High Quality, Comprehensive and Without Barriers to Access? The Future of Healthcare in Europe

There are likely to be significant demographic and economic pressures on health care systems in Europe over the coming years. The elderly population is set to increase, both in numbers and in proportion to the working age population. This represents a doubling in the ratio of elderly people to those of current working ages. This will create substantial new costs – of health and social care and pension payments. At the same time, improved availability of treatments, particularly those that extend the lives of terminally ill patients, are pushing up health care costs per patient. To counterbalance these pressures there is a need for action on the social determinants of health so as to improve health for all, but particularly among the most vulnerable. The healthcare system cannot deliver these improvements alone. Action is required across the whole of society. The cost of doing nothing is unsustainable. Work is currently being coordinated by UCL to document the scale of the problem across Europe and propose context-specific policies and interventions. Commissioned by the European Office of the WHO, the European Review on the Social Determinants of Health is conducted by a consortium of experts and institutions, chaired by Professor Sir Michael Marmot. The purpose of the review will be to identify the relevance of the findings of the WHO Commission on the Social Determinants of Health (CSDH), the Strategic Review of Health Inequalities in England post 2010 (Marmot Review), and other new evidence to the European context and specificity and translate these into policy proposals. It will feed into the development of a renewed European Regional Health Policy and contribute to specific aspects of the policy especially where it relates to the social determinants of health. Future of health care in Europe – a social determinants perspective Introduction There are major health inequalities within and between countries in the WHO European Region and the evidence shows that these inequalities should be mostly avoidable by reasonable means. Recognising that action to reduce inequities must be a priority for the WHO European Region – which comprises 53 countries from the Atlantic to the Pacific oceans and thus goes beyond the 27 member states of the European Union -, the WHO Regional Director for Europe commissioned UCL to lead a review of social determinants of health and the health divide in the European Region. Alongside these inequities, major changes are taking place in the age structure of the Region. These will affect the capacity of health systems to deliver, as well as placing other pressures on societies across Europe – such as pensions and other forms of social welfare. If, as is likely, this leads to rationing of resources, then the impact on social, economic and health inequalities is likely to be substantial. The purpose of this paper is to highlight the links between health inequity and the growing pressures on health care systems in Europe and to describe the work that is being done at UCL to produce recommendations to WHO on what actions are most likely to lead to reductions in health inequities across the European Region. Within the WHO European Region, average life expectancy differs between countries by 20 years for men and 12 years for women. Within countries, the levels of both health and life expectancy relate to and are graded by social and economic position. The lower a person’s social position, the worse is his or her health. Everyone except the people in the very highest social and economic positions adversely experiences some degree of inequality in health.(1) The final report of the Commission, Closing the gap in a generation,(2) concluded that achieving health equity requires action on the conditions in which people are born, grow, live, work and age and the structural drivers of these conditions at the global, regional, national and local levels. Ill health is not simply bad luck or the result of lack of health care but, as the Commission concluded, results from a toxic combination of poor social policies and programmes, unfair economic arrangements and bad politics and from the unintended and unanticipated consequences of other policies. Inequalities in the quality of early years, levels of education, employment status, welfare and health systems, level of income, the places where men, women and children live, the norms and values of society – including attitudes concerning gender and ethnicity – all contribute to inequities in health. They are known as the social determinants of health. Reducing health inequities requires action to reduce inequities in the social determinants of health. This is a priority, both because health