Eurostat, the statistical office of the European Union.

F5: Education, health and social protection

European Commission, Eurostat F.5, L-2920 Luxembourg, LUXEMBOURG

Non-expenditure healthcare data provide information on institutions providing healthcare in countries, on resources used and on output produced in the framework of healthcare provision.

Data on healthcare form a major element of public health information as they describe the capacities available for different types of healthcare provision as well as potential 'bottlenecks' observed. The quantity and quality of healthcare services provided and the work sharing established between the different institutions are a subject of ongoing debate in all countries. Sustainability - continuously providing the necessary monetary and personal resources needed - and meeting the challenges of ageing societies are the primary perspectives used when analysing and using the data.

The resource-related data refer to both human and technical resources, i.e. they relate to:

- Health care staff: 'manpower' active in the health care sector (doctors, dentists, nurses, etc.);

- Heath workforce migration: migration movements of doctors and nurses;

- Healthcare facilities: technical capacity dimensions (hospital beds, beds in nursing and residential care facilities, etc.).

The output-related data ('activities') refer to contacts between patients and the healthcare system, and to the treatment thereby received. Data are available for hospital discharges of in-patients and day cases, average length of stay of in-patients and medical procedures performed in hospitals.

Annual national and regional data are provided in absolute numbers and in population-standardised rates (per 100 000 inhabitants).

Wherever applicable, the definitions and classifications of the System of Health Accounts (SHA) are followed, e.g. International Classification for Health Accounts - Providers of health care (ICHA-HP). For hospital discharges, the International Shortlist for Hospital Morbidity Tabulation (ISHMT) is used. Surgical procedures are classified according to a shortlist mapped to ICD-9-CM.

These healthcare data are largely based on administrative data sources in the countries. Therefore, they reflect the country-specific way of organising healthcare and may not always be completely comparable.

Healthcare staff

In the context of comparing healthcare services across Member States, Eurostat gives preference to the concept 'practising', as it best describes the availability of healthcare resources. Definitions are laid down in Commission Regulation (EU) 2022/2294 on healthcare facilities, healthcare human resources and healthcare utilisation, http://data.europa.eu/eli/reg/2022/2294/oj .

Healthcare facilities

Definitions are laid down in Commission Regulation (EU) 2022/2294. The contents of the categories hospitals (HP.1) and nursing and residential care facilities (HP.2) should follow the ICHA-HP classification of providers of health care of the System of Health Accounts (SHA).

Healthcare Activities

Definitions are laid down in Commission Regulation (EU) 2022/2294. Patient related definitions follow the System of Health Accounts (SHA) whenever applicable. 

Discharges by diagnosis refer to the principal diagnosis, i.e. the main condition diagnosed at the end of the hospitalisation (in-patients) or day treatment (day cases). The main condition is the one primarily responsible for the patient's need for treatment or investigation (for additional details, see International statistical Classification of Diseases and related health problems - ICD-10 Volume 2).

The data is available according to the International Classification for Hospital Morbidity Tabulation (ISHMT). This shortlist for statistical comparison of hospital activity analysis was adopted in 2005 by Eurostat, the OECD (Organisation for Economic Co-operation and Development) and the WHO-FIC (Family of International Classifications) Network.

The surgical operations and procedures performed in hospitals are listed and presented according to the classification ICD-9-CM (Clinical Modification). However, at national level, different classifications are used for coding operations and procedures, e.g. the ICPM (International Classification of Procedures in Medicine) or ICD-9-CSP (ICD-surgical procedures), and it is not always possible to convert the data directly into ICD-9-CM and preserving the original meaning of the diagnosis or procedure category. Moreover, the ICD-9-CM includes a series of additions, which are not available in the ICD or in some of the national classifications like NOMESCO (Nordic Medico-Statistical Committee), OPCS4-UK (Classification of Surgical Operations and Procedures), CDAM France (Catalogue des Actes Médicaux), OPS301 Germany (Systematik des Operationenschlüssels) etc. 

The dataset on surgical operations and procedures present data according to the list proposed by the Hospital Data Project II.

Regional data follow the geographical classification NUTS2.

The sector covered is the Public Health sector. Public Health refers to all organized measures (whether public or private) to prevent disease, promote health, and prolong life among the population as a whole. 

Healthcare resources' statistics describe the process of providing healthcare services in countries by referring to the participating institutions. Institution-related data are mostly related to and derived from available resources and so focus primarily on a capacity dimension.

Health care activities' statistics describe the process of providing health care services in countries by referring to the services provided. Service-related data aim at quantifying directly elements of the healthcare delivery process.

