OCDE - Health at A Glance 2019 - 4dd50c09-En PDF

Health at a Glance 2019
OECD INDICATORS
Health at a Glance
2019
OECD INDICATORS
This work is published under the responsibility of the Secretary-General of the OECD. The
opinions expressed and arguments employed herein do not necessarily reflect the official
views of OECD member countries.
This document, as well as any data and any map included herein, are without prejudice
to the status of or sovereignty over any territory, to the delimitation of international
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Please cite this publication as:

OECD (2019), Health at a Glance 2019: OECD Indicators, OECD Publishing, Paris,
https://doi.org/10.1787/4dd50c09-en.
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Health at a Glance
ISSN 1995-3992 (print)
ISSN 1999-1312 (online)
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FOREWORD
Foreword
Health at a Glance compares key indicators for population health and health system
performance across OECD members, candidate and partner countries. This 2019 edition
presents the latest comparable data across 80 indicators, reflecting differences across
countries in health status, risk factors and health-seeking behaviour, access, quality of
care, and the financial and physical resources available for health. Alongside indicator-by-
indicator analysis, an overview chapter summarises the comparative performance of
countries and major trends, including how much health spending is associated with
staffing levels, access, quality, and health outcomes. This edition also includes a special
chapter on patient-reported outcomes and experiences.
The production of Health at a Glance would not have been possible without the
contribution of national data correspondents from OECD countries. The OECD gratefully
acknowledges their effort in supplying most of the data contained in this publication, as
well as their detailed feedback to a draft of the report. Special acknowledgement is
extended to members of the Patient-reported Indicator Surveys (PaRIS) Working Groups on
mental health, breast cancer care, and hip and knee replacement for their contribution to
Chapter 2, especially those individuals from countries, registries and health care
organisations that facilitated the provision of patient-reported data. The OECD also
recognises the contribution of other international organisations, notably the World Health
Organization and Eurostat, for providing data and comments. The European Union
provided financial and substantive assistance for work related to PaRIS, but the opinions
expressed and arguments employed herein do not necessarily reflect the official views of
the OECD member countries or the European Union.
This publication was prepared by the OECD Health Division under the coordination of
Chris James. Chapter 1 was prepared by Chris James and Alberto Marino; Chapter 2 by Luke
Slawomirski, Ian Brownwood, Emily Hewlett and Rie Fujisawa; Chapter 3 by Chris James,
Viviane Azaïs, Eileen Rocard, Yuka Nishina and Emily Hewlett; Chapter 4 by Cristian
Herrera, Jane Cheatley, Gabriel Di Paolantonio, Yuka Nishina and Michael Padget; Chapter 5
by Chris James, Michael Mueller, Viviane Azaïs, Alberto Marino and Marie-Clémence
Canaud; Chapter 6 by Frédéric Daniel, Michael Padget, Eliana Barrenho, Rie Fujisawa, Luke
Slawomirski and Ian Brownwood; Chapter 7 by David Morgan, Michael Mueller, Emily
Bourke, Luca Lorenzoni, Alberto Marino and Chris James; Chapter 8 by Karolina Socha-
Dietrich, Gaëlle Balestat, Gabriel Di Paolantonio, Emily Bourke and Emily Hewlett; Chapter 9
by Chris James, Gabriel Di Paolantonio, Gaëlle Balestat, Alberto Marino and Caroline Penn;
Chapter 10 by Valérie Paris, Ruth Lopert, Suzannah Chapman, Martin Wenzl, Marie-
Clémence Canaud and Michael Mueller; Chapter 11 by Elina Suzuki, Leila Pellet, Marie-
Clémence Canaud, Thomas Rapp, Eliana Barrenho, Michael Padget, Frédéric Daniel, Gabriel
Di Paolantonio, Michael Mueller and Tiago Cravo Oliveira Hashiguchi. The OECD databases
used in this publication are managed by Gaëlle Balestat, Emily Bourke, Ian Brownwood,
HEALTH AT A GLANCE 2019 © OECD 2019

3
FOREWORD
Marie-Clémence Canaud, Frédéric Daniel, David Morgan, Michael Mueller and Michael
Padget.
Detailed comments were provided by Frederico Guanais and Gaétan Lafortune, with
further useful inputs from Francesca Colombo, Mark Pearson, Stefano Scarpetta and Sarah
Thomson. Editorial assistance by Lucy Hulett, Lydia Wanstall and Marie-Clémence Canaud
is also gratefully acknowledged.
4 HEALTH AT A GLANCE 2019 © OECD 2019

TABLE OF CONTENTS
Table of contents
Executive summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Reader’s guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Chapter 1. Indicator overview: comparative performance of countries and major

trends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Health status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Risk factors for health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Access to care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Quality of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Health care resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
To what extent does health spending translate into better access, quality and
health outcomes, and more health professionals?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Chapter 2. Measuring what matters for people-centred health systems. . . . . . . . . . . . . . . 39

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
A people-centred health system needs to measure what matters to patients . . . . . . 40
Joint replacement rates are rising but are patients reporting improvement?. . . . . . . 44
Better information on breast cancer care outcomes helps patients facing difficult
treatment choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Existing mental health measures say little about experiences and outcomes of
care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Chapter 3. Health status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Trends in life expectancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Life expectancy by sex and education level. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Main causes of mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Avoidable mortality (preventable and treatable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Mortality from circulatory diseases. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Cancer incidence and mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Chronic disease morbidity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Infant health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Mental health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Self-rated health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Chapter 4. Risk factors for health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Smoking among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Alcohol consumption among adults. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Opioids use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

5
TABLE OF CONTENTS
Diet and physical activity among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Overweight and obesity among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Overweight and obesity among children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Air pollution and extreme temperatures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Chapter 5. Access to care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Population coverage for health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Extent of health care coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Use of primary care services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Unmet need for health care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Financial hardship and out-of-pocket expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Geographic distribution of doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Waiting times for elective surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Chapter 6. Quality and outcomes of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Safe primary care – prescribing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Safe acute care – surgical complications and health care-associated infections. . . . 122
Safe acute care – obstetric trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Avoidable hospital admissions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Diabetes care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Mortality following ischaemic stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Mortality following acute myocardial infarction (AMI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Hip and knee surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Care for people with mental health disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Breast cancer outcomes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Screening and survival for colorectal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Survival for other major cancers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Vaccinations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Patient experiences of ambulatory care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Chapter 7. Health expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Health expenditure per capita. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Health expenditure in relation to GDP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Prices in the health sector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Health expenditure by financing scheme. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Public funding of health spending. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Health expenditure by type of service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Health expenditure by provider. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Capital expenditure in the health sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Projections of health expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Chapter 8. Health workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Health and social care workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Doctors (overall number). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Doctors (by age, sex and category). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Remuneration of doctors (general practitioners and specialists). . . . . . . . . . . . . . . . . . . 176
Nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Remuneration of nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Medical graduates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

TABLE OF CONTENTS
Nursing graduates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

International migration of doctors and nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Chapter 9. Health care activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Consultations with doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Medical technologies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Hospital beds and discharge rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Average length of stay in hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Hip and knee replacement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Caesarean sections. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Ambulatory surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Chapter 10. Pharmaceutical sector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Pharmaceutical expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Pharmacists and pharmacies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Pharmaceutical consumption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Generics and biosimilars. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Research and development in the pharmaceutical sector. . . . . . . . . . . . . . . . . . . . . . . . . 214
Chapter 11. Ageing and long-term care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

Demographic trends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Life expectancy and healthy life expectancy at age 65. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Self-rated health and disability at age 65 and over. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Dementia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Safe prescribing in older populations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Safe long-term care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Recipients of long-term care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Informal carers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
Long-term care workers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Long-term beds in facilities and hospitals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
Long-term care spending and unit costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

7
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© OECD 2019
Executive summary
Health at a Glance 2019 provides the latest comparable data and trends over time on
population health and health system performance across OECD members, candidate and
partner countries.
Gains in longevity are stalling; chronic diseases and mental ill health affect more
and more people
• On average across OECD countries, a person born today can expect to live almost 81
years. But life expectancy gains have slowed recently across most OECD countries,
especially in the United States, France and the Netherlands. 2015 was a particularly bad
year, with life expectancy falling in 19 countries.
• The causes are multifaceted. Rising levels of obesity and diabetes have made it difficult
to maintain previous progress in cutting deaths from heart disease and stroke.
Respiratory diseases such as influenza and pneumonia have claimed more lives in
recent years, notably amongst older people.
• In some countries the opioid crisis has caused more working-age adults to die from drug-
related accidental poisoning. Opioid-related deaths have increased by about 20% since
2011, and have claimed about 400 000 lives in the United States alone. Opioid-related
deaths are also relatively high in Canada, Estonia and Sweden.
• Heart attacks, stroke and other circulatory diseases caused about one in three deaths
across the OECD; and one in four deaths were related to cancer. Better prevention and
health care could have averted almost 3 million premature deaths.
• Almost one in ten adults consider themselves to be in bad health. This reflects in part the
burden of chronic diseases – almost a third of adults live with two or more chronic
conditions. Mental ill health also takes its toll, with an estimated one in two people
experiencing a mental health problem in their lifetime.
Smoking, drinking and obesity continue to cause people to die prematurely and
worsen quality of life
• Unhealthy lifestyles – notably smoking, harmful alcohol use and obesity – are the root
cause of many chronic health conditions, cutting lives short and worsening quality of
life.
• Whilst smoking rates are declining, 18% of adults still smoke daily.
• Alcohol consumption averaged 9 litres of pure alcohol per person per year across OECD
countries, equivalent to almost 100 bottles of wine. Nearly 4% of adults were alcohol
dependent.
9
EXECUTIVE SUMMARY
• Obesity rates continue to rise in most OECD countries, with 56% of adults overweight or
obese and almost one-third of children aged 5-9 overweight.
• Air pollution caused about 40 deaths per 100 000 people, across OECD countries. Death
rates were much higher in partner countries India and China, at around 140 deaths per
100 000 people.
Barriers to access persist, particularly amongst the less well-off
• An estimated one in five adults who needed to see a doctor did not do so, with worse
access for the less well-off. Uptake of cancer screening is also lower amongst poorer
individuals, even though most OECD countries provide screening programmes at no
cost.
• Direct payments by households (out-of-pocket payments) make up just over a fifth of all
health spending on average, and over 40% in Latvia and Mexico. Cost concerns lead
people to delay or not seek care, with the least well-off three times more likely than
wealthier individuals to have unmet need for financial reasons.
• Waiting times and transportation difficulties hinder access in some countries. For
example, waiting times for a knee replacement were over a year in Chile, Estonia and
Poland.
• Such access constraints occur despite most OECD countries having universal or near-
universal coverage for a core set of services. Parts of the explanation are high cost
sharing, exclusion of services from benefit packages or implicit rationing of services.
Limitations in health literacy, imperfect communication strategies and low quality of
care are also contributing factors.
Quality of care is improving in terms of safety and effectiveness, but more

attention should be placed on patient-reported outcomes and experiences
• Patient safety has improved across many indicators, but more needs to be done. For
example, 5% of hospitalised patients had a health-care associated infection.
• Strong primary care systems keep people well and can treat most uncomplicated cases.
They also relieve pressure on hospitals: avoidable admissions for chronic conditions
have fallen in most OECD countries, particularly in Korea, Lithuania, Mexico and
Sweden.
• In terms of acute care, fewer people are dying following a heart attack or stroke, with
Norway and Iceland having low case-fatality rates for both conditions. Alongside
adherence to evidence-based medicine, timely care is critical.
• Survival rates for a range of cancers have also improved, reflecting better quality
preventive and curative care. Across all OECD countries, for example, women diagnosed
early for breast cancer have a 90% or higher probability of surviving their cancer for at
least five years.
• A deeper understanding of quality of care requires measuring what matters to people.

Yet few health systems routinely ask patients about the outcomes and experiences of
their care. Preliminary results show improvements in patient-reported outcomes. For

EXECUTIVE SUMMARY
example, following hip replacement, an individual’s quality of life – in terms of mobility,

self-care, activity, pain and depression – improved on average by around 20%.
Countries spend a lot on health, but they do not always spend it as well as they
could
• Spending on health was about USD 4 000 per person (adjusted for purchasing powers), on
average across OECD countries. The United States spent more than all other countries by
a considerable margin, at over USD 10 000 per resident. Mexico spent the least, at around
USD 1 150 per resident.
• Health expenditure has largely outpaced economic growth in the past, and despite a
slowdown in recent years, is expected to do so in the future. New estimates point to
health spending reaching 10.2% of GDP by 2030 across OECD countries, up from 8.8% in
2018. This raises sustainability concerns, particularly as most countries draw funding
largely from public sources.
• Reforms to improve economic efficiency are critical. Increased use of generics has
generated cost-savings, though generics only represent around half of the volume of
pharmaceuticals sold across OECD countries. Increases in day surgery, lower
hospitalisation rates and shorter stays may also indicate a more efficient use of
expensive hospital resources.
• In OECD countries, health and social systems employ more workers now than at any
other time in history, with about one in every ten jobs found in health or social care.
Shifting tasks from doctors to nurses and other health professionals can alleviate cost
pressures and improve efficiency.
• Population ageing increases demand for health services, particularly for long-term care.
This places more pressure on family members, particularly women, with around 13% of
people aged 50 and over providing informal care at least once a week for a dependent
relative or friend. By 2050, the share of the population aged 80 and over will more than
double.

11
READER’S GUIDE
Reader’s guide
Health at a Glance 2019: OECD Indicators compares key indicators for population health
and health system performance across the 36 OECD member countries. Candidate and
partner countries are also included where possible – Brazil, People’s Republic of China
(China), Colombia, Costa Rica, India, Indonesia, the Russian Federation (Russia) and South
Africa. On 25 May 2018, the OECD Council invited Colombia to become a Member. At the
time of preparation of this publication, the deposit of Colombia’s instrument of accession
to the OECD Convention was pending and therefore Colombia does not appear in the list of
OECD Members and is not included in the OECD zone aggregates.
Data presented in this publication come from official national statistics, unless
otherwise stated.
Conceptual framework
The conceptual framework underlying Health at a Glance assesses health system
performance within the context of a broad view of the determinants of health (Figure 1). It
builds on the framework endorsed by the OECD work stream on health care quality and
outcomes, which recognises that the ultimate goal of health systems is to improve people’s
health.
Many factors outside the health system influence health status, notably income,
education, the physical environment in which an individual lives, and the degree to which
people adopt healthy lifestyles. The demographic, economic and social context also affects
the demand for and supply of health services, and ultimately health status.
At the same time, the performance of a health care system has a strong impact on a
population’s health. When health services are of high quality and are accessible to all,
people’s health outcomes are better. Achieving access and quality goals, and ultimately
better health outcomes, depends critically on there being sufficient spending on health.
Health spending pays for health workers to provide needed care, as well as the goods and
services required to prevent and treat illness. However, these resources also need to be
spent wisely, so that value-for-money is maximised.
Structure of the publication

Health at a Glance 2019 compares OECD countries on each component of this general
framework. It is structured around eleven chapters. The first chapter presents an overview
of health and health system performance, based on a subset of core indicators from the
report. Country dashboards shed light on the relative strengths and weaknesses of OECD
countries’ health systems, alongside OECD-wide summary data. Linkages between how
much a country spends on health and outcomes that matter to people are also illustrated.

