Archive:Enlargement countries - health statistics

Data extracted in March 2022.

Planned article update: April 2023.

Highlights

In 2020, public expenditure on health relative to GDP was lower in all candidate countries and potential candidates than in the EU.

There were more discharges of in-patients from hospitals, relative to population size, in the EU than in any of the candidate countries and potential candidates in 2020.

Public expenditure on health, 2010 and 2020 (% of GDP)

Country codes: RS = Serbia; TR = Turkey; AL = Albania; BA = Bosnia and Herzegovina; XK = Kosovo*
* This designation is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo Declaration of Independence.
Note: data supplied by and under the responsibility of the national statistical authorities. Montenegro and North Macedonia, not available. Countries are ranked based on public expenditure in 2020.
EU and Kosovo: 2010: not available
EU, Serbia and Bosnia and Herzegovina: 2019 data instead of 2020.
Source: Eurostat (online data codes: hlth_sha11_hf and nama_10_gdp) and Eurostat data collection.

This article is part of an online publication and provides information on a range of health statistics for the European Union (EU) and candidate countries and potential candidates, otherwise known as the enlargement countries. Montenegro, North Macedonia, Albania, Serbia and Turkey currently have candidate status, while Bosnia and Herzegovina and Kosovo* are potential candidates.

Health statistics measure both objective and subjective aspects of people's health. They cover key indicators on the functioning of the health care systems and health and safety at work. Statistics on healthcare expenditure and financing may be used to evaluate how a healthcare system responds to the challenge of universal access to quality healthcare. Financial resources within the healthcare sector are measured, as are the allocation of these resources between healthcare activities, such as preventive and curative care, or groups of healthcare providers, for example, hospitals and ambulatory centres.

This article gives an overview of health developments in the candidate countries and potential candidates and in the EU, presenting an analysis of health expenditure, health resources, hospital discharges, healthcare personnel and health status.

Full article

Public expenditure on health

Public and total health expenditure as a percentage of gross domestic product (GDP) provide measures of how much resources are invested in the health of the population. In Figure 1, data on these ratios for 2020 (or the most recent year available) is compared to data for 2010 for the candidate countries and potential candidates, where available.

In Serbia, public health expenditure amounted to 5.1 % of GDP in 2018 (the most recent year available). In comparison, it stood at 6.2 % of GDP in 2010. Total health expenditure had also diminished as share of GDP over this period, from 10.1 % of GDP in 2010 to 8.6 % in 2018. In Turkey, the ratios had fallen more moderately between 2010 and 2020. While public expenditure on health had decreased from 4.2 % of GDP to 3.9 %, total expenditure on health had fallen from 5.3 % of GDP to 5.0 %. For Albania, data are only available for public health expenditure. This had increased as share of GDP from 2.7 % in 2010 to 3.2 % in 2020.

Bosnia and Herzegovina’s expenditure on health remained largely unchanged as percentage of GDP over the decade, with the share of public health expenditure slightly up from 6.3 % of GDP in 2010 to 6.4 % in 2019 (the most recent year available) and total expenditure on health up from 9.0 % to 9.1 %. In Kosovo, public expenditure on health was estimated at 3.6 % of GDP in 2020 and total expenditure on health 4.1 %; data are not available for 2010.

In 2019, the most recent year available, public expenditure on health in the EU was 7.9 % of GDP, while total expenditure amounted to 9.9 %. This was higher than in all of the candidate countries and potential candidates. Data for 2010 are not available.

Note that the developments described reflect changes both in health expenditure and in GDP; a falling health expenditure relative to GDP does not necessarily mean that the absolute level of health expenditure is lower than before. Alternatively, it may be an indication that health expenditures are not rising as rapidly as GDP.

