat

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Public spending on formal LTC in-kind as % of total public spending on LTC

Ageing Report 2018

Public spending on LTC related cash benefits as % of total public spending on LTC

Ageing Report 2018

Public spending on institutional care as % of total public spending on LTC in-kind

Ageing Report 2018

Public spending on home care as % of total public spending on LTC in-kind

Unit costs of institutional care per recipient, as % of GDP per capita

Unit costs of home care per recipient, as % of GDP per capita

Unit costs of cash benefits per recipient, as % of GDP per capita

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

Ageing Report 2018

502 

 
 
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