13
READER’S GUIDE
Figure 1. Mapping of Health at a Glance indicators into conceptual framework for health system
performance assessment
Health status
(dashboard 1, chapter 3)
Risk factors for health

(dashboard 2, chapter 4)
Health care system performance

How does the health system perform? What is the level of quality of care and access to services?
What does the performance cost?
Access Quality Health expenditure and financing

(dashboard 3, chapter 5) (dashboard 4, chapter 6) (dashboard 5, chapter 7)
Healthcare resources and activities (dashboard 5) Sub-sector analysis (dashboards 1 & 5)

Health workforce (chapter 8) Pharmaceutical sector (chapter 10)
Health care activities (chapter 9) Ageing and long-term care (chapter 11)
Demographic, economic & social context
Source: Adapted from Carinci, F. et al. (2015), “Towards Actionable International Comparisons of Health System Performance: Expert
Revision of the OECD Framework and Quality Indicators”, International Journal for Quality in Health Care, Vol. 27, No. 2, pp. 137-146.
The second chapter provides a special focus on patient-reported outcomes and

experiences, indicators that offer better measures of what matters to patients. It describes
the rationale for collecting and using information reported by patients. It also provides
preliminary results from a small number of countries in three clinical areas: elective hip
and knee replacement; breast cancer care; and mental health.
The next nine chapters then provide detailed country comparisons across a range of
health indicators, including where possible time trend analysis and data disaggregated by
demographic and socioeconomic characteristics.
Chapter 3 on health status highlights variations across countries in life expectancy, the
main causes of mortality, disease incidence and other indicators of population health. This
chapter also includes measures of inequality in health status by education and income
level for key indicators such as life expectancy and self-assessed health.
Chapter 4 analyses risk factors for health. The focus is on an individual’s health-related
behaviours, most of which effective public health and prevention policies can modify.
These include the major risk factors for non-communicable diseases of smoking, alcohol
and obesity; and new data on opioids use. Healthy lifestyles and population exposure to air
pollution and extreme temperatures are also analysed.
Chapter 5 on access to care investigates the extent to which people can access needed
services, with special attention paid to socioeconomic inequalities. Overall measures of

READER’S GUIDE
population coverage are also presented, as are the financial consequences for households
of accessing services.
Chapter 6 assesses quality and outcomes of care in terms of patient safety, clinical
effectiveness and the person responsiveness of care. Indicators across the full lifecycle of
care are included, from prevention to primary, chronic and acute care. This includes
analysis of prescribing practices, management of chronic conditions, acute care for heart
attacks and stroke, mental health, cancer care and prevention of communicable diseases.
Chapter 7 on health expenditure and financing compares how much countries spend on
health per person and in relation to GDP. It then analyses differences in prices paid, the
extent to which countries finance health through prepayment schemes or household out-
of-pocket payments, and the public-private funding mix. Spending by type of service and
health provider are also explored. Finally, projections estimate spending to 2030 under
different policy scenarios.
Chapter 8 examines the health workforce, particularly the supply and remuneration of
doctors and nurses. The chapter also presents data on the number of new graduates from
medical and nursing education programmes. Indicators on the international migration of
doctors and nurses compare countries in terms of their reliance on foreign-trained
workers.
Chapter 9 on health care activities describes some of the main characteristics of health
service delivery. It starts with the number of consultations with doctors, often the entry
point of patients to health care systems. The chapter then compares the use and supply of
hospital services, in terms of discharges, number of beds and average length of stay.
Utilisation of medical technologies, common surgical procedures, and the increased use of
ambulatory surgery are also analysed.
Chapter 10 takes a closer look at the pharmaceutical sector. Analysis of pharmaceutical
spending gives a sense of the varying scale of the market in different countries, as does
spending on research and development. The number of pharmacists and pharmacies,
consumption of certain high-volume drugs, and the use of generics and bio-similars, are
also compared.
Chapter 11 focuses on ageing and long-term care. It assesses key factors affecting the
demand for long-term care, such as demographic trends and health status indicators for
elderly populations. Dementia prevalence and the quality of dementia care is compared, as
is the safety of care for elderly populations. Recipients of long-term care, and the formal
and informal workers providing care for these people, are also assessed, along with trends
in spending and unit costs.
Presentation of indicators
With the exception of the first two chapters, indicators covered in the rest of the
publication are presented over two pages. The first page defines the indicator, highlights
key findings conveyed by the data and related policy insights, and signals any significant
national variation in methodology that might affect data comparability. A few key
references are also provided.
On the facing page is a set of figures. These typically show current levels of the
indicator and, where possible, trends over time. Where an OECD average is included in a
figure, it is the unweighted average of the OECD countries presented, unless otherwise

15
READER’S GUIDE
specified. The number of countries included in this OECD average is indicated in the figure,
and for charts showing more than one year this number refers to the latest year.
Data limitations
Limitations in data comparability are indicated both in the text (in the box related to
“Definition and comparability”) as well as in footnotes to figures.
Data sources
Readers interested in using the data presented in this publication for further analysis
and research are encouraged to consult the full documentation of definitions, sources and
methods presented in the online database OECD Health Statistics on OECD.Stat at https://
oe.cd/ds/health-statistics. More information on OECD Health Statistics is available at http://
www.oecd.org/health/health-data.htm.
Population figures
The population figures used to calculate rates per capita throughout this publication
come from Eurostat for European countries, and from OECD data based on the UN
Demographic Yearbook and UN World Population Prospects (various editions) or national
estimates for non-European OECD countries (data extracted as of early June 2019). Mid-year
estimates are used. Population estimates are subject to revision, so they may differ from
the latest population figures released by the national statistical offices of OECD member
countries.
Note that some countries such as France, the United Kingdom and the United States
have overseas territories. These populations are generally excluded. However, the
calculation of GDP per capita and other economic measures may be based on a different
population in these countries, depending on the data coverage.
OECD country ISO codes
Australia AUS Korea KOR

Austria AUT Latvia LVA
Belgium BEL Lithuania LTU
Canada CAN Luxembourg LUX
Chile CHL Mexico MEX
Czech Republic CZE Netherlands NLD
Denmark DNK New Zealand NZL
Estonia EST Norway NOR
Finland FIN Poland POL
France FRA Portugal PRT
Germany DEU Slovak Republic SVK
Greece GRC Slovenia SVN
Hungary HUN Spain ESP
Iceland ISL Sweden SWE
Ireland IRL Switzerland CHE
Israel ISR Turkey TUR
Italy ITA United Kingdom GBR
Japan JPN United States USA

READER’S GUIDE
Partner country ISO codes
Brazil BRA India IND

China (People’s Republic of) CHN Indonesia IDN
Colombia COL Russia RUS
Costa Rica CRI South Africa ZAF

17
© OECD 2019
Chapter 1
Indicator overview: comparative

performance of countries and major
trends
This chapter analyses a core set of indicators on health and health systems. Country
dashboards shed light on how OECD countries compare across five dimensions:
health status, risk factors for health, access, quality and outcomes, and health care
resources. OECD snapshots summarise the extent of variation in performance
across countries, as well as time trends. Finally, quadrant charts illustrate how
much health spending is associated with staffing, access, quality and health
outcomes.
The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli
authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights,
East Jerusalem and Israeli settlements in the West Bank under the terms of international law.
19
1. INDICATOR OVERVIEW: COMPARATIVE PERFORMANCE OF COUNTRIES AND MAJOR TRENDS
Introduction
Health indicators offer a useful ‘at a glance’ perspective on how healthy populations
are and how well health systems perform. This introductory chapter provides a
comparative overview of OECD countries across 20 core indicators. It also explores how
much health spending is associated with staffing, access, quality and health outcomes.
Such comparative analysis does not indicate which countries have the best performing
health systems overall. Rather, it identifies some of the relative strengths and weaknesses
of different OECD countries. This can help policymakers determine priority action areas for
their country, with subsequent chapters in Health at a Glance providing a more detailed
suite of indicators, organised by topic area.
Five dimensions of health and health systems are analysed in this chapter, covering
core aspects of population health and health system performance. For each of these
dimensions, four summary indicators are analysed (Table 1.1). These indicators are
selected from the publication based on how relevant and actionable they are from a public
policy perspective; as well as the more practical consideration of data availability across
countries.
Table 1.1. Population health and health system performance: summary indicators
Dimension Indicator
Health status Life expectancy – years of life at birth

(chapters 3 and 11) Avoidable mortality – deaths per 100 000 people (age standardised)
Chronic disease morbidity – diabetes prevalence (% adults, age standardised)
Self-rated health – population in poor health (% population aged 15+)
Risk factors for health Smoking – daily smokers (% population aged 15+)
(chapter 4) Alcohol – litres consumed per capita (population aged 15+)
Overweight/obese – population with BMI>=25 kg/m2 (% population aged 15+)
Air pollution – deaths due to pollution (per 100 000 population)
Access to care Population coverage – population eligible for core services (% population)
(chapter 5) Financial protection – expenditure covered by prepayment schemes (% total expenditure)
Service coverage, primary care – needs-adjusted probability of visiting a doctor (% population aged 15+)
Service coverage, preventive care – probability of cervical cancer screening (% population aged 15+)
Quality of care Safe prescribing – antibiotics prescribed (defined daily dose per 1 000 people)
(chapter 6) Effective primary care – avoidable asthma/COPD admissions (per 100 000 people, age-sex standardised)
Effective secondary care – 30-day mortality following AMI (per 100 000 people, age-sex standardised)
Effective cancer care – breast cancer 5-year net survival (%, age-standardised)
Health care resources Health spending – per capita (US dollars based on purchasing power parities)
(chapters 7-10) Health spending share – as a % of GDP
Doctors – number of practising physicians (per 1 000 people)
Nurses – number of practising nurses (per 1 000 people)
Note: AMI = acute myocardial infarction (heart attack); BMI = body mass index; COPD = chronic obstructive pulmonary
disease.
Based on these indicators, country dashboards are produced for each of these five
dimensions. These compare a country’s performance to others and to the OECD average.
Country classification for each indicator is into one of three colour-coded groups:

• Blue, when the country’s performance is close to the OECD average

• Green, when the country’s performance is considerably better than the OECD average
• Red, when the country’s performance is considerably worse than the OECD average
The only exception to this grouping is for the dashboard on health care resources
(Table 1.6), where indicators cannot be strictly classified as showing better or worse
performance. For this reason, the colour coding in this dashboard uses a lighter and darker
shade of blue to signal that a country has considerably less or more of a given health care
resource than the OECD average.
OECD snapshots provide accompanying summary statistics for each of these indicators.
They complement the country dashboards by providing an OECD-wide overview for each
indicator. Highest and lowest values per indicator, alongside the OECD average, provide a
general sense of the degree of cross-country variation. Countries with comparatively large
improvements over time in a given indicator are also shown.
Finally, quadrant charts illustrate basic associations between how much countries
spend on health and how effectively health systems function. That is, they show the extent
to which spending more on health translates into better health outcomes, higher quality of
care and improved access to care, across OECD countries; whilst also recognising the
importance of major risk factors. The relationship between spending and the number of
health professionals is also explored. These quadrant charts only show simple associations
at a macro level between indicators rather than causal relationships. That is, their purpose
is to stimulate deeper discussions on policy priority setting, by highlighting areas where
countries could potentially do better. The centre of each quadrant chart is the OECD
average, with health expenditure on the x-axis and the other variable of interest on the y-
axis. Figure 1.1 shows the basic interpretation of each quadrant, taking health outcome
variables as an example.
Figure 1.1. Interpretation of quadrant charts: Health expenditure and health outcome variables
Higher avoidable mortality →
Higher life expectancy →
Lower expenditure Higher expenditure Lower expenditure Higher expenditure

Higher life expectancy Higher life expectancy Higher avoidable mortality Higher avoidable mortality
Higher health expenditure → Higher health expenditure →
Lower expenditure Higher expenditure Lower expenditure Higher expenditure

Lower life expectancy Lower life expectancy Lower avoidable mortality Lower avoidable mortality

21
Methodology, interpretation and use

Country dashboards
The classification of countries being close to, better or worse than the OECD average is based on an
indicator’s standard deviation (a common statistical measure of dispersion). This method is preferred to
using a fixed percentage or fixed number of countries per category, since it reflects the degree of variation,
i.e. how far a country is from the OECD average. Countries are classified as “close to the OECD average”
(blue) whenever the value for an indicator is within one standard deviation from the OECD average for the
latest year. Particularly large outliers (values larger than three standard deviations) are excluded from the
calculation of the standard deviation in order to avoid statistical distortions. These exclusions are noted
under the relevant dashboards.
For a typical indicator, about 65% of the countries (24‑25 countries) will be close to the OECD average, with
the remaining 35% performing significantly better (green) or worse (red). When the number of countries that
are close to the OECD average is higher (lower), it means that cross-country variation is relatively low (high)
for that indicator. For example, for obesity rates, 27 countries are close to the OECD average. In contrast, for
avoidable mortality, only 16 countries are close to the OECD average.
OECD snapshots
For each indicator, the OECD average, highest and lowest values for the latest available year are shown,
corresponding to the data presented in the main chapters of the publication. Countries with comparatively
large improvements over time in a given indicator are also shown.
Quadrant charts
Quadrant charts plot health expenditure per capita against another indicator of interest (on health
outcomes, quality of care, access and physical resources). These show the percentage difference of each
indicator as compared with OECD averages. The intersection of the axes represents the OECD average for
both indicators, so deviations from the midpoint show countries that perform above or below average
compared to the OECD average. A simple correlation line is also included. Each country is colour-coded
based on a simple (unweighted) risk factors index averaging smoking, alcohol and obesity variables (with
blue, green and red having the same interpretation as in country dashboards).
Data from the latest available year are used for both variables in a given quadrant chart. A limitation of
this approach is that lagged effects are not taken into account – for example, it may take a few years before
higher health spending translates into longer life expectancy, or risk factors translate into higher avoidable
mortality rates.