The respective data are, due to their heterogeneity, collected, stored and disseminated via different tables. They are based on different, mainly administrative sources. This may lead to differences in the coverage of time series and/or in the geographical coverage; data validity, reliability and comparability may vary. Furthermore, it may not always be possible to have the healthcare system, implicitly underpinning the data collection, being consistently defined across data sources.

Non-expenditure healthcare resources data are grouped as follows:

- Healthcare staff: data refer to human resources available for providing health care services in the country, irrespective of the sector of employment (i.e. whether they are independent, employed by a hospital or any other health care provider). 'Manpower' categories focus on health care professionals (physicians, dentists, nursing and caring professionals, pharmacists, physiotherapists); socio-demographic elements (age, sex) are partly included.

Three different concepts are used to present the number of health care professionals:
- 'practising', i.e. health care professionals providing services directly to patients;
- 'professionally active', i.e. 'practising' health care professionals plus health care professionals for whom their medical education is a prerequisite for the execution of the job;
- 'licensed to practice', i.e. health care professionals who are registered and entitled to practice as health care professionals.

There is also a table on health workforce migration, which presents data on the number and annual inflow of foreign trained doctors and nurses.

- Healthcare facilities: data refer to available beds in hospitals (HP.1) and subcategories (such as curative care beds, rehabilitative care beds, etc.) and available beds in nursing and residential care facilities (HP.2) as well as medical technology and technical resources in hospitals (HP.1).

Total hospital beds (HP.1) are all hospital beds which are regularly maintained and staffed and immediately available for the care of admitted patients. Total hospital beds are broken down as follows:
- Curative care (acute care) beds;
- Rehabilitative care beds;
- Long-term care beds (excluding psychiatric care beds);
- Other hospital beds.

Beds in nursing and residential care facilities (HP.2) are available beds for people requiring ongoing health and nursing care due to chronic impairments and a reduced degree of independence in activities of daily living (ADL) in establishments primarily engaged in providing residential care combined with either nursing, supervision or other types of care as required by the residents. The care provided can be a mix of health and social services. 

The definition of healthcare facilities follows the International Classification for Health Accounts - Providers of health care (ICHA-HP) of the System of Health Accounts (SHA).

Hospital patients: data refer to (1) hospital discharges of in-patients and day cases by age, sex, and selected (groups of) diseases; (2) average length of stay of in-patients; (3) a selection of medical procedures applied in hospitals.

A (hospital) discharge is the formal release of a patient from a hospital after a procedure or course of treatment (episode of care). A discharge occurs anytime a patient leaves because of finalisation of treatment, signs out against medical advice, transfers to another health care institution or because of death. A discharge can refer to in-patients or day cases. Healthy newborns should be included. Transfers to another department within the same institution are excluded.

An in-patient is a patient who is formally admitted (or 'hospitalised') to an institution for treatment and/or care and stays for a minimum of one night or more than 24 hours in the hospital or other institution providing in-patient care.

Day case: day care comprises medical and paramedical services (episode of care) delivered to patients who are formally admitted for diagnosis, treatment or other types of health care with the intention of discharging the patient on the same day. An episode of care for a patient who is admitted as a day-care patient and subsequently stays overnight is classified as an overnight stay or other in-patient case.

Average length of stay (ALOS) is computed by dividing the number of hospital days (or bed-days or in-patient days) from the date of admission in an in-patient institution (date of discharge minus date of admission) by the number of discharges (including deaths) during the year. 

Procedures are all types of medical interventions with the intention of achieving a result in the care of persons with health problem.

Next to absolute numbers, density rates are provided for healthcare statistics.

Density rates are used to describe the availability of resources or the frequency of services rendered, expressed in per 100 000 inhabitants. They are calculated by dividing the absolute number of health care resources available or services rendered in a given period by the respective population in the same period and then multiplied by 100 000. For Luxembourg the density rates are calculated dividing the absolute number of healthcare services rendered in a given period by the resident population covered by the statutory health insurance scheme and then multiplied by 100 000.

The availability of resources may also be expressed by an inverse figure - e.g. the number of inhabitants per physician - which is selectively used here.

Administrative data sources refer to registered patients treated or procedures applied. The underlying totality of institutions, for which data collections are available, may differ. In some countries, data may not be available for a subgroup of institutions (e.g. private hospitals).

Depending on the data set, the target populations are (1) all healthcare staff or (2) all available beds or equipment in hospitals or in nursing and residential care facilities or (3) all discharges or procedures performed in all hospitals.