inequities have significant social and economic costs to individuals and the wider society and because the social determinants that lead to these health inequities have their own costs, in terms of societal and community well-being, levels of social cohesion and economic development. Demographic pressures Table 1 summarizes the current demographic profile of the Region and the projected profile in 2020 and in 2050. The overall size of the population is projected to increase slightly by 2020 – from 894 million to 910 million – but then to return to current levels by 2050. However, the number of people of working age will steadily decline and the number of people of older ages will increase, leading to an increase in the old-age dependency ratio, with a growing older generations relying for support, in terms of financial and time resources, on a shrinking proportion of people of working age (3). In particular, the number of people 85 years and older is set to rise from 14 million to 19 million by 2020 and to 40 million by 2050. Table 1 Estimated population, percentage age distribution and dependency ratios for the WHO European Regiona, 2010, 2020 and 2050 a Excluding Andorra, Monaco and San Marino. Source: World population prospects: the 2008 revision, population database (4). The countries of the WHO European Region are, however, at very different stages in the development of ageing societies. Table 2 summarizes the current demographic profile of 50 countries in the Region. Several countries have a very young age profile, with a high proportion of children and a low proportion of older people and some others, conversely, have a more elderly age profile. However, in many countries the demographic situation is more complex than either of these scenarios. In 11 countries the sex ratio (females for every 100 males) exceeded 110. These are all in the Commonwealth of Independent States (comprising former Soviet Republics) and Central Europe, which indicates the cumulative effect of high male mortality in these countries (5). Age (years) 2010 population % 2020 population % 2050 population % (thousands) (thousands) (thousands) All ages 893 700 100 910 900 100 895 651 100 0–14 155 719 17 157 682 17 140 665 16 15–64 608 960 68 600 909 66 531 218 59 65–84 115 349 13 133 370 15 183 600 20 85+ 13 672 2 18 939 2 40 168 4 Dependency ratios per 100 people 15–64 years old Children: 0–14 years 26 26 26 Older people: 65 years and over 21 25 42 Table 2 Estimated population, sex ratio and dependency ratios for 50 countries, WHO European Region, 2010 Source: World population prospects: the 2008 revision, population database (4). The population numbers are the projected population for 2010 from the source Dependency ratios per 100 people 15–64 years old Population Sex ratio (millions) (females per 100 males) 0–14 years 65 years and older Albania 3.2 103 34 14 Armenia 3.1 115 29 16 Austria 8.4 105 22 26 Azerbaijan 8.9 104 34 9 Belarus 9.6 115 20 19 Belgium 10.7 104 25 26 Bosnia and Herzegovina 3.8 108 21 20 Bulgaria 7.5 107 20 26 Croatia 4.4 108 22 26 Cyprus 0.9 105 25 19 Czech Republic 10.4 104 20 22 Denmark 5.5 102 28 26 Estonia 1.3 117 23 25 Finland 5.3 104 25 26 France 62.6 106 28 26 Georgia 4.2 113 24 21 Germany 82.1 104 20 31 Greece 11.2 102 21 27 Hungary 10.0 111 21 24 Iceland 0.3 94 30 17 Ireland 4.6 100 31 17 Israel 7.3 102 44 16 Italy 60.1 105 22 31 Kazakhstan 15.8 110 34 10 Kyrgyzstan 5.6 103 44 8 Latvia 2.2 117 20 25 Lithuania 3.3 113 21 24 Luxembourg 0.5 101 26 21 Malta 0.4 101 22 21 Montenegro 0.6 103 28 19 Netherlands 16.7 102 26 23 Norway 4.9 101 28 23 Poland 38.0 107 21 19 Portugal 10.7 106 23 27 Republic of Moldova 3.6 111 23 15 Romania 21.2 106 22 21 Russian Federation 140.4 117 21 18 Serbia 9.9 102 26 21 Slovakia 5.4 106 21 17 Slovenia 2.0 105 20 23 Spain 45.3 103 22 25 Sweden 9.3 101 25 28 Switzerland 7.6 105 22 26 Tajikistan 7.1 103 61 6 TFYR Macedonia 2.0 100 25 17 Turkey 75.7 99 39 9 Turkmenistan 5.2 103 43 6 Ukraine 45.4 117 20 22 United Kingdom 61.9 104 26 25 Uzbekistan 27.8 101 43 7 Health care costs in Europe Table 3 shows the level and distribution of expenditure on health care in countries providing data on this topic to Eurostat. While expenditure per head of population was highest in Luxembourg and countries outside the EU belonging to EFTA – in excess of 4,000 Euros per person per year, it was below 1,000 Euros in most countries that joined the EU in 2004 or later. In every country the largest proportion of this budget went on hospital provision – between 30% and 45%– while public health expenditure varied between 0% and 3%. Table 3 Expenditure on selected health care functions by providers of health care, per inhabitant, 2006 Source: European Union Statistics on Income and Living Conditions(6) Luxembourg 5,509 100 30 25 9 21 2 3 0 10 0