23
Health status
Four health status indicators reflect core aspects of both the quality and quantity of
life. Life expectancy is a key indicator for the overall health of a population; avoidable
mortality focuses on premature deaths that could have been prevented or treated. Diabetes
prevalence shows morbidity for a major chronic disease; self-rated health offers a more
holistic measure of mental and physical health. Figure 1.2 provides a snapshot on health
status across the OECD and Table 1.2 provide more detailed country comparisons.
Figure 1.2. Snapshot on health status across the OECD
LOW OECD HIGH LARGEST IMPROVEMENT

Latvia Japan Estonia +7.2 (10%)
Life expectancy Turkey +7.0 (10%)
Years of life at birth 70 90 Korea +6.7 (9%)
74.8 80.7 84.2
Avoidable mortality Switzerland Latvia
Deaths per 100 000 population Insufficient time series available
0 850
(age-standardised) 125 208 426
Chronic disease morbidity Ireland Mexico

Diabetes prevalence Insufficient time series available
0 20
(% adults, age-standardised) 3.3 6.4 13.1
Self-rated health New Zealand Korea Israel -11.8 (51%)

Population in poor health Hungary -8.9 (41%)
0 20
(% population aged 15+) 2 9 17 Slovenia -6.5 (40%)
Note: Largest improvement shows countries with largest changes in value over time (% change in brackets).
Source: OECD Health Statistics 2019.
Across these indicators, Japan, Spain, Switzerland and the Netherlands generally have
the best overall health outcomes. Hungary, Latvia, Mexico, Poland and the Slovak Republic
are consistently below the OECD average for these indicators. Stronger health systems
contribute to gains in health outcomes, by offering more accessible and higher quality care.
Differences in risk factors such as smoking, alcohol and obesity also explain cross-country
variation in health outcomes. Wider determinants of health matter too, notably rising
incomes, better education and improved living environments.
Japan, Switzerland and Spain lead a large group of 26 OECD countries in which life
expectancy at birth exceeds 80 years. A second group, including the United States and a
number of central and eastern European countries, has a life expectancy between 77 and
80 years. Latvia, Lithuania, Mexico and Hungary have the lowest life expectancy, at less
than 76 years in 2017. Across the OECD, whilst life expectancy has increased steadily over
time, there has been a slowdown in longevity gains in recent years.
Avoidable mortality rates (from preventable and treatable causes) were lowest in
Switzerland, Iceland, Japan, Sweden and Norway, where less than 300 per 100 000 people
died prematurely. Latvia, Lithuania and Hungary had the highest avoidable mortality rates,
at over 800 premature deaths per 100 000 people.
Diabetes prevalence is highest in Mexico, Turkey and the United States, with over 10%
of adults living with diabetes (age-standardised data). Age-standardised diabetes
prevalence rates have stabilised in many OECD countries, especially in Western Europe, but
increased markedly in Turkey. Such upward trends are due in part to rising rates of obesity
and physical inactivity, and their interactions with population ageing.
Almost 9% of adults consider themselves to be in bad health, on average across the
OECD. This ranges from over 15% in Korea, Lithuania, Latvia and Portugal to under 4% in

Table 1.2. Dashboard on health status

Life expectancy Avoidable mortality Chronic disease morbidity Self-rated health
Deaths per 100 000 people Diabetes prevalence Population in poor health
Years of life at birth
(age-standardised) (% adults, age-standardised) (% population aged 15+)
OECD 80.7 ⦿ 208 ⦿ 6.4 ⦿ 8.7 ⦿

Australia 82.6 ⦿ 145  5.1 ⦿ 3.7 
Austria 81.7 ⦿ 175 ⦿ 6.4 ⦿ 8.1 ⦿
Belgium 81.6 ⦿ 172 ⦿ 4.3  8.6 ⦿
Canada 82.0 ⦿ 176 ⦿ 7.4 ⦿ 3.2 
Chile 80.2 ⦿ 206 ⦿ 8.5  6.6 ⦿
Czech Republic 79.1 ⦿ 245 ⦿ 6.8 ⦿ 10.7 ⦿
Denmark 81.2 ⦿ 184 ⦿ 6.4 ⦿ 7.5 ⦿
Estonia 78.2  297  4.0  14.6 
Finland 81.7 ⦿ 184 ⦿ 5.8 ⦿ 5.7 ⦿
France 82.6 ⦿ 154  4.8 ⦿ 8.3 ⦿
Germany 81.1 ⦿ 186 ⦿ 8.3  8.4 ⦿
Greece 81.4 ⦿ 187 ⦿ 4.6  10.4 ⦿
Hungary 75.9  388  7.6 ⦿ 11.9 ⦿
Iceland 82.7 ⦿ 140  5.3 ⦿ 6.4 ⦿
Ireland 82.2 ⦿ 172 ⦿ 3.3  3.4 
Israel 82.6 ⦿ 134  6.7 ⦿ 10.9 ⦿
Italy 83.0 ⦿ 143  4.8 ⦿ 5.8 ⦿
Japan 84.2  138  5.7 ⦿ 14.1 
Korea 82.7 ⦿ 159 ⦿ 6.8 ⦿ 17.0 
Latvia 74.8  426  4.9 ⦿ 15.5 
Lithuania 75.6  385  3.7  16.4 
Luxembourg 82.2 ⦿ 152  4.4  9.3 ⦿
Mexico 75.4  367  13.1  –
Netherlands 81.8 ⦿ 153  5.3 ⦿ 4.6 
New Zealand 81.9 ⦿ 178 ⦿ 8.1 ⦿ 2.3 
Norway 82.7 ⦿ 145  5.3 ⦿ 7.2 ⦿
Poland 77.9  268  5.9 ⦿ 13.6 
Portugal 81.5 ⦿ 180 ⦿ 9.9  15.3 
Slovak Republic 77.3  323  7.3 ⦿ 11.3 ⦿
Slovenia 81.1 ⦿ 210 ⦿ 7.3 ⦿ 9.7 ⦿
Spain 83.4  146  7.2 ⦿ 6.6 ⦿
Sweden 82.5 ⦿ 144  4.8 ⦿ 5.7 ⦿
Switzerland 83.6  125  5.6 ⦿ 4.1 
Turkey 78.1  257 ⦿ 12.1  9.4 ⦿
United Kingdom 81.3 ⦿ 189 ⦿ 4.3  7.1 ⦿
United States 78.6 ⦿ 262  10.8  2.6 
Note:  Better than OECD average; ⦿ Close to OECD average;  Worse than OECD average. Hungary, Latvia and
Lithuania excluded from the standard deviation calculation for avoidable mortality, while Mexico and Turkey
excluded from diabetes prevalence.
New Zealand, the United States, Canada, Ireland and Australia. However, socio-cultural
differences, the share of older people and differences in survey design affect cross-country
comparability. People with lower incomes are generally less positive about their health as
compared with people on higher incomes, in all OECD countries.

25
Risk factors for health

Smoking, alcohol consumption and obesity are the three major risk factors for non-
communicable diseases, contributing to a large share of worldwide deaths. Air pollution is
also a critical non-medical determinant of health. Figure 1.3 provides a snapshot on risk
factors for health across the OECD and Table 1.3 provides more detailed country
comparisons.
Figure 1.3. Snapshot on risk factors for health across the OECD

Smoking Mexico Greece Estonia -15.6 (46%)
Daily smokers Norway -13.0 (52%)
(% population aged 15+) 0
7.6 18.0 27.3
30 Greece -11.3 (29%)
Alcohol Turkey Lithuania Denmark -3.6 (28%)

Litres consumed per capita Greece -3.5 (35%)
0 15 Spain -3.3 (28%)
(population aged 15+) 1.4 9 12
Overweight/obese Japan Chile

Population with BMI ≥ 25 Insufficient time series available
0 100
(% population aged 15+) 25.9 55.6 74.2
Air pollution New Zealand Latvia
Deaths due to pollution Insufficient time series available

0 120
(per 100 000 population) 14 40 98
Source: OECD Health Statistics 2019, WHO Global Health Observatory.
Norway and Sweden perform well across these indicators. Smoking causes multiple
diseases – the World Health Organization estimates tobacco smoking kills 7 million people
in the world every year. Smoking rates range from over 25% in Greece, Turkey and Hungary,
to below 10% in Mexico and Iceland. Daily smoking rates have decreased in most OECD
countries over the last decade, from an average of 23% in 2007 to 18% in 2017. In the Slovak
Republic and Austria, though, smoking rates have risen slightly.
Alcohol use is a leading cause of death and disability worldwide, particularly in those
of working age. Measured through sales data, Lithuania reported the highest consumption
(12.3 litres of pure alcohol per person per year), followed by Austria, France, the Czech
Republic, Luxembourg, Ireland, Latvia and Hungary, all with over 11 litres per person.
Turkey, Israel and Mexico have comparatively low consumption levels (under 5 litres).
Average consumption fell in 27 OECD countries since 2007. Harmful drinking is of particular
concern in certain countries, notably Latvia, Hungary and the Russian Federation.
Obesity is a major risk factor for many chronic diseases, including diabetes,
cardiovascular diseases and cancer. Obesity rates have been increasing in recent decades
in almost all OECD countries, with an average of 56% of the population being overweight or
obese. Obesity rates are considerably higher than the OECD average in Chile, Mexico, the
United States, Finland, Portugal and New Zealand. Obesity is lowest in Japan, Korea, and
Switzerland. The measure reported here for overweight (including obese) adults is based on
both measured and self-reported data. Caution should be taken when comparing countries
with reporting differences, since measured data are generally higher.
Air pollution is not only a major environmental threat, but also worsens health. OECD
projections estimate that outdoor air pollution may cause 6 to 9 million premature deaths a

Table 1.3. Dashboard on risk factors for health

Smoking Alcohol Overweight / obese Air pollution
Daily smokers Litres consumed per capita Population with BMI ≥ 25 Deaths due to pollution
(% population aged 15+) (population aged 15+) (% population aged 15+) (per 100 000 people)
OECD 18.0 ⦿ 8.9 ⦿ 55.6 ⦿ 39.6 ⦿

Australia 12.4  9.4 ⦿ 65.2 ⦿ 16.8 
Austria 24.3  11.8  46.7* ⦿ 38.7 ⦿
Belgium 18.9 ⦿ 10.4 ⦿ 51.0 ⦿ 39.4 ⦿
Canada 12.0  8.1 ⦿ 59.1 ⦿ 14.7 
Chile 24.5  7.9 ⦿ 74.2  34.8 ⦿
Czech Republic 18.4 ⦿ 11.6  55.0 ⦿ 64.3 
Denmark 16.9 ⦿ 9.1 ⦿ 51.0* ⦿ 30.4 ⦿
Estonia 17.2 ⦿ 10.3 ⦿ 51.3 ⦿ 59.9 
Finland 14.0 ⦿ 8.4 ⦿ 67.6  18.7 
France 25.4  11.7  49.0 ⦿ 25.2 ⦿
Germany 18.8 ⦿ 10.9 ⦿ 60.0 ⦿ 45.3 ⦿
Greece 27.3  6.5 ⦿ 55.0* ⦿ 76.7 
Hungary 25.8  11.1 ⦿ 62.3 ⦿ 82.7 
Iceland 8.6  7.7 ⦿ 65.4* ⦿ 16.9 
Ireland 17.0 ⦿ 11.2 ⦿ 62.0 ⦿ 20.2 
Israel 16.9 ⦿ 2.6  50.9 ⦿ 23.2 ⦿
Italy 19.9 ⦿ 7.6 ⦿ 46.0* ⦿ 48.7 ⦿
Japan 17.7 ⦿ 7.2 ⦿ 25.9  42.9 ⦿
Korea 17.5 ⦿ 8.7 ⦿ 33.7  35.0 ⦿
Latvia 24.1  11.2 ⦿ 54.6 ⦿ 97.8 
Lithuania 20.3 ⦿ 12.3  53.3* ⦿ 82.1 
Luxembourg 14.5 ⦿ 11.3 ⦿ 58.1 ⦿ 22.6 ⦿
Mexico 7.6  4.4  72.5  33.0 ⦿
Netherlands 16.8 ⦿ 8.3 ⦿ 47.3* ⦿ 31.3 ⦿
New Zealand 13.8 ⦿ 8.8 ⦿ 66.6  13.6 
Norway 12.0  6.0  46.0* ⦿ 18.7 
Poland 22.7 ⦿ 10.6 ⦿ 53.3* ⦿ 76.3 
Portugal 16.8 ⦿ 10.7 ⦿ 67.6  28.3 ⦿
Slovak Republic 22.9 ⦿ 9.7 ⦿ 51.5 ⦿ 59.1 
Slovenia 18.9 ⦿ 10.1 ⦿ 55.6* ⦿ 56.8 ⦿
Spain 22.1 ⦿ 8.6 ⦿ 53.0* ⦿ 27.1 ⦿
Sweden 10.4  7.1 ⦿ 48.2* ⦿ 18.5 
Switzerland 19.1 ⦿ 9.2 ⦿ 41.8*  25.2 ⦿
Turkey 26.5  1.4  64.4 ⦿ 46.2 ⦿
United Kingdom 17.2 ⦿ 9.7 ⦿ 64.3 ⦿ 32.1 ⦿
United States 10.5  8.9 ⦿ 71.0  24.1 ⦿
Note:  Better than OECD average; ⦿ Close to OECD average;  Worse than OECD average. Hungary, Latvia and
Lithuania excluded from standard deviation calculation for air pollution. * Likely under-estimate of obesity as self-
reported.
year worldwide by 2060. Death rates in 2016 ranged from over 80 deaths in Latvia, Hungary
and Lithuania, to 15 deaths or less per 100 000 people in New Zealand and Canada.

27
Access to care
Ensuring equitable access is critical for inclusive societies and high performing health
systems. Population coverage, measured by the share of the population eligible for a core
set of services, offers an initial assessment of access to care. The share of spending covered
by prepayment schemes provides further insight on financial protection. The probability of
visiting a doctor, adjusted for need, and the share of women aged 20-69 screened for
cervical cancer measure use of needed services. Figure 1.4 provides a snapshot on access to
care across the OECD and Table 1.4 provides more detailed country comparisons.
Figure 1.4. Snapshot on access to care across the OECD

Population coverage Mexico OECD Mexico +25.7 (40%)
Population eligible for core services Chile +6.5 (7%)
85 100 Turkey +6 (6%)
(% population) 89.3 98.4
Financial protection Mexico Norway Slovak Rep. +10.6 (15%)
Expenditure covered by prepayment Germany +9.2 (12%)
40 100 Mexico +7.7 (18%)
schemes (% total expenditure) 51.3 71 85
Service coverage, primary care Sweden France

Needs-adjusted prob. of visiting doctor Insufficient time series available
60 100
(% of the population aged 15+) 64.0 78.6 89
Service coverage, preventive care Netherlands Czech Rep.

Prob. of cervical cancer screening Insufficient time series available
40 100
49 73 87
(% of the population aged 15+)
Austria, the Czech Republic, France, Germany and Luxembourg perform well across
these indicators, In terms of population coverage, most OECD countries have achieved
universal (or near-universal) coverage for a core set of services. However, in seven
countries coverage remains below 95% – Chile, Estonia, Hungary, Mexico, Poland, the
Slovak Republic and the United States.
Population coverage, though, is not sufficient by itself. The degree of cost sharing
applied to those services also affects access to care. Across the OECD, almost three-quarters
of all health care costs are covered by government or compulsory health insurance
schemes. However, in Mexico, Latvia and Korea less than 60% of all costs are covered by
publicly mandated schemes. Mexico, though, has significantly expanded population
coverage and financial protection over the last decade.
One in five people report not seeing a doctor despite having medical need. Cross-
country differences in utilisation are large, with need-adjusted probabilities of visiting a
doctor ranging from around 65% in Sweden and the United States to 89% in France.
Excepting Denmark and the Slovak Republic, wealthier individuals are more likely to see a
doctor than individuals in the lowest income quintile, for a comparable level of need.
Uptake of cancer screening is also lower amongst the less well-off. This is despite most
OECD countries providing screening programmes at no cost. Overall uptake of cervical
cancer screening ranged from just under 50% of women aged 20 to 69 in the Netherlands, to
over 85% in the Czech Republic and Austria.

