Archive:Social protection statistics - sickness and health care benefits

This Statistics Explained article has been archived - for recent articles on social protection see here.

Data from June 2022.

Planned article update: April 2023.

Highlights

In 2019, the total expenditure on sickness and healthcare benefits in the EU amounted to €1 111 billion, or 7.9 % of GDP.

In 2019, average expenditure per inhabitant on sickness and healthcare benefits in the EU was €2 484.

Cash payments made up 14.7 % of the expenditure on sickness and healthcare benefits in the EU while the rest (85.3 %) was for benefits in kind.

Expenditure on sickness and healthcare benefits relative to population size, 2019

This article presents statistics relating to expenditure on social protection benefits concerning sickness and healthcare benefits. These statistics are collected through the European system of integrated social protection statistics (ESSPROS). Data are presented for the European Union (EU) Member States, European Free Trade Association (EFTA) and enlargement countries.

Full article

Relative importance of expenditure on sickness and healthcare benefits

Expenditure on sickness and healthcare benefits was valued at €1 111 billion in 2019. This sum was equivalent to 7.9 % of gross domestic product (GDP) and 29.5 % of all expenditure on social protection benefits (see Figure 1).

In the vast majority of the EU Member States, the level of spending on sickness and healthcare benefits in 2019 ranged between 4.5 % and 7.7 % of GDP; it exceeded this range in France (9.0 %), the Netherlands (9.4 %) and Germany (10.3 %). Among the non-member countries shown in Figure 1, the level of spending on sickness and healthcare benefits in 2019 was also above 7.7 % of GDP in the three EFTA countries for which data are available, while spending was below 4.5 % of GDP in North Macedonia (4.2 %; 2017 data) and Turkey (3.4 %).

Relative to the total expenditure on social protection benefits in 2019, expenditure on sickness and healthcare benefits among the EU Member States generally ranged between 22 % and 35 %. Nevertheless, it was above this range in Germany (35.7 %), Malta (36.6 %) and Ireland (39.4 %), while it was lower in Denmark (21.2 %) and Greece (19.7 %).

Figure 1: Expenditure on sickness and healthcare benefits, 2019
(%)
Source: Eurostat (spr_exp_sum)

The analysis of the proportion of social benefit expenditure allocated to sickness and healthcare benefits is impacted to some extent by the amounts spent on all other types of benefits, which are in turn affected by a wide range of socioeconomic factors. For example, expenditure on unemployment related benefits is linked to the state of the labour market, while expenditure on old age pensions and family/children benefits is linked to the age structure of the population. However, this is also the case to some extent for sickness and healthcare benefits, as these tend to be higher for older people.

An alternative analysis of expenditure on sickness and healthcare benefits can be made on the basis of expenditure per inhabitant, as shown in Figure 2. Two measures are presented, the first in euro terms and the second in purchasing power standards (PPS). The latter are used to eliminate price differences between EU Member States, with €1 set to 1 PPS for the EU as a whole. Member States with relatively high price levels, such as many western and Nordic Member States as well as Italy, have a lower average expenditure when calculated in PPS terms than in euro terms, whereas Member States with relatively low price levels – all other southern, eastern and Baltic Member States – have a higher average expenditure when calculated in PPS terms than in euro terms.

In euro terms, the expenditure per inhabitant on sickness and healthcare benefits in 2019 averaged €2 484 in the EU, peaking at €5 613 in Luxembourg ^[1] while it was lowest at €426 in Bulgaria. As such, the ratio between the highest and lowest average expenditure per inhabitant on these benefits among the EU Member States was about 13 : 1.

Turning to the average expenditure per inhabitant in PPS terms, the EU average remained the same (by definition), while Germany (3 999 PPS) and Bulgaria (866 PPS) recorded the highest and lowest expenditure on sickness and healthcare benefits (adjusted for price level differences), giving a ratio of about 5 : 1. The overall impact of expressing this ratio in PPS terms is that it greatly narrows the range of the average expenditure among the EU Member States. As can clearly be seen from Figure 2, this was not just the case for the two extreme values: the 11 Member States with the highest average expenditure per inhabitant in euro terms all recorded lower averages in PPS terms, while the remaining 16 Member States recorded higher averages in PPS terms.