Figure 1: Expenditure on health, 2010 and 2020
(% of GDP)
Source: Eurostat (hlth_sha11_hf) and (nama_10_gdp) and Eurostat data collection

Healthcare resources

Figure 2 presents data on hospital discharges of in-patients, an indicator of the level of healthcare activity in hospitals. A hospital discharge occurs when a patient is formally released after an episode of care: discharge may result from the end of the treatment; a decision by the patient to sign out against medical advice; the patient’s transfer to another healthcare institution; or because of death. Trends in hospital discharges per 100 000 population over time can be affected by a number of factors: the level of hospital capacity and activity; the average length of the treatments carried out in the hospitals; the introduction of new medical treatments in the hospitals; and in-patient treatments being replaced by out-patient treatments (which are normally less expensive) for all or for a part of the total treatment period. For most of the countries presented, including the estimated EU total, 2019 is the latest year for which data are available; it is also the last year before the data begin to be affected by the Covid-19 pandemic. At the time of writing, 2020 data were available for Montenegro, Albania and Kosovo (estimated).

Turkey had 16 603 hospital discharges per 100 000 inhabitants in 2019, the most recent year available. This was the highest among the candidate countries and potential candidates. Between 2010 and 2019, the number of discharges relative to the population increased by 16 %; however, please note that there is a break in series and that the definition differs from the standard definition. Serbia had the next highest level of hospital discharges per 100 000 inhabitants in 2019, at 14 888. This represented a decrease by 6 % compared to 2010; also for Serbia, there was a break in the data series between these two years. In Montenegro, the hospital discharges stood at 10 280 per 100 000 inhabitants in 2020, which was 13 % lower than in 2010.

There were 7 311 hospital discharges per 100 000 inhabitants in Albania in 2020, the lowest ratio of in-patient discharges relative to population size in the region. In comparison, Kosovo registered 8 466 hospital discharges per 100 000 inhabitants in 2020. Data for 2010 were neither available for Albania nor for Kosovo. Data was not available for either year for North Macedonia and Bosnia and Herzegovina.

In 2019, the most recent year available for most of the EU Member States, there were approximately 17 400 hospital discharges per 100 000 inhabitants across the EU. This number had decreased by 1 % since 2010. Figure 2 also shows the two EU Member States with the highest and lowest number of hospital discharges per 100 000 population, respectively, in 2019 (2020 data not yet available). The highest value among the EU Member States was recorded in Bulgaria, at 34 464 discharges per 100 000 inhabitants in 2019, an increase by one third (33 %) from 2010 to 2019 and much higher than for any candidate country or potential candidate. The lowest rate was registered in Cyprus, with 7 927 hospital discharges per 100 000 inhabitants in 2019, a decrease by 4 % compared to 2010.

Figure 2: Hospital discharges of in-patients, 2010 and 2020
(number per 100 000 inhabitants)
Source: Eurostat (hlth_co_disch1) and (demo_pjan) and Eurostat data collection

Figure 3 provides information on healthcare personnel. Physicians need to possess a degree in medicine and are licensed to provide treatment to patients, including: giving advice, conducting medical examinations and making diagnoses; applying preventive medical methods; prescribing medication and treating diagnosed illnesses; giving specialised medical or surgical treatment.

Nursing professionals typically provide services to patients in hospitals, ambulatory care and patients’ homes: nurses assume responsibility for the planning and management of patient care, including the supervision of other healthcare workers, working autonomously or in teams with medical doctors and others in the application of preventive and curative care.

Midwives plan, manage, provide and evaluate care services during pregnancy and after childbirth, providing delivery care for reducing health risks to women and new-born children; they may work autonomously or in teams with other healthcare providers.

Among the five candidate countries and potential candidates for which data are available, the highest numbers of physicians relative to population size in 2020 were recorded in Serbia with 283.2 and Montenegro with 277.0 physicians per 100 000 inhabitants. Bosnia and Herzegovina followed with 223.1 physicians per 100 000 inhabitants (2019 data instead of 2020). However, the data for Bosnia and Herzegovina covers only professionals working in public institutions and is therefore not directly comparable with the other candidate countries and potential candidates. Turkey recorded 193.4 physicians per 100 000 inhabitants (2019 data instead of 2020), covering only professionally active physicians. Kosovo followed far behind, reporting 9.1 physicians per 100 000 inhabitants in 2020.