Table 1.4. Dashboard on access to care

Service coverage, primary Service coverage,
Population coverage Financial protection
care preventive care
Population eligible for core Expenditure covered by prepayment Needs-adjusted prob. of Prob. of cervical cancer
services (% population) schemes (% total expenditure) visiting doctor (% pop 15+) screening (% pop 15+)
OECD 98.4 ⦿ 71.2 ⦿ 78 ⦿ 73 ⦿

Australia 100 ⦿ 68.6 ⦿ – –
Austria 99.9 ⦿ 74.0 ⦿ 86  87 
Belgium 98.7 ⦿ 77.2 ⦿ 86  76 ⦿
Canada 100 ⦿ 73.0 ⦿ 75 ⦿ 76 ⦿
Chile 94.0  50.1  – 72 ⦿
Czech Republic 100 ⦿ 82.1 ⦿ 85  87 
Denmark 100 ⦿ 84.0  81 ⦿ 64 
Estonia 94.1  74.7 ⦿ 75 ⦿ 58 
Finland 100 ⦿ 76.7 ⦿ 74 ⦿ 79 ⦿
France 99.9 ⦿ 77.1 ⦿ 89  82 
Germany 100 ⦿ 77.7 ⦿ 86  81 ⦿
Greece 100 ⦿ 60.8 ⦿ 76 ⦿ 76 ⦿
Hungary 94.0  68.7 ⦿ 84 ⦿ 71 ⦿
Iceland 100 ⦿ 81.8 ⦿ 75 ⦿ 80 ⦿
Ireland 100 ⦿ 73.3 ⦿ 75 ⦿ 69 ⦿
Israel 100 ⦿ 63.6 ⦿ – –
Italy 100 ⦿ 73.9 ⦿ 80 ⦿ 68 ⦿
Japan 100 ⦿ 84.0  – –
Korea 100 ⦿ 57.4  – –
Latvia 100 ⦿ 57.2  76 ⦿ 78 ⦿
Lithuania 98.1 ⦿ 65.5 ⦿ 76 ⦿ 62 
Luxembourg – 84.9  88  84 
Mexico 89.3  51.3  – –
Netherlands 99.9 ⦿ 81.5 ⦿ 75 ⦿ 49 
New Zealand 100 ⦿ 78.6 ⦿ – –
Norway 100 ⦿ 85.5  77 ⦿ 66 ⦿
Poland 92.6  69.0 ⦿ 80 ⦿ 72 ⦿
Portugal 100 ⦿ 66.3 ⦿ 86  71 ⦿
Slovak Republic 94.6  79.9 ⦿ 74 ⦿ 69 ⦿
Slovenia 100 ⦿ 71.8 ⦿ 71  78 ⦿
Spain 99.9 ⦿ 70.6 ⦿ 84 ⦿ 69 ⦿
Sweden 100 ⦿ 83.7  64  81 ⦿
Switzerland 100 ⦿ 30.5  – –
Turkey 99.2 ⦿ 77.7 ⦿ – –
United Kingdom 100 ⦿ 79.4 ⦿ 76 ⦿ 63 
United States 90.8  50.2  65  80 ⦿
Note:  Better than OECD average; ⦿ Close to OECD average;  Worse than OECD average.

29
Quality of care
Good quality care requires health services to be safe, appropriate, clinically effective
and responsive to patient needs. Antibiotics prescriptions and avoidable hospital
admissions for asthma and chronic obstructive pulmonary disease (COPD) measure the
safety and appropriateness of primary care. 30-day mortality following acute myocardial
infarction (AMI) and breast cancer survival are indicators of clinical effectiveness of
secondary and cancer care. Figure 1.5 provides a snapshot on quality and outcome of care
across the OECD and Table 1.5 provides more detailed country comparisons.
Figure 1.5. Snapshot on quality of care across the OECD

Safe prescribing Estonia Greece
Antibiotics prescribed Insufficient time series available
(defined daily dose per 1 000 people) 0 40
10.1 18.5 32.1
Effective primary care Japan Hungary
Asthma/COPD admissions Insufficient time series available
0 500
(per 100 000 people, age-sex standardised) 58 225 428
Effective secondary care Iceland Mexico Slovak Republic -5.7 (49%)

AMI 30-day mortality Chile -5.6 (41%)
0 30 Netherlands -5.3 (60%)
(per 100 000 people, age-sex standardised) 2.3 6.9 27.5
Effective cancer care Lithuania United States Lithuania +8.9 (14%)

Breast cancer 5-year net survival Latvia +7.6 (11%)
60 100
74 85 90 Korea +7.1 (9%)
(%, age-standardised)
The overuse, underuse or misuse of antibiotics and other prescription medicines

contribute to increased antimicrobial resistance and represent wasteful spending. Total
volumes of antibiotics prescribed vary more than three-fold across countries, with Estonia
and Sweden reporting the lowest volumes, whereas Italy and Greece report the highest
volumes. Across the OECD, the number of antibiotics prescribed has increased slightly over
time.
Asthma and COPD are conditions for which effective treatment at the primary care
level is well established – and hospital admissions for these conditions may signal quality
issues in primary care. Admission rates for asthma vary 12‑fold across countries with
Mexico, Italy, and Colombia reporting the lowest rates and Latvia, Turkey and Poland
reporting rates over twice the OECD average. International variation in admissions for
COPD is 15‑fold across OECD countries, with Japan, Italy and Mexico reporting the lowest
rates and Hungary, Turkey and Australia the highest rates. Combined, there is a lower
7‑fold variation across countries for these two respiratory conditions.
Mortality following acute myocardial infarction (AMI) is a long-established indicator of
the quality of acute care. It has been steadily declining since the 1970s in most countries,
yet important cross-country differences still exist. Mexico has by far the highest 30‑day
mortality following AMI (28 deaths per 100 admissions); rates are also relatively high in
Latvia, Japan, Korea and Estonia. The lowest rates are found in Iceland, Denmark, Norway,
Netherlands, Australia and Sweden (all 4% or less).
Breast cancer survival is an important measure of clinical effectiveness, with generally
high survival across the OECD. Some of the best survival rates are found in Australia, Japan

Table 1.5. Dashboard on quality of care

Safe prescribing Effective primary care Effective secondary care Effective cancer care
Antibiotics prescribed Avoidable asthma / COPD 30-day mortality following Breast cancer 5-year net
(defined daily dose per 1 000 admissions (per 100 000 AMI (per 100 000 people, age- survival (%, age-
people) people, age-sex standardised) sex standardised) standardised)
OECD 17.8 ⦿ 225 ⦿ 6.9 ⦿ 84.5 ⦿

Australia 23.5 ⦿ 403  3.8  89.5 
Austria 12.1  248 ⦿ 6.2 ⦿ 84.8 ⦿
Belgium 15.9 ⦿ 291 ⦿ 6.8 ⦿ 86.4 ⦿
Canada 14.8 ⦿ 253 ⦿ 4.8 ⦿ 88.6 ⦿
Chile – 98  8.2 ⦿ 75.5 
Czech Republic 19.6 ⦿ 174 ⦿ 6.2 ⦿ 81.4 ⦿
Denmark 13.9 ⦿ 325  3.2  86.1 ⦿
Estonia 10.1  122  9.6  76.6 
Finland 12.6 ⦿ 182 ⦿ 8.0 ⦿ 88.5 ⦿
France 23.0 ⦿ 150 ⦿ 5.6 ⦿ 86.7 ⦿
Germany 12.3  289 ⦿ 8.5 ⦿ 86.0 ⦿
Greece 32.1  – – –
Hungary 13.4 ⦿ 428  – –
Iceland 24.6  201 ⦿ 2.3  89.1 ⦿
Ireland 24.6  329  5.4 ⦿ 82.0 ⦿
Israel 20.5 ⦿ 214 ⦿ 5.5 ⦿ 88.0 ⦿
Italy 28.3  64  5.4 ⦿ 86.0 ⦿
Japan – 58  9.7  89.4 
Korea 26.5  263 ⦿ 9.6  86.6 ⦿
Latvia 12.1  242 ⦿ 13.4  76.9 
Lithuania 13.6 ⦿ 263 ⦿ 8.6 ⦿ 73.5 
Luxembourg 25.3  203 ⦿ 8.5 ⦿ –
Mexico – 85  27.5  –
Netherlands 14.3 ⦿ 236 ⦿ 3.5  86.6 ⦿
New Zealand 25.8  363  4.7 ⦿ 87.6 ⦿
Norway 14.6 ⦿ 244 ⦿ 3.5  87.2 ⦿
Poland 23.8 ⦿ 236 ⦿ 4.1  76.5 
Portugal 16.4 ⦿ 90  7.3 ⦿ 87.6 ⦿
Slovak Republic 23.6 ⦿ 209 ⦿ 5.9 ⦿ 75.5 
Slovenia 19.0 ⦿ 128 ⦿ 4.1  83.5 ⦿
Spain 12.6 ⦿ 210 ⦿ 6.5 ⦿ 85.3 ⦿
Sweden 10.2  169 ⦿ 3.9  88.8 ⦿
Switzerland – 138 ⦿ – 86.2 ⦿
Turkey 16.6 ⦿ 425  6.8 ⦿ 82.1 ⦿
United Kingdom 17.5 ⦿ 281 ⦿ 7.0 ⦿ 85.6 ⦿
United States – 268 ⦿ 5.0 ⦿ 90.2 
Note:  Better than OECD average; ⦿ Close to OECD average;  Worse than OECD average. Mexico excluded from
standard deviation calculation for AMI mortality.
and the United States, while rates significantly below the OECD average are found in Chile,
Estonia, Latvia, Lithuania, Poland and the Slovak Republic.

31
Health care resources

Having sufficient health care resources is critical to a well-functioning health system.
More resources, though, do not automatically translate into better health outcomes – the
effectiveness of spending is also important. Health spending per capita and as a share of
GDP summarise overall resource availability. The number of practising doctors and nurses
provide further information on the supply of health workers. Figure 1.6 provides a snapshot
on health care resources across the OECD and Table 1.6 provide more detailed country
comparisons.
Figure 1.6. Snapshot on health resources across the OECD
LOW OECD HIGH LARGEST INCREASE

Health spending Mexico Estonia Greece
United States United States +3.4K (48%)
Per capita Switzerland +2.5K (53%)
0 40 Norway +1.9K (43%)
(USD based on PPPs) 1.1K 4.0K 19.0 36.3
10.5K
Turkey
Japan United States
Hungary Japan +3.0 (38%)
Health spending share Sweden +3.0 (37%)
As a % of GDP 0 20
500 Chile +2.7 (44%)
58 4.2 8.8
225 16.9
427.51…
Doctors Iceland Turkey Greece Mexico Portugal +1.5 (41%)

Practising physicians Chile +1.0 (71%)
0 30
8 New Zealand +1.0 (42%)
(per 1 000 population) 2.3033… 6.9
1.9 3.5 6.1 27.5
Nurses Turkey Lithuania Norway

United States Switzerland +3.9 (29%)
Practising nurses Norway +3.7 (27%)
0
60 20
100
2.1 8.8 17.7 France +2.8 (37%)
(per 1 000 population) 74 85 90
Overall, countries with higher health spending and higher numbers of health workers
and other resources have better health outcomes, quality and access to care. However, the
absolute amount of resources invested is not a perfect predictor of better outcomes –
efficient use of health resources and the wider social determinants of health are also
critical. The next section will further investigate the associations between health spending
and staffing, access, quality and health outcomes.
The United States spends considerably more than any other country (over USD 10 000
per person, adjusted for purchasing power). Health care spending per capita is also high in
Switzerland, Norway and Germany. Mexico and Turkey spend the least, at around a quarter
of the OECD average. Health spending has grown consistently across most countries over
the past decades, other than a temporary slowdown following the 2008 financial crisis.
Rising incomes, new technologies and ageing populations are key drivers of health
spending growth.
In terms of health spending as a share of GDP, the United States spends by far the most
on health care, equivalent to 16.9% of its GDP - well above Switzerland, the next highest
spending country, at 12.2%. Germany, France, Sweden and Japan devote the next highest
shares of GDP to health. A large group of OECD countries spanning Europe, but also
Australia, New Zealand, Chile and Korea, spend between 8‑10% of GDP. A few OECD
countries spend less than 6% of their GDP on health care, including Mexico, Latvia,
Luxembourg, and Turkey at 4.2%.
A large part of health spending is translated into wages for the workforce. The number
of doctors and nurses in a health system is therefore an important way of monitoring how
resources are being used. The number of doctors ranged from about two per 1 000

Table 1.6. Dashboard on health resources

Health spending Health spending share Doctors Nurses
Per capita (USD based on As a % of Gross Domestic Practising physicians (per Practising nurses (per 1 000
purchasing power parities) Product (GDP) 1 000 population) population)
OECD 3 994 ⦿ 8.8 ⦿ 3.5 ⦿ 8.8 ⦿

Australia 5 005 ⦿ 9.3 ⦿ 3.7 ⦿ 11.7 ⦿
Austria 5 395 ⦿ 10.3 ⦿ 5.2  6.9 ⦿
Belgium 4 944 ⦿ 10.4 ⦿ 3.1 ⦿ 11.0 ⦿
Canada 4 974 ⦿ 10.7 ⦿ 2.7 ⦿ 10.0 ⦿
Chile 2 182  8.9 ⦿ 2.5  2.7 
Czech Republic 3 058 ⦿ 7.5 ⦿ 3.7 ⦿ 8.1 ⦿
Denmark 5 299 ⦿ 10.5 ⦿ 4.0 ⦿ 10.0 ⦿
Estonia 2 231  6.4  3.5 ⦿ 6.2 ⦿
Finland 4 228 ⦿ 9.1 ⦿ 3.2 ⦿ 14.3 
France 4 965 ⦿ 11.2  3.2 ⦿ 10.5 ⦿
Germany 5 986  11.2  4.3 ⦿ 12.9 
Greece 2 238  7.8 ⦿ 6.1*  3.3 
Hungary 2 047  6.6  3.3 ⦿ 6.5 ⦿
Iceland 4 349 ⦿ 8.3 ⦿ 3.9 ⦿ 14.5 
Ireland 4 915 ⦿ 7.1 ⦿ 3.1 ⦿ 12.2 ⦿
Israel 2 780 ⦿ 7.5 ⦿ 3.1 ⦿ 5.1 ⦿
Italy 3 428 ⦿ 8.8 ⦿ 4.0 ⦿ 5.8 ⦿
Japan 4 766 ⦿ 10.9  2.4  11.3 ⦿
Korea 3 192 ⦿ 8.1 ⦿ 2.3  6.9 ⦿
Latvia 1 749  5.9  3.2 ⦿ 4.6 
Lithuania 2 416  6.8  4.6  7.7 ⦿
Luxembourg 5 070 ⦿ 5.4  3.0 ⦿ 11.7 ⦿
Mexico 1 138  5.5  2.4  2.9 
Netherlands 5 288 ⦿ 9.9 ⦿ 3.6 ⦿ 10.9 ⦿
New Zealand 3 923 ⦿ 9.3 ⦿ 3.3 ⦿ 10.2 ⦿
Norway 6 187  10.2 ⦿ 4.7  17.7 
Poland 2 056  6.3  2.4  5.1 ⦿
Portugal 2 861 ⦿ 9.1 ⦿ 5.0*  6.7 ⦿
Slovak Republic 2 290  6.7  3.4 ⦿ 5.7 ⦿
Slovenia 2 859 ⦿ 7.9 ⦿ 3.1 ⦿ 9.9 ⦿
Spain 3 323 ⦿ 8.9 ⦿ 3.9 ⦿ 5.7 ⦿
Sweden 5 447 ⦿ 11.0  4.1 ⦿ 10.9 ⦿
Switzerland 7 317  12.2  4.3 ⦿ 17.2 
Turkey 1 227  4.2  1.9  2.1 
United Kingdom 4 070 ⦿ 9.8 ⦿ 2.8 ⦿ 7.8 ⦿
United States 10 586  16.9  2.6 ⦿ 11.7 ⦿
Note:  Above OECD average; ⦿ Close to OECD average;  Below OECD average. United States excluded from standard
deviation calculation for both health expenditure indicators. *Includes all doctors licensed to practice, resulting in a
large over-estimation.
population in Turkey, Japan, Chile, and Korea, to five or more in Portugal, Austria, and
Greece. However, numbers in Portugal and Greece are over-estimated as they include all
doctors licensed to practise. There were just under nine nurses per 1 000 population in
OECD countries in 2017, ranging from about two per 1 000 in Turkey to more than 17 per
1 000 in Norway and Switzerland.