EU Member States, Iceland, Liechtenstein, Norway, Switzerland, Montenegro, North Macedonia, Albania, Serbia and Turkey.

For several data sets, time series for the EU Member States, Iceland, Liechtenstein, Norway, Montenegro, Switzerland, North Macedonia, Albania, Serbia and Turkey are available from 1960 onwards. However, the availability of the data varies across countries and data sets.

Not applicable.

The data are published in absolute numbers and rate per 100,000 inhabitants. The data may also be expressed by an inverse figure - e.g. the number of inhabitants per physician.

Calendar year; depending on the data set this can be annual average data or data as reported by 31st December.

One exception is the influenza vaccination programme data, which can be reported according to the influenza season. In this case, data refer to the season preceeding the reference year, e.g. 2021 data refer to influenza season 2020/2021. 

Countries submit data to Eurostat on the basis of Regulation (EU) 2022/2294 on statistics on healthcare facilities, healthcare human resources and healthcare utilisation, and based on a gentlemen's agreement established in the framework of the Eurostat Working Group on 'Public Health Statistics'.

Data are collected jointly with OECD and WHO-Europe and shared between the three organisations, except for hospital discharges on regional level which are for Eurostat only. 

Regulation (EC) No 223/2009 on European statistics (recital 24 and Article 20(4)) of 11 March 2009 (OJ L 87, p. 164) stipulates the need to establish common principles and guidelines ensuring the confidentiality of data used for the production of European statistics and the access to those confidential data with due account for technical developments and the requirements of users in a democratic society.

As most of the data are transmitted to Eurostat in an aggregated form, they are not considered confidential. Data on regional hospital discharges are considered confirdential.

Confidential data are treated in Eurostat's secure environment and disseminated as aggregated data according to a shortlist.

The data collected from countries and the EU aggregates are released annually according to Eurostat's release calendar, normally in July.

https://ec.europa.eu/eurostat/web/main/news/release-calendar?start=1675206000000&type=listMonth 

https://ec.europa.eu/eurostat/web/main/news/release-calendar?start=1675206000000&type=listMonth

In line with the Community legal framework and the European Statistics Code of Practice Eurostat disseminates European statistics on Eurostat's website (see item 10 - 'Accessibility and clarity') respecting professional independence and in an objective, professional and transparent manner in which all users are treated equitably. The detailed arrangements are governed by the Eurostat protocol on impartial access to Eurostat data for users.

Annual.

News releases on-line.

Statistics Explained: Health

Health in the European Union – facts and figures

For more information on publications, see also the Health dedicated section on Eurostat website.

Eurostat's online dissemination database: https://ec.europa.eu/eurostat/web/main/data

Not applicable.

Data on healthcare non-expenditure are used in other Eurostat publications, such as the Regional Yearbook

https://ec.europa.eu/eurostat/web/main/publications/flagship-publications

For the comprehensive metadata of each variable/country, see the national metadata reports attached to this European metadata file.

National quality reports will be requested from countries periodically.

Eurostat offered online training of countries concerning the data and metadata in January 2023. A Eurostat manual on healthcare non-expenditure statistics has been produced and is available on Eurostat's website. It provides guidance to reporting countries and information to users. 

Eurostat applies automatic and manual validation checks to the data and metadata provided by countries. The outcome is documented internally and used for the compliance assessment. The compliance is reported annually in Eurostat's expert group Directors of Social statistics.

The quality of the data is subject to the way in which healthcare provision is organised in countries, and which information is available to and collected by the respective institutions.

The quality, comparability and coverage are discussed at annual technical meetings of the Technical Group Healthcare non-Expenditure statistics and at the annual Eurostat's Working Group "Public Health Statistics".

It is also subjected to annual discussions with OECD and WHO-Europe at annual trilateral meetings concerning the Joint Questionnaire on Health Care Non-Monetary Statistics, which is the basis for the data collection.

National quality reports will be requested from countries periodically and disseminated together with the national metadata.

The main users of the data are European Commission DG Health and Food Safety (SANTE) and DG Employment, Social Affairs & Inclusion (EMPL) in view of health policy papers and health strategies. Secondly, national policy-makers and statistical offices use the data for country comparisons. Researchers and the general public are also using the data.

The results of the ongoing ESS review of Health related statistics will become available in 2024 and will better describe User Needs, met and unmet.

Eurostat carries out an annual User satisfaction survey on a central level, see the latest results here:

https://ec.europa.eu/eurostat/en/web/products-eurostat-news/w/wdn-20230104-1

For the Health domain, 263 out of 291 respondents ranked the Health data quality as Very good, Good or Adequate.