Turkey recorded the highest rate of dentists in the region, with 39.6 per 100 000 inhabitants (2019 data instead of 2020), covering only the professionally active. Bosnia and Herzegovina followed with 24.7 dentists per 100 000 inhabitants (2019 data instead of 2020), counting only those working in public institutions. Serbia recorded 23.4 and Kosovo 22.6 dentists per 100 000 inhabitants in 2020. Montenegro reported a much lower level of dentist coverage in 2020, just like in the preceding years, corresponding to 5.2 dentists per 100 000 inhabitants.

The coverage of pharmacists did not vary as much throughout the region as the coverage of some other categories of health personnel. Turkey had the highest coverage with 40.7 pharmacists per 100 000 inhabitants, while the lowest coverage was seen in Bosnia and Herzegovina with 13.3 (2019 data instead of 2020 for both countries). Between these, Kosovo recorded 29.7, Montenegro 23.0 and Serbia 15.9 pharmacists per 100 000 inhabitants in 2020.

Bosnia and Herzegovina registered 585.1 nursing professionals per 100 000 inhabitants (2019 data instead of 2020), the highest in the region, only covering nurses in public institutions. Kosovo with 552.6 and Montenegro with 501.8 nursing professionals per 100 000 inhabitants also reported coverage above 500 in 2020. Much lower ratios were recorded in Turkey with 238.2 professionally active nurses (2019 data instead of 2020) and Serbia with 95.8 per 100 000 inhabitants.

The ratio of midwives to population was by far the highest in Turkey, with 67.3 professionally active midwives per 100 000 inhabitants (2019 data instead of 2020). In 2020, Montenegro had 41.2 and Bosnia and Herzegovina 30.4 midwives (2019 data instead of 2020) per 100 000 inhabitants, respectively, with Bosnia and Herzegovina only registering those working in public institutions. In Serbia and Kosovo, coverage by midwives was substantially lower, with ratios of 15.6 and 4.9 per 100 000 inhabitants in 2020.

In comparison, in the EU there were an estimated 388.1 physicians, 73.2 dentists, 93.3 pharmacists, 683.2 nursing professionals and 35.7 midwives per 100 000 inhabitants in 2019; the estimates are based on the closest reference period available for each EU Member State (2020 data not yet available). The Member State with the highest coverage of physicians, Greece, had 615.9 physicians per 100 000 inhabitants in 2019, while the lowest coverage registered was 237.8 for Poland (2017 data instead of 2020).

Figure 3: Healthcare personnel, 2020
(number per 100 000 inhabitants)
Source: Eurostat (hlth_rs_phys), (hlth_rs_prs1), (hlth_rs_prsns) and (demo_pjan) and Eurostat data collection

Figure 4 below illustrates the number of midwives per 1 000 live births, which takes account of the birth rate. Most of the candidate countries and potential candidates for which data are available for both 2010 and 2020 showed a decrease in this ratio over the decade. Turkey had the highest ratio of midwives, at 67.3 professionally active midwives per 1 000 live births (2019 data instead of 2020), down from 68.3 in 2010. Montenegro was the only country in the region that recorded an increase in the coverage of midwives to assist at birth, rising from 39.4 midwives per 1 000 live births in 2010 to 41.2 in 2020. In Bosnia and Herzegovina there were 30.4 midwives working in public institutions per 1 000 live births in 2019 (2020 data not available), compared to 34.7 in 2010. Serbia recorded 15.6 midwives per 1 000 live births in 2020, less than half of the ratio of 36.2 in 2010. In Kosovo, there were 4.9 midwives per 1 000 live births in 2020; there are no data for Kosovo for 2010.

For the EU, the ratio of midwives per 1 000 live births stood at 38.6 in 2020, up from 31.6 in 2010.

Figure 4: Practicing midwives, 2010 and 2020
(number per 1 000 live births)
Source: Eurostat (demo_gind), (demo_pjan) and (hlth_rs_prsns) and Eurostat data collection

Health status

This section examines the maternal mortality rate and the incidence of two diseases, tuberculosis and hepatitis B. The maternal mortality rate is defined by the United Nations as the annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of the termination of pregnancy, irrespective of the duration/place of pregnancy. It is expressed as a ratio per 100 000 live births. Deaths related to pregnancy and childbirth are very rare and so, particularly within smaller populations, even a difference of two or three deaths between years can result in relatively large percentage changes.