33
To what extent does health spending translate into better access, quality and health
outcomes, and more health professionals?
Quadrant charts plot the association between health spending and another variable of
interest. They illustrate the extent to which spending more on health translates into
stronger performance across four dimensions: health outcomes, quality of care, access, and
more health professionals. Note, though, that only a small subset of indicators for these
four dimensions are compared against health spending. Quadrant charts also show pure
statistical correlations, they do not imply causality.
The midpoint of a quadrant chart represents the OECD average, with dots the relative
position of countries across health spending and the given indicator analysed. Each
country is also colour-coded, based on a simple risk factors index (RFI) of smoking, alcohol
and obesity indicators. Green dots indicate countries with a relatively low RFI (e.g. Israel,
Norway), blue dots countries with a RFI close to the OECD average, and red dots countries
with a relatively high RFI (e.g. Chile, Hungary). The RFI is an unweighted average of these
three risk factors. Hence, the United States, for example, is coloured blue despite having
high obesity rates, because of relatively low smoking rates and alcohol consumption. See
box on “methodology, interpretation and use” for further methodological details.
Health spending and health outcomes

These quadrant charts illustrate the extent to which countries that spend more on
health have better health outcomes (noting such associations do not guarantee a causal
relationship).
There is a clear positive association between health spending per capita and life
expectancy (Figure 1.7). Amongst the 36 OECD countries, 17 countries spend more and have
higher life expectancy than the OECD average (top right quadrant). A further 10 countries
spend less and have lower life expectancy at birth (bottom left quadrant).
Of particular interest are countries that deviate from this basic relationship. Eight
countries spend less than average but achieve higher life expectancy overall (top left
quadrant). These countries are Italy, Korea, Portugal, Spain, Slovenia, Greece, Israel and
New Zealand. The only country in the bottom right quadrant is the United States, with
much higher spending than in all other OECD countries, but lower life expectancy than the
OECD average.
Most countries with high overall risk factors (red dots) have lower life expectancy than
the OECD average. They are also typically below the trend line, which shows the average
spending to life expectancy ratio across OECD countries. The converse generally holds for
countries with low risk factors (green dots).
For avoidable mortality, there is also a clear association in the expected direction
(Figure 1.8). Amongst 36 countries with comparable data, 16 countries spend more and have
lower avoidable mortality rates (bottom right quadrant). A further nine countries spend
less and have more deaths that could have been avoided (top left quadrant). Seven
countries spend less than average but achieve lower avoidable mortality rates – for
example, Italy, Israel and Spain (bottom left quadrant). The United States spends more than
the OECD average and has worse avoidable mortality rates. Consistent with life expectancy,
countries with higher (lower) risk factors (respectively in red and green dots) typically have
higher (lower) avoidable mortality rates.

Figure 1.7. Life expectancy and health expenditure Figure 1.8. Avoidable mortality (preventable and
treatable) and health expenditure
Low risk factors Average risk factors High risk factors Low risk factors Average risk factors High risk factors
1.08 2.5
▼ Spend ▲LE ▲ Spend ▲LE ▼ Spend ▲ Av ▲ Spend ▲ Av
LVA
1.05
LTU
JPN 2
ISR CHE HUN
ESP
FRA
PRT NOR
1.02 SWE
MEX
SVK
GRC
AUT
DEU 1.5
EST
GBR
CHL SVN POL
0.99 USA
TUR CZE
CZE
CHL SVN GBR DEU
USA
TUR POL 1
GRC DNK
0.96
SVK PRT
NOR
HUN ITA
ESP CHE
JPN
LTU 0.5 ISR
MEX
0.93
LVA
▲ Health spending ▲ Health spending

▼ Spend ▼LE ▼ Life expectancy (LE) ▼ Spend ▼ Av ▼ Avoidable mortality (Av)
0.9 0
0 0.5 1 1.5 2 2.5 0 0.5 1 1.5 2 2.5
Health spending, access and quality of care

health deliver more accessible and better quality care (noting such associations do not
guarantee a causal relationship).
In terms of access, Figure 1.9 shows that universal (or near-universal) coverage of a
core set of services can be achieved even with comparatively low health spending levels –
for example, Turkey and Latvia spend under USD 2 000 per person (less than half the OECD
average) and still achieve universal population coverage.
Still, six of the seven countries with population coverage rates below 95% do spend
relatively less – Mexico, Poland, Chile, Estonia, the Slovak Republic and Hungary (bottom
left quadrant). The one OECD country with high spending levels and lower population
coverage is the United States. Replacing health expenditure per person with spending by
government or compulsory insurance, or spending as a share of GDP, results in very similar
patterns.
In terms of quality of care, Figure 1.10 shows the relationship between health spending
and breast cancer five-year net survival (an indicator reflecting the quality of both
prevention and curative care). There is a clear positive association: among 32 OECD
countries, 16 countries spend more on health and have better net survival (top right
quadrant); and nine countries spend less and have lower net survival (bottom left
quadrant). Six countries have relatively high breast cancer survival despite spending less
than the OECD average (Israel, Italy, Korea, Portugal, New Zealand and Spain). In Ireland,
health spending is almost 25% higher than the OECD average, yet net survival is slightly
below the OECD average.

35
Figure 1.9. Population coverage for a core set of Figure 1.10. Breast cancer survival and health
services and health expenditure expenditure
Low risk factors Average risk factors High risk factors Low risk factors Average risk factors High risk factors
1.1
▼ Spend ▲Cov ▲ Spend ▲Cov ▼ Spend ▲ BCS ▲ Spend ▲ BCS
JPN
LVA FRA NZL AUS USA
ISR SWE
1 1.05 KOR
CAN
CHE
NOR
PRT
CHE
ITA
LTU
1
AUT DEU
SVN
TUR IRL
CZE
0.95
SVK
0.95 EST POL
HUN EST
LVA
CHL
0.9
POL CHL SVK
LTU
USA 0.85
MEX
▲ Health spending ▲ Health spending
▼ Spend ▼ Cov ▼ Health coverage (Cov) ▼ Spend ▼ BCS ▼ Breast cancer survival (BCS)
0.90 0.8
0 0.5 1 1.5 2 2.5 0 0.5 1 1.5 2 2.5
Health spending and number of health professionals

health also have more doctors and nurses (noting such associations do not guarantee a
causal relationship).
There is only a weak positive association between spending on health and number of
doctors (Figure 1.11). Nine countries spend more than the OECD average yet have fewer
doctors (e.g. Canada, Luxembourg, United States); a further six countries spend relatively
little yet have more doctors than average (Czech Republic, Greece, Italy, Lithuania, Portugal,
Spain). However, numbers in Portugal and Greece are over-estimated as they include all
doctors licensed to practise. Such divergences may also reflect differences in remuneration
levels, staff composition and the prominence given to nurse practitioners and other health
professionals (as compared with doctors).
The positive association between health spending and number of nurses is much more
clear-cut (Figure 1.12). Amongst the 36 OECD countries, 16 countries spent more than the
OECD average and also had more nurses per 1 000 people. Likewise, 16 countries spent
relatively little and had fewer nurses. Only two countries spent less than the OECD average
and had more nurses (Slovenia and, to a lesser extent, New Zealand). Two other countries
had comparatively high spending but fewer nurses (Austria and the United Kingdom).

Figure 1.11. Number of doctors and health Figure 1.12. Number of nurses and health
expenditure expenditure
2 2.4
▼ Spend ▲ Dr ▲ Spend ▲ Dr ▼ Spend ▲ Nu ▲ Spend ▲ Nu
GRC
2 NOR
CHE
1.6
AUT
PRT ISL
ISL NOR FIN
DEU CHE 1.6
LTU
ITA IRL LUX
1.2 DEU
SWE
AUS USA
NZL
AUS
1.2 FRA
LVA IRL SVN
DNK
LUX
0.8 GBR CAN
CHL USA PRT GBR
MEX CAN
POL
0.8 AUT
JPN
KOR SVK ESP
TUR
LVA ITA
ISR
0.4
0.4 MEX GRC
CHL
TUR
Health spending
▲ ▲ Health spending
▼ Spend ▼ Dr ▼ Number of doctors (Dr) ▼ Spend ▼ Nu ▼ Number of nurses (Nu)
0 0
0 0.5 1 1.5 2 2.5 0 0.5 1 1.5 2 2.5

37
© OECD 2019
Chapter 2
Measuring what matters for people-

centred health systems
The key objective of a health system is to improve the health of patients and
populations. However, few health systems routinely ask patients about the
outcomes and the experience of their care. This chapter presents patient-reported
outcomes following hip and knee replacement, and breast cancer surgery, as well as
patient-reported experiences of people with mental health problems, from a subset
of OECD countries. Patients who underwent joint replacement surgery reported, on
average, improved function and quality of life with hip replacements generating
slightly higher gains. Women who underwent autologous breast reconstruction
surgery reported, on average, better outcomes than women who underwent implant
reconstruction. Meanwhile results of a 2016 Commonwealth Fund survey of 11
countries suggest that people with a mental health problem report a worse
experience in some aspects of care. Such information is valuable for other health
service users, for clinicians, providers, payers and policymakers.
The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli
authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights,
East Jerusalem and Israeli settlements in the West Bank under the terms of international law.
39
2. MEASURING WHAT MATTERS FOR PEOPLE-CENTRED HEALTH SYSTEMS
Introduction
The primary objective of any health system, service or organisation is to maximise the
health of the individuals and populations they serve, and to do so in an equitable way
within budgetary parameters.
Good health is not just important in its own right. It also promotes personal, social and
economic well-being. Healthy people create healthy communities and contribute towards a
well-functioning, prosperous and more productive society. For example, good health can
enhance a person’s lifetime earnings by up to 25% (OECD, 2017[1]; OECD, 2018[2]).
Yet very few health systems assess their impacts on health and well-being from the
perspective of the people they serve. While the concept of health-related quality of life
(QoL) has existed for almost three decades, it is not measured or reported systematically.
Performance metrics in health tend to focus principally on inputs and outputs. Outcomes
such as life expectancy are important, but they are silent on a range of other things valued
by patients, including pain, function and QoL as well as the experience of care itself. This
means that the picture of health care and health system performance is missing an
essential part.
The patient perspective on the outcomes and experience of their care is essential in
driving continuous quality improvement of health services. It is also increasingly relevant
in overcoming the broader demographic, epidemiological and economic challenges faced
by all health systems. The rise of chronic conditions as the main source of disease burden,
coupled with better but also more expensive technologies to manage them and prolong life,
heightens the need for a more people-centred approach to both policy and practice. But
people-centred health systems remain an empty promise without more information on
how health care and health policy actually affect the lives of individual patients.
This chapter presents the results of a preliminary data collection on patient-reported
outcomes from a sample of OECD countries. The areas covered are joint replacement
surgery and breast cancer surgery. The next section discusses the importance of using
patient-reported data in mental health. These areas of work are part of a broader OECD
initiative – the Patient-Reported Indicator Surveys (PaRIS) – which aims to promote
systematic use of these important metrics in health systems (see https://www.oecd.org/
health/paris.htm).
A people-centred health system needs to measure what matters to patients

People’s assessment of their health, and the outcomes of their care, go beyond
whether they survive a disease or medical intervention. A range of inter-related physical
and mental health domains including pain, mobility, fatigue, anxiety and depression all
contribute to person’s health-related QoL. Patients also value their care experience, which
includes having one’s autonomy respected, feeling invited and empowered to participate in
decisions about one’s care, and if organisational aspects of the care pathway are well co-
ordinated or disjointed and burdensome.

It makes sense to capture this knowledge in a way that is systematic and useful for
decision-making. Yet the health sector has been remiss at measuring the effects of its
activities on outcomes and experiences as reported by patients. Forward thinking provider
organisations, disease registries and in some health systems have been collecting this
information for some conditions or procedures. However, coherent and systematic patient
reporting across the entire range of health system activities and interventions is not yet in
place.
Outputs provide only a partial picture of health system performance

Processes and activities, on the other hand, are routinely collected and reported. While
these are an important part of the overall picture, in isolation they reveal quite little about
performance, quality and value. For example, the average rate of total knee replacement in
OECD countries doubled between 2000 and 2016 (Figure 2.1). Rates also vary up to 5‑fold
between and within countries (OECD, 2014[3]). Are the increased rates and the variation
warranted? Do these operations make a difference to people’s lives, or are some of them
performed unnecessarily? What is the effect of waiting times for knee replacement, and
patient’s age at surgery? Are some patients better off choosing other treatments for their
symptoms?
Figure 2.1. Total knee replacement rates have doubled since 2000
Total knee replacement rates per 100 000 population – adjusted for population ageing – selected countries and OECD average
Australia Austria Finland OECD

Ireland Israel Netherlands United Kingdom
Per 100 000 population
250
200
150
100
50
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Note: OECD is age-adjusted rate of countries submitting data. Countries chosen based on data availability over this period.
StatLink 2 https://doi.org/10.1787/888934014574
Such questions cannot be answered without knowing care outcomes. Case fatality or
hospital re-admission are useful measures but are becoming rare in routine procedures
such as joint replacement. They are also silent on other outcomes valued by these patients
such as reduction in pain, and increase of mobility and function.
We know how medicine treats diseases but what about the patient’s quality of
life?
Traditional outcome measures like survival or mortality will remain useful but cannot
capture more subtle yet important effects. For example, people diagnosed with cancer

41
value survival highly, but therapeutic success entails more than just survival (Abahussin
et al., 2018[4]). Survival and mortality say little about nausea, pain, sleep quality, body
image, sexual function, independence and time spent with loved ones. Also, for some
conditions, mortality and survival are now similar between OECD countries (Figure 2.2),
with little separating the ‘best from the rest’. This hinders continued learning about best
therapeutic approaches, techniques and interventions (Donovan et al., 2016[5]; Hamdy
et al., 2016[6]).
Figure 2.2. Cancer survival is similar between countries

Breast cancer age-standardised five-year survival of patients diagnosed from 2010-2014
Age-standardised five-year net survival (%)

100
90
80
70
60
50
40
30
20
90.2
89.5
89.4
89.1
88.8
88.6
88.5
88.0
87.6
87.6
87.2
86.7
86.6
86.6
86.4
86.2
86.1
86.0
86.0
85.6
85.3
84.8
83.5
82.1
82.0
81.4
78.1
76.9
76.5
75.5
75.5
73.5
10
0
Note: H lines show 95% confidence intervals. 1. Coverage less than 100% of national population. 2. Survival estimates considered less
reliable.
Source: CONCORD programme, London School of Hygiene and Tropical Medicine.
That medicine has become quite successful at treating disease should be celebrated.
However, continual improvement must include assessment of the impact treatments have
on people’s lives. This makes outcomes valued by patients a key indicator of success. Men
diagnosed with prostate cancer are now very likely to survive this condition. Beyond
survival they also highly value preserving erectile function and avoiding incontinence (Nag
et al., 2018[7]) – outcomes of significant interest to patients, providers as well as
policymakers.
A good care experience contributes to better outcomes and is also an end in

itself
In addition to outcomes, how people are treated also matters. This includes being
treated with respect and compassion and being supported, listened to and involved in
decision-making. It also means that care is better integrated across teams who
communicate well with each other and with the patient.
A positive care experience is a strong signal of quality care and is instrumental in
outcomes achieved, especially for those who manage multiple chronic conditions (Stein
et al., 2014[8]; Trzeciak et al., 2016[9]; Luxford, Safran and Delbanco, 2011[10]). In mental
health, for example, a positive care experience influences the relationship with the care
team, manifesting in better communication, therapeutic continuity, adherence and health
outcomes (Wong et al., 2019[11]). But it is also an important end in itself. All patients expect

and deserve to be treated with respect. In some sectors, such as palliative care, being cared
for with compassion and dignity are among the most important components of care.
Yet despite considerable progress in some specific cases, the care experience is not
captured systematically. This needs to change, given the growing importance of this
dimension of service delivery.
Shared decision making requires patient-reporting