In euro terms, Switzerland recorded higher average expenditure per inhabitant on sickness and healthcare benefits in 2019 than in any of the EU Member States, while in Norway and Iceland this ratio was only lower than that observed in Luxembourg. After adjusting for price level differences, the ratios expressed in PPS were, nevertheless, lower in the EFTA countries than in Germany, Luxembourg and the Netherlands. By contrast, the ratios in the five enlargement countries for which data are shown were lower than in any of the Member States, both in euro terms and in PPS.

Figure 2: Expenditure on sickness and healthcare benefits relative to population size, 2019
Source: Eurostat (spr_exp_sum)

Developments for expenditure on sickness and healthcare benefits

Between 2009 and 2019, the total expenditure on sickness and healthcare benefits in the EU increased 30.7 % in current price terms. Part of this increase reflects price changes over time: the increase in real (constant price) terms was 15.8 %. Adjusting for the increase in the population during this period, the average expenditure per inhabitant on sickness and healthcare benefits increased from €1 929 to €2 484, an overall increase of 28.8 % in current price terms and 14.0 % in constant prices.

Figure 3 presents average expenditure per inhabitant on sickness and healthcare benefits in PPS terms for 2009 and 2019. Apart from Greece, all EU Member States reported higher average expenditure per inhabitant on such benefits (in PPS terms) in 2019 than in 2009. Large relative increases were observed in several eastern and Baltic Member States, as well as in Germany, Malta and Austria, with particularly large increases in Bulgaria and Romania. Among the eastern Member States, the most subdued increase was observed in Hungary, although there is a break in series. The large increases recorded for many Member States that had low levels of average expenditure meant that there was a general convergence in levels of expenditure per inhabitant between the Member States during the period under consideration. For example, in 2009 the ratio of the highest to the lowest average expenditure on sickness and healthcare benefits among the Member States was about 9 : 1, whereas by 2019 it was about 5 : 1 (as noted earlier).

Figure 3: Expenditure on sickness and healthcare benefits relative to population size, 2009 and 2019
(PPS per inhabitant)
Source: Eurostat (spr_exp_sum)

Analysis of the type of expenditure on sickness and healthcare benefits

Sickness and healthcare benefits can be distinguished between cash benefits (comprising paid sick leave and other cash benefits) and benefits in kind: the latter mainly include benefits for in-patient health care and for out-patient health care (comprising expenditure for pharmaceuticals and other health care), but also includes other benefits in kind.

The largest types of expenditure across the EU for sickness and healthcare benefits in 2019 were two types of benefits in kind: in-patient health care (41.1 %) and out-patient health care other than pharmaceuticals (29.7 %). Paid sick leave (14.2 %) and pharmaceuticals (12.2 %) were the other large types of expenditure.

Figure 4 shows this analysis for the EU Member States, EFTA and enlargement countries. Within each of these groupings, the countries are ranked on the relative importance of cash (blue shades) and in kind (other colours) benefits. Benefits in kind accounted for the majority of expenditure for sickness and healthcare benefits in 2019 in all EU Member States, ranging from 95.3 % in Romania to 77.5 % in Luxembourg; in most Member States (19 out of 27) the share of benefits in kind was between 81 % and 91 %.