Data is available on the maternal mortality ratio for four of the candidate countries and potential candidates. It is presented in Figure 5 for 2010 and 2020. The rate in Turkey in 2019 (2020 data not available) was 13.1 deaths per 100 000 live births, a fall from the 2010 figure of 16.4. Serbia recorded a substantial reduction, from 17.6 in 2010 to 9.7 deaths per 100 000 live births in 2020. North Macedonia recorded a maternity mortality rate of 5.3 in 2020, but 2010 data for comparison is not available. In Albania, the maternal mortality ratio decreased from 5.9 deaths per 100 000 live births in 2010 to 3.6 in 2020.

Figure 5: Maternal mortality ratio, 2010 and 2020
(deaths per 100 000 live births)
Source: Eurostat annual data collection cycle – see Data Sources

In 2020, the incidence of tuberculosis among candidate countries and potential candidates – presented in Figure 6 – was highest in Kosovo, at 39.4 cases per 100 000 inhabitants (2010 data not available for Kosovo). This was far higher than elsewhere in the region, as the next highest incidence rate was recorded in Turkey at 13.5 (2019 data instead of 2020); however, this was considerably lower than in 2010, when the incidence of tuberculosis in Turkey was 22.0 per 100 000 inhabitants. In Albania, the incidence stood at 8.5 in 2020, down from 14.4 in 2019; 2010 data are not available for comparison. However, both Montenegro and Serbia recorded strong declines in their tuberculosis incidences over the past decade. In 2020, Montenegro registered 6.5 cases per 100 000 inhabitants — in 2010, the incidence was 20.0. Similarly, in Serbia the incidence of tuberculosis fell from 19.7 cases per 100 000 inhabitants in 2010 to 4.8 in 2020. Data on the incidences of tuberculosis are not available for North Macedonia and for Bosnia and Herzegovina.

For all of the candidate countries and potential candidates for which such data are available, there was a sharp decline in the incidence of hepatitis B from 2019 to 2020. In this context; it should be kept in mind that the prevention measures put in place in connection with the Covid-19 pandemic, such as social distancing, wearing protection masks, frequent disinfection and teleworking / tele schooling, may have limited the spread also of other transmittable diseases such as tuberculosis and hepatitis.

Among the candidate countries and potential candidates, Kosovo registered the highest incidence of hepatitis B, at 3.7 newly registered cases per 100 000 inhabitants. However, this refers to 2018 estimated data. The highest incidences reported for 2020 were 1.8 cases of hepatitis B per 100 000 inhabitants, which were reported by both Albania and North Macedonia. For Albania, this was considerably lower than the incidence recorded the previous year, when it was 7.1. (2010 data for comparison are not available for Albania.) For North Macedonia, the tuberculosis incidence was down from 4.4 the previous year and from 7.5 in 2010.

For Turkey, the most recent reported incidence of hepatitis B was 1.4 (2019 data instead of 2020), which was down from 4.2 in 2010. Montenegro and Serbia (all registered cases of acute hepatitis B) had similar outcomes 2020, with 0.3 and 0.2 cases per 100 000 inhabitants respectively, down from 2.3 for Montenegro and 4.8 for Serbia in 2010.

Figure 6: Incidence of tuberculosis and hepatitis B, 2010 and 2020
(per 100 000 inhabitants)
Source: Eurostat annual data collection cycle – see Data Sources

Source data for tables and graphs

Enlargement countries — health: tables and figures

Data sources

The enlargement countries are expected to increase the volume and quality of their data progressively, and to transmit these data to Eurostat and the wider ESS in the context of the EU accession process. The final objective of the EU in relation to official statistics is to obtain harmonised, high-quality data that conforms to both European and international standards. More details on the statistical aspects of the accession process can be found in the article Enlargement policy and statistical cooperation.