In the clinical setting, measuring patient-reported metrics helps to focus the health
care interaction on the needs of the individual. The discussion moves from ‘what’s the
matter with you?’ to ‘what matters to you?’ – a critical first step in shared decision making, a
core principle of people-centred care. Aggregated patient-reported outcomes can inform
care decisions and help choose the right therapeutic option where various interventions
(including ‘watchful waiting’) are available (Veroff, Marr and Wennberg, 2013[12]). People
see what the most likely outcomes of an intervention may be and can decide accordingly.
Regular reporting by patients throughout their care journey adds structure and rigour
to assessment, decision-making and action. Care can be better tailored to individual needs,
and enables a rapid and accurate response to clinical deterioration. For example, reporting
of symptoms by patients during chemotherapy has been found to significantly prolong
survival and reduce hospitalisation (Basch, 2017[13]; Basch et al., 2017[14]).
Knowledge derived from patient-reported data can be used to develop decision aids
and update clinical practice guidelines. It also informs providers on how their work affects
patient health and well-being. Patient-reported outcome measures, for example, provide a
way to measure clinical progress more objectively. They can complement other metrics to
provide a fuller assessment of performance of therapies and services. If implemented well,
benchmarking and even public reporting can be a powerful driver of quality improvement
(Greenhalgh et al., 2017[15]).
Data generated by patients can also contribute towards assessing the performance of
medical products, combination therapies, care pathways, health services and the health
system as a whole. Combined with other data, these can furnish researchers, regulators,
health technology agencies, payers, researchers and policy makers with the knowledge to
make more informed decisions to maximise health system performance, and meet the
expectations of patients, citizens and communities (Calvert, O’Connor and Basch, 2019[16]).
Patient-reported measures are robust and reliable

The ability to elicit information from individuals on their health status, quality of life
and care experience is now decades old. The available instruments and surveys have
undergone rigorous psychometric testing and statistical validation, with results published
in the peer-reviewed literature. The field is mature and evidence supports that these
instruments reliably measure what is intended (Black, 2013[17]). Box 2.1 outlines the
different types of patient-reported outcome and experience measures (PROMs and PREMs)
as well as some of the technical aspects of how these are collected, interpreted and used.
In the end, no single data source can provide information for a complete assessment of
how a highly complex, adaptive health system performs. Patient-reported data need to be
interpreted in the context of other metrics on health system activity and performance.
They are not meant to supplant but to complement existing data that are collected in an
effort to avoid tunnel vision and generate a more complete picture of performance for all
involved: patients, providers, regulators and policy makers. In order for patient-reported

43
Box 2.1. Measuring patient-reported outcomes and experiences of care

Instruments to elicit information from patients on self-reported health status, outcomes and experiences
of care typically comprise questionnaires of varying length and format. These are administered in a range of
ways (verbally, electronically or on paper). The two main categories of patient-reported outcome measures
(PROMs) are condition-specific PROM instruments and health-related Quality of Life (QoL) instruments –
commonly termed ‘generic’ PROMs.
Condition-specific PROMs
These are designed specifically for a condition (e.g. osteoarthritis) or a procedure (e.g. joint replacement).
These PROMs are tailored to the symptoms of a specific condition, or those that a specific procedure tries to
address. As such their advantage is sensitivity and specificity. Their key limitation is a lack of
generalisability – that is, their results cannot be directly compared with results from instruments designed
for other conditions or procedures, unless validated mapping algorithms (‘crosswalks’) exist to convert
scores between one and the other.
Health-related QoL instruments (‘generic’ PROMs)
‘Generic’ PROMs instruments attempt to capture a broader range of physical and psychosocial domains
that are considered important determinants of health-related QoL. Their advantage is that they can be
compared across different conditions, procedures and interventions. For this reason they are often used in
cost-utility analysis and health technology assessment (HTA).
Patient-reported experience measures (PREMs)
The patient experience is also measured using surveys or questionnaires. These can be administered in
various ways and a number of approaches and questions have been developed. Questions can be tailored to
a certain setting (e.g. primary, hospital, long-term care) or assess a specific aspect of care (e.g. continuity,
autonomy, information provision). PREMs are now sophisticated and anchored to objective events, having
moved well beyond the more subjective patient ‘satisfaction’ surveys of the past. They elicit scaled data
across a range of dimensions including accessibility, communication, continuity and confidence. These
data are now used to inform assessment and international comparisons of health systems (Schneider W,
2017[18]).
Collecting and using patient-reported data
A range of factors influence the outcomes of care as reported by patients. These factors include behaviour,
adherence, age and comorbidities. But more traditional outcome measures such as readmission and
mortality are subject to the same confounding variables. All data, whether patient-reported or not, have
limitations and should be interpreted with the necessary caution. Like any outcome data that are used for
benchmarking, confounders for patient-reported indicators should usually be adjusted in order to enable
meaningful comparisons (Nuttall, Parkin and Devlin, 2013[19]).
measures to fulfil their promise in service provision, research and policy, standardisation
of methods for data collection, analysis and reporting are essential. This relies heavily on
international collaboration (Calvert, O’Connor and Basch, 2019[16]).
Joint replacement rates are rising but are patients reporting improvement?
Each year, over 2.2 million people undergo an elective hip or knee replacement in OECD
countries. Knee replacement rates have doubled since the year 2000 (Figure 2.1), while hip
replacements have increased by 30%. Inter- and intra-country variation in rates can be as
high as 5-fold (OECD, 2014[3]).
Patients typically undergo these procedures to manage symptoms of osteoarthritis
such as pain and loss of mobility and function, which have a considerable impact on
health-related QoL. Both procedures are invasive and, like all surgery, involve a degree of
risk. They require a long period of rehabilitation. They are also expensive. In Australia, for
example, they account for over 2% of total health expenditure.1

Given that alternative non-surgical ways of managing hip and knee pain exist
(physical therapy, exercise and medication) patients should be able to base their decision to
proceed with surgery on the expected outcomes including pain, mobility and capacity to
perform daily activities following a period of recovery. Payers should expect that the
procedures represent value compared to the alternatives.
The orthopaedic community has been among the most active in encouraging the
collection of patient-reported data. Nevertheless, national-level reporting is the exception.
Most patient-reported data collections are part of regional and local programmes, or
voluntary registries covering a subset of a country’s providers and hospitals.
A range of instruments measuring dimensions such as pain, function and QoL are in
use around the world. Questionnaires are typically completed by the patient pre-surgery
and then at a specified time point after the operation (usually 6 or 12 months). The
numerical difference between the pre-operative and post-operative scores is the key value
of interest.
The OECD has been working with a range of stakeholders and experts, including
patients and clinicians, to collect PROM data internationally. Ten programmes across eight
countries contributed to a recent pilot data collection. These included national initiatives
(England, Netherlands, Sweden), regional (Canada – Alberta and Manitoba, Switzerland –
Geneva), sub-national registries (the Australian Clinical Outcomes Registry – ACORN –
which collects data from providers in two States) and single hospitals (Coxa hospital,
Finland;2 the Galeazzi Institute Italy). Various PROM instruments are used among the
contributing programmes, and the post-operative data were collected at either 6 or
12 months.
Adult patients with a diagnosis of osteoarthritis3 who underwent a unilateral, primary
elective total replacement procedure were included in the data collection. The three most
recent years of data were collected and aggregated to provide one result per participating
programme.
On average, hip replacement patients reported improvement

Hip replacement results derived from the generic instruments (EQ-5D-3L, EQ-5D-5L
and SF12) are presented on a common scale – the EQ-5D-3L index with a United States-
derived valuation (Shaw JW, 2005[20]). The maximum score on the EQ-5D scale, is 1.0
(denoting optimal health-related QoL) while a negative score suggests health-related QoL
rated as worse than death (Box 2.2).
Figure 2.3 presents the average difference between the pre- and post-operative scores4
– i.e. the mean change in QoL – adjusted for patients’ age, sex and pre-operative score
(Box 2.2).5 Results suggest that the average patient in each programme reported
improvement in their health-related QoL following a hip replacement. The average mean
adjusted change across the programmes was +0.23, which equates to approximately 21%
improvement on this index at the respective post-operative time points of 6 or
12 months.6,7,8
The adjusted changes between pre-and post-operative scores derived from condition-
specific instruments (Oxford Hip Score, HOOS-PS)9 are presented in Figure 2.4. These need
to be displayed on separate axes because algorithms to convert scores from one to the other
are not available at present. The Oxford scale ranges from 0 to 48, the HOOS-PS from 0 to
100. In both cases a higher value represents a more desirable outcome.10 Results suggest, on
average, improvement of similar magnitude in all programmes. The average adjusted

45
Figure 2.3. Hip replacement: adjusted mean change between pre- and post-operative EQ-5D-3L
scores (US valuation), 2013-16 (or nearest years)
Adjusted mean change between pre- and post-op score
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
Australia - England* Canada - Netherlands Sweden Canada - Italy - Switzerland - AVERAGE
ACORN* Alberta Manitoba~ Galeazzi^* Geneva~
Note: ^ results converted from SF-12v1 instrument; ~converted from SF-12v2 instrument; *6-month post-op collection - lighter shade blue
(all others are 12 months). H lines show 95% confidence intervals.
Source: PaRIS Hip/Knee Replacement Pilot Data Collection.
mean change (not shown) was +23 on the Oxford scale and +32 on the HOOS-PS scale,
which equates to about 48% and 32% improvement respectively.11 More condition-specific
results are provided in Chapter 6.
Improvements reported following knee replacement were more modest

The adjusted changes between pre-and post-operative knee replacement scores
derived from condition-specific instruments are presented in Figure 2.5 (the scales are the
same as for hip replacement). On average, patients in each programme reported
improvement of similar magnitude. The average adjusted mean change (not shown) was
+17 on the Oxford scale and +22 for KOOS-PS,12 or 36% and 22% improvement respectively
(the corresponding values for hip replacement were 48% and 32%).13
Knee replacement results derived from generic instruments are presented using the
EQ-5D-3L index with US valuation (see Box 2.2). Data derived from EQ-5D-5L and SF-12
scales were converted using validated algorithms (van Hout et al., 2012[21]; Sullivan and
Ghushchyan, 2006[22]; Le, 2013[23]). Figure 2.6 shows the mean changes between pre- and
post-op scores, adjusted for age, sex and pre-operative score (Box 2.2). On average, patients
in each programme reported improvement ranging from +0.08 to +0.22. The average
adjusted mean change across all programmes was +0.18 (about 16% improvement).14 In
comparison, as shown above, the hip replacement equivalent value was +0.23 (21%), a
statistically significant difference at the 95% level.
The EQ-5D results suggest that – all other things being equal – the average 65-year-old
patient undergoing a knee replacement in the contributing programmes gained an
additional (incremental) 3.3 quality adjusted life years (QALYs).15 In other words, the gain

Box 2.2. The common EQ-5D index and data standardisation

Different instruments and measures of health-related QoL are used in the participant programmes and
countries. Here, data derived from the EQ-5D-5L, and the SF-12 version 1 and version 2 instruments were
converted to the EQ-5D-3L scale using validated mapping algorithms (van Hout et al., 2012[21]; Sullivan and
Ghushchyan, 2006[22]; Le, 2013[23]).
The EQ-5D instrument
The EQ-5D health-related QoL instrument comprises questions covering five dimensions: mobility, self-
care, usual activities, pain/discomfort and anxiety/depression. The patient rates each from 1-3 (on the 3L
version) or 1-5 (on the 5L version) with 1 being best and 3 or 5 worst. The output is a five-digit ‘health state’ –
e.g. 11111 (perfect health), 33333 or 55555 (worst possible state for 3L and 5L respectively) and a range of
permutations in between.
The health states are converted to a single index by referring to so-called valuations specific to a
population or country. These valuations have been determined by asking a sample of that population about
how they would rate a particular health state against being in perfect health (1.0) and death (0) using a
method called time trade-off (TTO). The resulting function is called a valuation or value set. Currently, over
a dozen national valuations exist for the 3L version, but fewer have been completed for the newer 5L. The
functions can differ considerably between countries (Zhuo et al., 2018[24]). Some remain above zero, others
decline into negative values at the worst possible health states. This means respondents rated these states
as worse than death, and were willing to trade off time in good health to avoid that health state.
The EQ-5D was designed to generate quality-adjusted life years (QALYs) - a measure that combines
morbidity and mortality and is often used assess the effectiveness of medical interventions. For example,
living in a health state of 0.8 on the index for 10 years equates to 8 QALYs.
The EQ-5D-3L index (US valuation) as the common scale
The EQ-5D-3L index was chosen as the common metric because (a) the majority of countries use this
instrument; (b) algorithms exist to convert – or map – scores from other generic instruments to the
EQ-5D-3L. Score conversions were conducted using patient-level data.
‘Native’ EQ-5D-3L health state valuations (see above) exist for most participation programmes. A single
valuation, rather than a mix of respective native value sets, is preferred because it goes some way to
mitigate cultural, demographic, socio-economic and other confounders of self-reported health status
(Devlin, 2019[25]). It de facto presents results consistent with their underlying health state, and removes the
additional variability created by a country’s unique valuation of these states.
The choice of the US valuation was pragmatic. It was the only ‘end point’ of the available algorithms to
generate EQ-5D-3L scores from the other instruments used by the contributing programmes (van Hout et al.,
2012[21]; Sullivan and Ghushchyan, 2006[22]; Le, 2013[23]).
Standardising results to enhance comparability
To enhance comparability and mitigate the effect of demographic and other variables, results shown
(derived from both generic and condition-specific tools) were adjusted for age, sex as well as the reported
pre-operative PROM score, to a population based on the pooled data of the contributing programmes. Three
age categories and two pre-operative score categories were used. Differences between crude and adjusted
results were small in the majority of cases. Results were not adjusted for co-morbidity or socio-economic
status due to the lack of consistent data.
was the equivalent of 3.3 years with ‘full’ health-related QoL over the expected remainder
of their life compared to the pre-operative status quo (i.e. a ‘no intervention alternative).
The corresponding figure for hip replacement is higher at 4.3 QALYs (Figure 2.7).16 The
difference between the procedures is consistent with existing literature (Konopka et al.,
2018[26]). It should be noted, however, that knee replacement procedures typically have a
longer recovery period than hip replacements. This may explain some of the difference.