Turning to the six types of benefits identified in Figure 4, in-patient health care was most commonly the largest expenditure item: in the 10 EU Member States where this was not the case – Belgium, Estonia, Italy, Latvia, Luxembourg, Portugal, Slovenia, Slovakia, Finland and Sweden – other out-patient health care was the largest. Generally, these two types of benefits were the two largest in terms of expenditure, but there were some exceptions. In Portugal, expenditure on in-patient health care was particularly low (9.2 %, the fourth largest type of benefit) and pharmaceuticals was the second largest type of expenditure. In several south-eastern Member States – Bulgaria, Greece, Cyprus and Romania – other out-patient health care was relatively low (often under 20 %) and pharmaceuticals was also the second largest type of expenditure, followed by other out-patient health care in third place. In Malta and Spain, other out-patient health care was also relatively low, in both cases below paid sick leave and in Malta also below pharmaceuticals. Among the EFTA countries a broadly similar situation was observed, although the share of expenditure for paid sick leave was higher than for other out-patient health care in Norway.

In-patient health care exceeded half of all sickness and healthcare benefits in 2019 in Malta (where it peaked at 65.8 %), Denmark, Romania, Greece, Spain and Poland; it was also a majority in North Macedonia (2017 data), Iceland, Serbia and Norway. The share of other out-patient health care was highest in Finland, at 48.2 % of the expenditure on sickness and healthcare benefits. The share of pharmaceuticals was high in Portugal (35.2 %) as already mentioned, with this share elsewhere in the EU peaking in Cyprus (25.7 %); a share of 29.2 % was observed in Turkey. Paid sick leave only surpassed one fifth of the expenditure in Luxembourg (22.4 %) and Germany (20.3 %) among the EU Member States but reached 23.3 % in Norway. Other benefits in kind accounted for less than 5.0 % of expenditure on sickness and healthcare benefits except in Estonia (5.4 %), Romania (6.7 %) and Portugal (16.4 %) among the EU Member States, and in Montenegro (5.2 %) and Switzerland (8.6 %) among the enlargement and EFTA countries. The share of other cash benefits was below 3.0 % except in Ireland (6.0 %), Malta (6.1 %) and Latvia (6.5 %).

Figure 4: Analysis of sickness and healthcare benefits by type of expenditure, 2019
(%)
Source: Eurostat (spr_exp_fsi)

The final analysis looks at expenditure on benefits in kind for in-patients and out-patients: together these benefits accounted for 83.0 % of all expenditure on sickness and healthcare benefits in the EU in 2019; excluded are cash benefits and other benefits in kind. Figure 5 shows the nature of these benefits, whether they were direct expenditure or reimbursements. In the case of direct payments, the institutional unit running the social protection scheme provides medical care benefits directly to patients (or enters into contracts with health care providers to do so). In the case of reimbursements, the patient pays for the health care and then claims part or all of the costs from the social protection scheme ^[2].

Across the EU as a whole, 86.1 % of expenditure for benefits in kind for in-patients and out-patients were direct expenditure and the remaining 13.9 % were for reimbursements. However, this average needs to be interpreted carefully, as in many EU Member States all or nearly all of this type of expenditure was direct expenditure and there were only a few Member States – including Germany and France – where reimbursements were substantial. In 16 of the Member States, reimbursements accounted for less than 1.0 % of such expenditure. Reimbursements also accounted for a relatively small share of expenditure for benefits in kind for in-patients and out-patients in Denmark (1.5 %), Portugal (3.0 %), Greece (3.3 %) and Cyprus (4.9 %), as well as in Germany (8.0 %), although the latter had a relatively large impact on the EU average because of its size. Reimbursements accounted for more than one tenth to approximately one fifth of expenditure for benefits in kind for in-patients and out-patients in Estonia, Latvia and Finland. The share in France was over one third (36.0 %), which strongly influenced the EU average due to its size, while the share in Luxembourg approached a half (45.6 %). The situation in Belgium was almost the exact opposite of that in the majority of Member States, as reimbursements accounted for nearly all (98.1 %) of this kind of expenditure.

For the EFTA and enlargement countries shown in Figure 5, most reported a similar situation to that for the vast majority of EU Member States. In Switzerland, the share of reimbursements was 6.7 % and it was 1.6 % in Turkey; elsewhere, healthcare expenditure for benefits in kind for in-patients and out-patients was almost exclusively composed of direct payments.