The results of the ongoing ESS review of Health related statistics will become available in 2024 and will describe User Satisfactionmore detailed.

Administrative data sources refer to registered health human resources and health care facilties. The underlying totality of institutions for which data collections are available may differ. In some countries, data may not be available for a subgroup of institutions (e.g. private hospitals) or professionals (e.g. practising nurses).

Not available.

Not applicable as the data are based on administrative data and not on surveys.

Not applicable as the data are based on administrative data and not on surveys.

Regulation (EU) 2022/2294 fixes the deadline for data delivery at N+14 months for the year N for the mandatory variables relating to

• Health graduates,
• Hospital beds and beds in residential long-term care facilities,
• Devices on medical imaging,
• Data on ambulatory care.

Data for health employment, hospital care and surgical procedures will become mandatory for countries to transmit from reference year 2023 with a deadline of N+20 months.

There is no binding release date for healthcare non-expenditure statistics on European level. The statistics are normally released in July.

The comparability of the data across different countries is limited by the fact that the quality of the country data is subject to the way in which healthcare provision is organised in countries, and which information is available to and collected by the respective institutions. The newly produced Eurostat Manual assists countries in harmonising their data.

Some countries are unable to cover all providers of care (the inclusion of private providers seems particularly difficult) or are only able to provide data for selective regions.

Sometimes regional data cannot be made available as the available breakdown does not coincide with the NUTS classification.

Ongoing work to increase quality, comparability and coverage is reported to Eurostat's Working Group "Public Health Statistics".

The comparability of the data over time is checked before dissemination.

Some countries may have a change in their data collection resulting in a break in series. These break in series are flagged (b-flag) and some information are given in the annexes of the metadata.

Not applicable.

Cross-checks are made where data are available, for example the total number of practising physicians and numbers in the sub-categories of practising physicians. 

This is a joint data collection together with other international organisations, in order to limit the cost and burden on reporting countries.

The general Eurostat revision policy applies to this domain.

Countries may update the time series of data provided at each annual collection. Eurostat disseminated the revised data at the next data release, or in urgent cases, as soon as possible.

All reported errors (once validated) result in corrections of the disseminated data.

Reported errors are corrected in the disseminated data as soon as the correct data have been validated.

Data may be published even if they are missing for certain countries or flagged as provisional for certain countries. They are replaced with final data once transmitted and validated. 

European aggregates are updated for consistency with new country data if possible and where necessary.

Whenever new data are provided and validated, the already disseminated data are updated as soon as possible.

Major revisions have not been carried out, nor are major revisions foreseen to be carried out for the disseminated data of this domain.

Health care non-expenditure data are mainly derived from administrative sources, and these sources may vary by country and by variable. Sources for each variable/country are mentioned in the national metadata reports attached to this European metadata report.

Please note that the data sources used may not have been created initially for statistical purposes, and that the initial purpose of a data source may differ across countries. Both facts may influence the validity and comparability of results.

Annual.

Data are collected based mainly on administrative sources and national registers. These sources may vary by country and by variable, depending on how the healthcare systems are set up in the countries.

Eurostat applies automatic and manual validation checks to the data and metadata provided by countries. 

Consistency checks: comparing the statistics with previous years, investigating inconsistencies in the statistics, performing macro data editing, outlier detection. Comparison of validation results with OECD and WHO in view of data collected by the Joint Questionnaire on Non-Monetary Health Care Statistics.

The absolute numbers for EU aggregates are the sum of the country numbers. When there is no available data for a country, the calculation of the EU aggregate takes into account the available data in the 5 previous years for the countries for which data is missing. For the density rates these EU totals are divided by the corresponding total EU population.

No adjustments are made by Eurostat.

Note on hospital discharges data with COVID-19 diagnosis:

Since reference year 2020, all the hospital discharges tables that are available in Eurostat’s dissemination database include the hospital discharges having COVID-19 as principal diagnosis. Detailed information on discharges with COVID-19 as principal diagnosis can be found in the tables that include a breakdown by diagnosis. There are 24 tables in total in the following Eurobase folders:

https://ec.europa.eu/eurostat/data/database?node_code=hlth_hosd

https://ec.europa.eu/eurostat/data/database?node_code=hlth_hosd_r

https://ec.europa.eu/eurostat/data/database?node_code=hlth_hostay

However, some countries have not declared COVID-19 as principal diagnosis, as the inpatients with COVID-19 have been discharged with another principal diagnosis (i.e. pneumonia). Therefore, for some countries, only very few or no hospital discharges are recorded with COVID-19 as principal diagnosis at discharge.