47
Figure 2.4. Adjusted mean change between pre- and post-operative Oxford Hip
Score and HOOS-PS scores, 2013-16 (or nearest years)
Oxford Hip Score HOOS-PS
30 40
35
25
30
20
25
15 20
15
10
10
5
5
0 0
Finland - Australia - Canada - Netherlands England* Italy - Galeazzi* Netherlands
Coxa ACORN* Manitoba
Note: *post-op collection at 6 months – lighter shade blue (all others at 12 months); Scales: Oxford 0-48; HOOS-PS 0-100.
H lines show 95% confidence intervals.
Figure 2.5. Adjusted mean change between pre- and post-operative Oxford Knee
Score and KOOS-PS scores, 2013-16 (or nearest years)
Oxford Knee Score KOOS-PS
25 35
30
20
25
15
20
15
10
10
5
5
0 0
Finland-Coxa Australia-ACORN* Netherlands Canada-Manitoba England* Italy - Netherlands Sweden
Galeazzi*
Note: *post-op collection at 6 months – lighter shade BLUE (all others at 12 months); Scales: Oxford 0-48; KOOS-PS
0-100. H lines show 95% confidence intervals.
Results should be interpreted with caution

On average, patients undergoing hip or knee replacement procedures in the
participating programmes reported an improvement in their symptoms and health-related
QoL. This does not mean that all patients improved. In fact, a small but significant
proportion reported no change or a worsening in their symptoms and health-related QoL
for both procedures across the participating programmes. While this may still be a better

Figure 2.6. Knee replacement: adjusted mean change between pre- and post-operative EQ-5D-3L
scores (US valuation), 2013-16 (or nearest years)
0.3
0.25
0.2
0.15
0.1
0.05
0
Australia - Netherlands England* Sweden Canada - Alberta Italy - Galeazzi^* Canada - Switzerland - AVERAGE
ACORN* Manitoba~ Geneva~
Note: ^ results converted from SF-12v1 instrument; ~converted from SF-12v2 instrument; *6-month post-op collection – lighter shade
green (all others are 12 months). H lines show 95% confidence intervals.
Figure 2.7. Both hip and knee replacements generate additional QALYs for patients
Knee replacement Hip replacement
AVERAGE
*Australia - ACORN
Canada - Alberta
*England
Netherlands
Canada - Manitoba~
Sweden
*Italy - Galeazzi^
Switzerland - Geneva~
0 1 2 3 4 5 6
Note: ^ results converted from SF-12v1 instrument; ~converted from SF-12v2 instrument; *6-month post-op collection (all others are 12
months).
outcome compared to the counterfactual (the status quo), receiving no intervention is

unlikely given the availability of other treatment modalities in most health systems.
Results presented here are, in fact, silent on how the outcomes of hip and knee
replacement surgery compare with other, more conservative surgical or non-surgical

49
treatments including exercise therapy and pharmaceuticals. This would require expanding
the study cohort to patients who choose non-surgical therapy for joint pain. The literature
suggests that non-surgical interventions indeed improve joint pain and function in people
suffering from osteoarthritis, although joint replacement (followed by exercise therapy)
results in greater patient-reported improvement (Skou, Bricca and Roos, 2018[27]; Skou
et al., 2018[28]). However, joint replacement is associated with a higher number of serious
adverse events such as infection than non-surgical treatment (Skou et al., 2015[29]).
Although results were standardised for age, sex and pre-operative score, a number of
programme-specific variables limit their comparability. The number of patients differ
considerably in each programme. Some of the contributing programmes collect post-
operative scores at 6 months, others at 12 months. The latter is considered to be the optimal
time for post-operative assessment as full recovery is expected 1 year after surgery. It is
unknown how outcomes change beyond the respective time points when data are collected
post-operatively. Programmes also deploy different modes of collecting data (paper,
electronic, telephone) which is known to influence results. The response rates vary
between programmes. Despite adjustment for pre-operative score, differences in wait
times between countries may also influence results. Finally, results from three
programmes were converted from, EQ-5D-5L and SF-12 to the EQ-5D-3L index (US
valuation), which may bias the final results.
In addition, results have not been adjusted for casemix and co-morbidities because
consistent data were not available across all programs. A range of cultural, demographic
and socio-economic factors influence self-reported health status and will also influence
the comparability of results, even when a common index and valuation are used.
Better information on breast cancer care outcomes helps patients facing difficult
treatment choices
Breast cancer is the most prevalent form of cancer in women worldwide, with about
2.1 million newly diagnosed cases in 2018 accounting for almost 1 in 4 cancer cases among
women (Bray et al., 2018[30]). While an increase in the incidence of breast cancer over the
past decade has been observed, mortality has declined in most OECD countries. Early
diagnosis as well as improved treatments have contributed to this result, with most OECD
countries now having 5-year net survival rates of 80% (see earlier discussion and Figure 2.2).
Although surgery is the preferred local treatment for the majority of early breast
cancer patients, a range treatment options exist when considering the specific approach
for each women’s care. For example, primary systemic treatment with chemotherapy or
hormonal therapy can improve surgical options by reducing tumour size before surgery.
Post-surgical radiation therapy, chemotherapy, and/or hormonal therapy can lower the
risk of recurrence of the cancer.
The three main surgical interventions for breast cancer are:
• Breast conserving therapy (BCT) involves a surgical operation to remove the cancer
while leaving as much of the breast as possible – commonly an option in early-stage
cancer. This is the primary surgical choice for breast cancer, with 60%–80% of newly
diagnosed cancers amenable to breast conservation at diagnosis or after primary
systemic therapy for women in Western Europe (Cardoso et al., 2019[31]).
• Mastectomy involves complete removal of the breast surgically and is often undertaken
when a woman cannot be treated with breast conserving therapy. However, a woman

may prefer a mastectomy over a breast conserving therapy and women at very high risk
of getting a second cancer sometimes have both breasts removed.
• Breast reconstruction may be chosen by women who have had mastectomy of their
breast to rebuild the shape and look of the breast. The two main types of breast
reconstruction are: 1) implant reconstruction surgery which involves the insertion of a
silicone implant after the removal of the woman’s breast tissue; and 2) autologous
reconstruction surgery, which uses tissue from other parts of the woman’s body, such as
her belly, back, thighs, or buttocks to rebuild the breast shape. This form of
reconstruction is generally considered to look more natural and behave more like
natural breast tissue than breast implants.
The choice of treatment and outcomes for women with cancer are influenced by a
number of factors including the size and location of the tumour, biology or type and
characteristic of the tumour, age, general health status, service availability, related health
risks and patient preferences.
As such, the choice of surgical approach can influence a woman’s subsequent quality
of life. Women diagnosed with breast cancer can therefore face difficult decisions when
considering treatment options. While factors such as age, general health status and the size
and location of primary tumour are important to clinical decision making, the preferences
of the patient are also central to the choice of treatment strategy (Cardoso et al., 2019[31]).
Beyond the overarching objective to stay alive, QoL is also a key consideration. In
weighing treatment options, information about the outcomes of other women who have
been in similar circumstances can potentially be of great help in the decision making
process and ongoing reflection of progress during and after treatment and into
survivorship.
The collection and use of PROMs in breast cancer care is growing

Motivated providers and patients across OECD countries are increasingly measuring
patient-reported care outcomes to help inform difficult clinical decisions. The utility of
such measurement is increasingly appreciated. For example, in the Netherlands breast
cancer has been identified as one of the possible priority areas as part of a current national
policy effort to measure patient-reported outcomes systematically and implement ‘value-
based’ care (van Egdom et al., 2019[32]). Nevertheless, a variety of different PROM
instruments are used, making comparability of outcomes more difficult. In addition, the
scale of uptake is still largely localised and isolated to specific initiatives and clinical
champions at specific sites.
In an effort to address this emerging priority, the OECD worked with a group of experts
(including patients, clinicians, policymakers and industry representatives) and
collaborating organisations to understand the current state of the art in breast cancer
PROMS and to explore opportunities for international data collections and comparisons.
These efforts have culminated in a preliminary international data collection involving
10 clinical sites from 7 countries (Flinders Medical Centre, Adelaide, Australia; Charité –
Universitätsmedizin Berlin, Germany; Erasmus Medical Center, Rotterdam, Netherlands;
Capio St Göran Breast Unit, Södersjukhuset Bröstcentrum and Karolinska Univ.sjukhuset
Bröst Endokrin och Sarkom, Stockholm, Sweden; Universitätspital Basel, Basel,
Switzerland; Manchester University Hospitals NHS Foundation Trust, Manchester, UK;
Memorial Sloan Kettering Cancer Center, New York, US and Brigham and Women's
Hospital, Boston, US).

51
The postoperative breast satisfaction scale of the breast conserving therapy and breast
reconstruction modules of the Breast Q tool was used. This is an internationally validated
instrument used to measure breast surgery outcomes reported by patients (Pusic et al.,
2009[33]) (Box 2.3).
The data collection involved women aged 15 years and older who received unilateral
breast conserving therapy or a breast reconstruction following a mastectomy during the
primary treatment of breast cancer. Women undergoing bilateral breast surgery were
excluded, given the possible differential impact this surgery may have on breast
satisfaction.
Box 2.3. Breast Q Postoperative Breast Satisfaction Scales

The Breast Q suite of tools is one of the more widely used amidst the range of instruments currently in use
internationally to measure patient-reported outcomes from breast cancer surgery (Tevis et al., 2018[34]).
The breast satisfaction scales of the Breast Q tools measure body image in terms of a woman’s satisfaction
with her breasts and asks questions regarding how comfortably bras fit and how satisfied a woman is with
her breast area both clothed and unclothed. Postoperative items ask about breast appearance (e.g., size,
symmetry, softness), clothing issues (e.g., how bras fit; being able to wear fitted clothes) and location and
appearance of scars. There are separate modules for lumpectomies, mastectomies and reconstructions,
with each module consisting of multiple separate scales covering such issues as psychosocial wellbeing,
sexual wellbeing, physical wellbeing, satisfaction with breasts and satisfaction with care. There are also
implant-specific items, including the amount of rippling that can be seen or felt.
The scores from each scale of the breast conserving therapy and reconstruction scales, along with the
other Breast Q scales can be transformed to an Equivalent Rasch Transformed Score of 1‑100 to allow direct
comparison between scales.
See http://qportfolio.org/breast-q/breast-cancer/ for more details.
Results suggest higher breast satisfaction outcomes after breast conserving

therapy in some, but not all sites
The crude (unadjusted) outcomes scores at 6-12 months following breast conserving
therapy, breast reconstruction, and the aggregate of the two are provided in Figure 2.8.
Results are from relatively small samples and are not intended to be representative of the
outcomes of breast cancer patients across each country. However, they demonstrate the
capacity for metrics of this kind to be reported internationally.
Crude data from sites that reported scores for breast conserving therapy and
reconstruction suggest that women in most sites may have higher breast satisfaction
outcomes after breast conserving therapy, aligning with conventional wisdom in this area
(for example (Flanagan et al., 2019[35])). However, in some sites women may have higher
satisfaction scores for reconstruction. Further work and more extensive data collection are
needed to validate this observation and consider the generalisability of the data outcomes,
but these early observations may provide some basis for further sharing and learning of
outcomes across sites. For example, follow up beyond 6-12 months may be warranted,
given the timing of outcomes for women can vary as a result of differences in the duration
and impact of the usual treatment pathways for BCT and breast reconstruction.
A number of personal factors can influence a woman’s postoperative satisfaction with
the outcomes of her breast cancer surgery, including age, smoking, obesity, tumour burden,
education level, cultural background and overall satisfaction with breasts and physical
health before surgery. For example, smoking and obesity can impair tissue healing and

Figure 2.8. Crude PROM scores for breast cancer point to variations in surgical outcomes
Breast Conserving Therapy Reconstruction following mastectomy
Mean crude score
100
90
80
70
60
50
40
30
20
n=100
n=113
n=106
n=641
10
n=29
n=46
n=16
n=29
n=50
n=49
n=54
n=13
n=48
n=39
n=24
0
Australia- France-Nantes- Germany- Netherlands- Sweden- Switzerland- UK-Manchester US-Brigham US-Memorial
Flinders Angers Cancer Charité Erasmus Stockholm Basel University University and Women's Sloan Kettering
Medical Centre Centres University Medical Centre Breast Cancer Hospital Hospitals Hospital Cancer Center
Hospital Clinics
Note: Measurement extended beyond 12 months after surgery for sites in both Sweden and Switzerland. The data labels at the base of the
histogram refer to the sample size at each site. H lines show 95% confidence intervals.
Source: PaRIS Breast Cancer PROMS Pilot Data Collection, 2019.
have a negative impact on implant reconstruction results, including aesthetic outcomes

(Kern et al., 2015[36]). These factors are largely outside of the health service’s direct
influence and their impact should ideally be taken into account when comparing the
quality of care across sites. Data were collected from participating sites on key patient
variables, including age, smoking and obesity but limitations on sample size and
incomplete capacity for reporting by all sites prevented risk-adjusting results for the time
being.
Women report slightly more satisfaction following autologous than implant

breast reconstruction
Consolidated crude scores from the participating sites indicate that women are 6%
more satisfied with their breasts after autologous reconstruction surgery than women after
a breast implant (Figure 2.9). This result aligns with existing evidence (Matros et al.,
2015[37]) and can be an important consideration where choice of surgical intervention is
possible.
It follows that the variation in breast satisfaction scores presented in Figure 2.8 may be
influenced, among other factors, by the proportion of women undergoing autologous
reconstruction surgery. Table 2.1 presents the sample size of women and the proportion
undergoing autologous reconstruction reported by each site. The proportion ranges from
100% of women receiving autologous reconstructions (Dutch and Swiss sites) to 0% in the
Swedish site, where all women would have received implant reconstructions. However, it is
likely some sites have not included all women undergoing reconstruction. For example,
data may have been only provided by the plastics surgery unit in some sites and so not
include the implant reconstructions performed by the breast surgeons and vice versa.

53
Figure 2.9. Crude patient-reported outcomes for implants and autologous reconstructions
Self-reported satisfaction with breasts by type of reconstruction surgery, 2017-18 (or nearest years)
Mean crude score

100
90
80
70 66.7
61.2
60
50
40
30
20
10
0
Implant Autologous without implant
Note: Derived from consolidated data from all 11 participating sites.

While no clear relationship between the proportion of women undergoing autologous

reconstruction and the overall crude outcomes scores (Figure 2.8) is apparent, further
consideration of the factors contributing to the observed wide variation across sites may be
warranted, particularly given the conventional wisdom regarding care outcomes. For
example, the role of each site within the broader service arrangements for women with
breast cancer or the representativeness of the sites’ data.
Table 2.1. Total breast reconstructions and the proportion of autologous reconstructions by site
Total breast reconstructions Autologous reconstructions without implant
No. of Women % of total reconstructions
Australia-Flinders Medical Centre 100 57% (57)

Germany-Charité University Hospital 16 19% (3)
Netherlands-Erasmus Medical Centre 29 100% (29)
Sweden-Stockholm Breast Cancer Clinics 49 0% (0)
Switzerland-Basel University Hospital 13 100% (13)
UK-Manchester University Hospitals 48 25% (12)
US-Brigham and Women's Hospital 24 38% (9)
US-Memorial Sloan Kettering Cancer Center 641 24% (153)


Recent use of PROMs indicates that autologous reconstruction may be cost-

effective
Significant variation in treatment pathways and practices persists for women with
breast cancer, including the use of different surgical approaches, even in the face of
established clinical practice guidelines (Cardoso et al., 2019[31]; OECD, 2013[38]). Figure 2.10
presents the rates, setting and mix of breast conserving therapy and mastectomy surgery
across OECD countries. This Figure suggests that different treatment patterns are evident,
even across countries showing a very similar level of cancer incidence. Data need of course
to be interpreted cautiously as patients’ cancer stages, comorbidity and pre-operative
patient performance status may also vary.
Figure 2.10. Breast cancer surgery type and setting (2017) and incidence (2012) per 100 000
women
Mastectomy-Inpatient Mastectomy-Day Cases BCT-Inpatient BCT-Day Cases Breast Cancer Incidence (2012)
Surgical Procedure per 100 000 Women Breast Cancer Incidence per 100 000 Women
300 120
250 100
200 80
150 60
100 40
50 20
0 0

Variation in the treatment patterns can also be affected by a number of other factors.
For example, regional differences in breast reconstruction surgery in Sweden have recently
been attributed to variation in patient information, availability of plastic surgery services
and the involvement of women in decision‐making (Frisell, Lagergren and de Boniface,
2016[39]).
Treatment choices made by patients in consultation with their clinical teams have not
only consequences for survival and QoL, but also financial implications. For example, after
a mastectomy a woman faces the choice of whether to have breast reconstruction (as an
immediate or delayed procedure) or not and if she proceeds with breast reconstructive
surgery, what type of reconstruction she should have. While the outcomes in terms of
survival of having a breast reconstruction or not after a mastectomy are generally