Figure 5: Healthcare expenditure for benefits in kind for in-patients and out-patients – direct provision or reimbursement, 2019
(%)
Source: Eurostat (spr_exp_fsi)

Source data for tables and graphs

Social protection statistics – sickness and health care benefits: tables and figures

Data sources

The statistics presented in this article were collected from national statistical offices and/or ministries of social affairs. Most of the data were compiled from administrative sources. For more detailed information, please refer to:

The European system of integrated social protection statistics (ESSPROS) was jointly developed in the late 1970s by Eurostat and representatives of the EU Member States in response to the need for a specific statistical instrument for the observation of social protection issues.

ESSPROS is a common framework which enables international comparisons of administrative data on national social protection systems. It provides a coherent comparison of social protection benefits for households and their financing across European countries.

ESSPROS is composed of a core system and a set of modules. The modules contain supplementary statistical information on particular aspects of social protection and essentially relate to the number of beneficiaries of social protection pensions and to net social protection benefits. On the other hand, the core system contains data that have been collected by Eurostat since 1990, namely:

quantitative data – social protection expenditure and receipts by scheme (a distinct body of rules, supported by one or more institutional units, governing the provision of social protection benefits and their financing);
qualitative data – metadata for the different schemes and detailed social protection benefits.

The receipts for social protection schemes may be classified according to type and origin. The expenditure of social protection is classified by type, indicating the nature of, or the reason for, the expenditure:

social protection benefits;
administrative costs;
transfers to other schemes; and,
other expenditure.

Social protection benefits are transfers to households, in cash or in kind, that are designed/intended to relieve households from the financial burden of a number of different risks/needs that are classified as functions. The following list of functions is identified within ESSPROS:

old age and survivors;
sickness/healthcare;
disability;
family/children;
unemployment;
housing and social exclusion.

The way in which healthcare systems are organised varies considerably from one EU Member State to another. Data relating to in-patient and out-patient health care are broken down into directly provided benefits and reimbursements. There are three main patterns of health care provision.

The indirect system: the social protection scheme provides medical care benefits for protected people by paying all or part of the cost of the medical care supplied by the providers. The patient pays the medical bill, all or part of which is then reimbursed by the social protection scheme. The benefits therefore take the form of reimbursements.
The direct system: the institutional unit running the social protection scheme owns, operates and controls the necessary medical facilities and employs the medical, para-medical and administrative staff. In this system benefits are directly provided to the protected people.
Direct settlement system: an alternative pattern of provision, intermediate between direct and indirect. The social protection scheme enters into a variety of contracts or agreements with health care providers. The medical care is provided to the beneficiary free or at the contractual rate (below its cost) by the providing unit (which is not a social protection scheme). The providing unit is then reimbursed by the social protection scheme. This type of benefit is also recorded as directly provided.

Context

The organisation and financing of social protection systems is the responsibility of each of the EU Member States. The models used in the Member States are therefore somewhat different from each other, while the EU plays a coordinating role to ensure that people who move across borders continue to receive adequate protection. The EU seeks to promote actions among the Member States to combat poverty and social exclusion, and to reform social protection systems on the basis of policy exchanges and mutual learning. This policy is known as the social protection and social inclusion process. Furthermore, the European Commission provides guidance to Member States to assist them in modernising their welfare systems through the social investment package.

The European pillar of social rights sets out a number of key principles and rights to support fair and well-functioning labour markets and welfare systems. The pillar contains three main categories for action, one of which concerns social protection and inclusion. Right number 16 states that ‘Everyone has the right to timely access to affordable, preventive and curative health care of good quality’ and right number 18 states that ‘Everyone has the right to affordable long-term care services of good quality, in particular home-care and community-based services’.

Notes

↑ The particularly high value for Luxembourg is, at least to some extent, the result of a significant proportion of benefits being paid to persons living outside the country.
↑ See also 'Data sources' for more details on the different healthcare systems.