The enlargement countries are not at the same level of development and are progressing towards an efficient and modern statistical system at different speeds. In a number of areas, candidate countries (and sometimes also potential candidates) are in a position to provide harmonised data in accordance with the EU acquis with respect to methodology, classifications and procedures for data collection and the principles of official statistics as laid down in the European statistics Code of Practice. In these cases, the candidate countries (and potential candidates) concerned report their data to Eurostat following the same procedures and under the same quality criteria as the EU Member States and the EFTA countries. Data from the enlargement countries that meet these quality requirements are published along with data for EU Member States and EFTA countries.

In addition, the enlargement countries provide data for a wide range of indicators for which they do not yet fully adhere to the quality requirements specified in the EU acquis and the methodology, classifications and procedures for data collection specified in the relevant Regulations, Directives and other legal documents. These data are collected on an annual basis through a questionnaire sent by Eurostat to the candidate countries or potential candidates. A network of contacts has been established for updating these questionnaires, generally within the national statistical offices, but potentially including representatives of other data-producing organisations (for example, central banks or government ministries). This annual exercise also provides an opportunity to provide methodological recommendations to the enlargement countries.

In December 2008, the European Parliament and the Council adopted Regulation 1338/2008 on Community statistics on public health and health and safety at work. It was designed to ensure that health statistics provide adequate information for all EU Member States to monitor Community actions in the field of public health and health and safety at work. It lists five domains for which implementing regulations specifying (in detail) the list of variables and methodological aspects were to be developed, including:

health status and health determinants: Regulation (EU) No 141/2013 on European Health Interview Survey;
health care: as covered by Regulation (EU) No 141/2013 and Regulation (EU) 2015/359 on statistics on health care expenditure and financing;
causes of death: Regulation (EU) No 328/2011 on statistics on causes of death;
accidents at work: Regulation (EU) No 349/2011 on statistics on accidents at work;
occupational diseases and other work-related health problems and illnesses.

Tables in this article use the following notation:

Value in italics	data value is forecasted, provisional or estimated and is therefore likely to change;
:	not available, confidential or unreliable value.

Context

EU policies seek to improve and foster health in the European Union; protect people in the European Union from serious cross-border threats to health; improve medicinal products, medical devices and crisis-relevant products; and strengthen health systems. The COVID-19 pandemic has a major impact on patients, medical and healthcare staff, and health systems in Europe. The 2021-2027 EU4Health programme will go beyond crisis response to address healthcare systems’ resilience. Established by Regulation (EU) 2021/522, it will provide funding to eligible entities, health organisations and NGOs from EU countries and to non-EU countries associated to the programme. Health statistics are used to monitor the EU’s health strategy as well as their contribution to the sustainable development goals (SDGs). These statistics have a key role to support the development of evidence-based policies both nationally and within the EU. They also serve as a basis for calculating indicators to monitor some aspects of social protection and social inclusion and a set of indicators known as the European core health indicators (ECHI).

While basic principles and institutional frameworks for producing statistics are already in place, the candidate countries and potential candidates are expected to increase progressively the volume and quality of their data and to transmit these data to Eurostat in the context of the EU enlargement process. EU standards in the field of statistics require the existence of a statistical infrastructure based on principles such as professional independence, impartiality, relevance, confidentiality of individual data and easy access to official statistics; they cover methodology, classifications and standards for production.

Eurostat has the responsibility to ensure that statistical production of the candidate countries and potential candidates complies with the EU acquis in the field of statistics. To do so, Eurostat supports the national statistical offices and other producers of official statistics through a range of initiatives, such as pilot surveys, training courses, traineeships, study visits, workshops and seminars, and participation in meetings within the European Statistical System (ESS). The ultimate goal is the provision of harmonised, high-quality data that conforms to European and international standards.

Additional information on statistical cooperation with the enlargement countries is provided here.

Notes

* This designation is without prejudice to positions on status, and is in line with UNSCR 1244/1999 and the ICJ Opinion on the Kosovo Declaration of Independence.