55
comparable (Platt et al., 2015[40]), the choice of reconstruction can lead to different
outcomes that are important to women, such as quality of life or satisfaction with breasts
as well as different costs faced by the women and the health system.
While autologous reconstructions appear to result in better patient outcomes than
implant surgery, they tend to be more complex and expensive, raises questions about value
for money (Scurci et al., 2017[41]). A recent study in the United States compared the Breast
Q scores of patients who had implant and those who underwent autologous
reconstructions and calculated the average additional cost for obtaining 1 year of perfect
breast-related health for a unilateral autologous reconstruction at just under USD 12 000 in
2010, compared with implant reconstruction, with lower additional costs for younger
patients and earlier stage breast cancer (Matros et al., 2015[37]).
Although society’s value for a year of perfect breast-related quality of life is unknown,
a threshold of USD 50 000 to USD 100 000 for a year in perfect overall health is commonly
been used to classify interventions as cost-effective and considered as acceptable for
adoption of new technologies or techniques in OECD countries (Cameron, Ubels and
Norström, 2018[42]). On this basis, further consideration of the relative cost-effectiveness of
autologous reconstructions may be warranted, along with broader economic evaluation of
both BCT and breast reconstruction surgery.
Routine collection of data on outcomes that matter for breast cancer patients is useful
not only for direct patient care but also for system improvement through better
understanding of the impact of different care pathways. They complement traditional
measures such as survival, mortality, complications and readmissions. Bringing measures
of what matters to patients into the equation creates potential to evaluate alternative
modes of treatment both in terms of outcome and value for patients, policy makers and
third party payers (Cardoso et al., 2019[31]).
Existing mental health measures say little about experiences and outcomes of care
Mental health is a vital component of individual well-being as well as social and
economic participation. However, many OECD countries consider that their mental health
care is inadequate. It is estimated that about one in five people experience a mental health
problem in any given year, while every second individual will experience a mental health
problem in their lifetime (Institute for Health Metrics and Evaluation, 2019[43]). The most
common mental health problems are anxiety disorder (5.1% of the population), followed by
depressive disorders (4.5%), and drug and alcohol use disorders (2.9%) (ibid.).
The economic and social costs of mental ill-health are significant. Direct spending on
mental health services was estimated to account for around 13% of total health spending –
or 1.3% of GDP – across EU countries in 2015 (OECD/EU, 2018[44]). But larger costs are also
borne outside of the health system. Lower employment rates and productivity of people
with mental health issues incur economic impact equivalent to 1.6% of GDP in EU
countries; with greater spending on social security programmes, such as disability benefits
or paid sick leave, accounting for a further 1.2% of GDP (OECD/EU, 2018[44]).
Comparable cost estimates have been established in OECD countries beyond the EU. In
Australia, for example, the total costs of mental ill-health amount to 4% of GDP, 45% of
which are indirect costs (Australian Government - National Mental Health Commission,
2016[45]), Similar figures are reported in Canada and Japan (Sado et al., 2013[46]; Sado et al.,
2013[47]; Mental Health Commission of Canada, 2012[48]).

The impact of mental health problems on individuals’ lives, and on societies and
economies, can be addressed through more effective policies and interventions to prevent
and manage them. However, understanding of the impact that mental health care makes
on service users’ lives is still weak; there is a pressing need to measure the effects and
impact of prevention and treatment approaches more consistently and methodically.
Traditional measures say little about the lasting impact that mental health care has on
the patient. For example, inpatient suicide is a critical safety measure which indicates
when something has gone terribly wrong (Figure 2.11), and is one of the limited measures of
care quality that can currently be reported internationally. Thankfully inpatient suicide is
very rare, which means for the vast majority of psychiatric patients we do not have a
meaningful insight into their experience or outcomes of care.
Figure 2.11. Inpatient suicide among patients with a psychiatric disorder, 2015-2017
Age-sex standardised rate per 10 000 patients
25
8.6
20
11.1
15
5.3
6.6
7.7
6.4
10
4.4
6.1
2.7
2.5
2.8
3.5
5
1.5
2.1
1.9
1.7
1.1
0.6
0.6
0.7
0.4
0.3
0.0
Note: H line shows 95% confidence intervals. Three year average except for New Zealand.
Patient-reported measures are a critical tool for improving policy and practice in
mental health care. An example of how patient-reported measures (in this case PREMs) can
shed light on potential problems with mental health care is provided in Box 2.4, which
report survey data on the care experience of people who report having been told by a doctor
that they have a mental health condition, compared to those who have not.
Collaboration to enhance patient-reporting in mental health

Given the health and economic impact of mental ill-health, it is important to assess
the quality and outcomes of care in this area. Existing outcome and process indicators –
while very useful in some circumstances – do not provide the entire picture of quality and
performance. This information gap impedes efforts to improve care, practice and policy.
However, patient-reporting in mental health is still at a relatively nascent stage. Data
collection is patchy, and routine reporting and use of the information is far from the norm.
As of 2018, only five of the twelve countries surveyed (Australia, Israel, Netherlands,
Sweden, United Kingdom – England) reported that PROMs and PREMs were collected
regularly in the mental health setting. Only Australia, the Netherlands and England

57
Box 2.4. The Commonwealth Fund International Health Policy Survey of Adults
The Commonwealth Fund 2016 International Health Policy Survey of Adults (The Commonwealth Fund,
2016[49]) was conducted in 11 countries - Australia, Canada, France, Germany, the Netherlands, New
Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States – with a total of 26 863
adults interviewed by phone about their experiences with their country’s health care system, their health
and well-being.
The survey included the question “Have you ever been told by a doctor that you have depression, anxiety or
other mental health problems”. While there are some methodological challenges in using the survey in this
way, including around comparability of response groups and sample sizes, comparing responses across all
the survey questions for respondents who answered ‘yes’ with those who responded ‘no’ to the mental
health question can shed light on how people who manage a mental health condition in the participating
countries experience their health care journey.
Respondents who answered ‘yes’ reported similar experiences to the remaining respondents in some
areas of care. In others, their reported care experience appears to be inferior. In several countries, for
example, people with a mental health problem were significantly more likely to report having received
conflicting information from different health care professionals (Figure 2.12). The differences were most
pronounced in Australia, Sweden and France.
Figure 2.12. People who have been told by a doctor that they have depression, anxiety or
other mental health problems are more likely to report receipt of conflicting information
from health care professionals
People with mental health problem People without mental health problem
%
80
70
60
50
40
30
20
10
0
Note: ‘People with a mental health problem’ are the respondents who answered “yes” to the question “thinking about the past
2 years, when receiving care for a medical problem, was there EVER a time when you received conflicting information from different
doctors or health care professionals?” Data limitations. The number of respondents in the 11 countries ranged from 1 000 (Germany)
to 7 124 (Sweden). Lowest response rates were observed in Norway (10.9%), Sweden (16.9%), and the United States (18.1%) and the
highest were in the New Zealand (31.1%), the Netherlands (32.4%) and Switzerland (46.9%). The sample sizes of respondents who
answered ‘yes’ to the mental health question were therefore small, which is reflected in the large confidence intervals (H refers to
95% confidence intervals). In addition, the mental health survey question does not permit distinguishing between individuals who
were suffering from a mental health problem at the time of the survey, and those who had experienced mental ill-health in the past
but have since recovered. Cultural and linguistic differences in how the question was interpreted could also influence responses.
Results have not been risk-adjusted for co-morbidities and socio-economic status.
Source: OECD analysis based on Commonwealth Fund 2016 International Health Policy Survey (The Commonwealth Fund,
2016[49]).
reported collecting and routinely reporting both. As such, a limited pool of national data
exists that are not readily comparable at an international level.

This needs to change, and the OECD has been working with patients, clinicians and
policymakers and other experts from 13 countries to develop PREM and PROM data
collection standards in mental health to enable international reporting, and foster the
capacity to collect and use this important information in OECD countries.
Conclusion
A fundamental objective of health care is to improve the health and wellbeing of
patients and populations. Yet, collecting information from patients on how successful
health systems are in this endeavour is not the norm. In addition, emerging demographic,
epidemiological and financial challenges are increasing the need to orient health systems
around the needs of people and communities. This will not be possible without knowledge
sourced directly from patients themselves to complement existing information on health
system performance.
Results from preliminary data on patient-reported outcomes were presented in the
areas of hip/knee replacement and breast cancer care, while work is underway in the area
of mental health.
Over 2.2 million patients undergo a hip or a knee replacement each year in OECD
countries. Since 2000, age-adjusted knee replacement rates have doubled in OECD
countries, while hip replacement rates have grown by a third. The international landscape
for collecting outcomes data from people undergoing hip or knee replacement is varied.
Nevertheless, ten programmes from eight OECD countries contributed data reported by
adult patients following an elective hip or knee replacement procedure. Results suggest
that:
• In each country, both hip and knee replacement surgery improved the pain, function and
health-related QoL as reported by patients, with results adjusted for age, sex and pre-
operative score.
• Greater gains were reported by patients who underwent a hip replacement. If performed
at age 65, hip replacement would, on average, generate an additional 4.3 QALYs
compared to of 3.3 QALYs for the average knee replacement (although the longer
recovery period following knee replacement surgery must be noted).
• Inter-country variation was modest, suggesting that methods to collect and analyse the
pilot data were sound.
Public knowledge of these types of results are very important as a way to improve
informed decision-making by patients, and to calibrate patients’ goals and expectations
when deciding to undergo elective procedures. Results also enable policy decisions and
assessing the cost-effectiveness, cost-utility and value from the patient perspective. More
patient-reported data will enable solid, temporal analysis and inter-country comparisons
in the future. It is important that countries harmonise their data collection at national
level.
Breast cancer is the most prevalent form of cancer in women worldwide. While an
increase in the incidence has been observed over the past decade, most OECD countries
display 5-year net survival rates of 80% or higher. A range of surgical interventions can be
deployed to treat breast cancer but relatively little is known about their outcomes valued by
women such as pain, breast satisfaction and QoL. Ten sites spanning 7 countries
participated in a pilot collection of patient-reported outcomes data for women undergoing
surgical breast cancer treatment. The preliminary results from this data collection - which
have not been risk-adjusted - generate the following tentative observations:

59
• Postoperative breast satisfaction of women may vary by type of surgery (whether this be
a mastectomy or breast conserving therapy) and by the site of surgery, with some sites
reporting higher scores for lumpectomies and others higher scores for reconstructions.
This may offer additional opportunities for sharing and learning across sites and
countries.
• Of the women who had a breast reconstruction after a mastectomy, the women who
underwent autologous breast reconstruction surgery reported, on average, slightly better
outcomes to women who underwent implant reconstruction. This aligns with
conventional wisdom, providing women with potentially greater assurance in the use of
such information to help assess treatment options.
• Autologous reconstruction may be a cost-effective alternative to implant surgery, when

the additional costs for an additional year of perfect breast-related health is compared
with broadly accepted cost-effectiveness thresholds.
A number of clinical factors need to be taken into account when considering these
observations and ongoing data collection and analytical refinement is required explore
their veracity. However, these results illustrate how this type of information derived
directly from patients can potentially be very useful for other women when making
difficult decisions and trade-offs on the optimal treatment pathway for their individual
needs and preferences, providers when assessing the ‘success’ of various interventions,
and payers and policymakers when considering the comparative cost-effectiveness and
cost-utility of various treatments.
Mental ill-health exerts a considerable health and economic burden across the world,
but systematic collection of patient-reported outcomes and experiences in mental health is
at a nascent stage. Despite limitations in the data, the 2016 Commonwealth Fund survey of
11 countries suggests that people with a mental health problem report a worse care
experience than those without mental health problems in some aspects of health care,
such as receiving consistent information from providers. The OECD is working with
international stakeholders including patients, clinicians and policymaker to advance
measurement of mental health outcomes and experiences.
Overall, these results demonstrate that presenting valid and comparable results from
patient-reported data at international level is eminently possible. However, capacity within
and among countries must be increased to collect and report these data in a consistent and
harmonised way. OECD will continue to work with countries to promote consistent
collection and reporting of these data, in partnership with national and international
stakeholders including patients and health care professionals.
Notes
1. Based on 45 600 hip replacements and 49 500 knee replacements reported in 2016 and 2017
respectively, at a ‘national efficient price’ (NEP) -- the official price paid by the national payer for
conducting these procedures in the public sector. The 2019-20 NEP is just under AUD 20 000 for
each procedure (https://www.ihpa.gov.au/publications/national-efficient-price-determination-2019-20).
The overall national figure is likely to be higher because approximately half of procedures are
carried out in the private sector where higher prices are typically paid.
2. Coxa hospital has a patient catchment covering an entire region of Finland.
3. With the exception of Galeazzi, which included all principal diagnoses.
4. The value is derived by subtracting the pre-operative score from the post-operative score. A
positive value therefore represents an improvement in QoL.

5. Charts showing the average pre- and post-operative results for each participating programme
are presented in Chapter 6 (Section: Hip and knee surgery).
6. The degree of improvement was statistically significant at the 95% confidence level in all
programmes and in aggregate.
7. The generic and condition-specific scales are not linear – i.e. a change from 0.2 to 0.3 is not
necessarily the same magnitude in terms of health-related QoL than 0.7 to 0.8. The percentage
improvements are provided for illustrative purposes and should be interpreted cautiously.
8. This does not mean that a joint replacement results in greater health gain than other, more
conservative interventions for joint pain, which may be equivalent or even superior in this
regard for some patients and on average. This comparison is beyond the scope of this chapter
(Section: A good care experience contributes to better outcomes and is also an end in itself).
9. HOOS-PS: Hip disability and Osteoarthritis Outcome Score–Physical Function Shortform.
10. An alternative scoring system exists for both instruments where a lower value represents a better
result.
11. See 6 and 7.
12. KOOS-PS: Knee injury and Osteoarthritis Outcome Score-Physical Function Shortform.
13. See 6 and 7.
14. See 6 and 7.
15. As valued by a US population sample (Shaw JW, 2005).
16. The incremental QALYs are derived by multiplying the adjusted mean change by 20.5 years -- the
average life expectancy at age 65 in the countries of the contributing programs , minus one year
to account for recovery and rehabilitation (OECD, 2019[50]).
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63
3. HEALTH STATUS
Trends in life expectancy
Life expectancy by sex and education level
Main causes of mortality
Avoidable mortality (preventable and treatable)
Mortality from circulatory diseases
Cancer incidence and mortality
Chronic disease morbidity
Infant health
Mental health
Self-rated health
The statistical data for Israel are supplied by and under the responsibility of the relevant
Israeli authorities. The use of such data by the OECD is without prejudice to the status of the
Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of
international law.
65
3. HEALTH STATUS
Life expectancy has increased in all OECD countries over the progress in cutting deaths from such circulatory diseases.
last few decades, although gains have slowed in recent Respiratory diseases such as influenza and pneumonia have
years. In 2017, life expectancy at birth was 80.7 years on claimed more lives in recent years – most notably in 2015,
average across OECD countries, over 10 years higher than it but also in the winters of 2012‑13 and 2016‑17. In some
was in 1970 (Figure 3.1). countries, particularly the United States and Canada, the
Japan, Switzerland and Spain lead a large group of 26 OECD opioid crisis has caused more working-age adults to die from
countries in which life expectancy at birth exceeds 80 years. drug-related accidental poisoning.
A second group, including the United States and a number of More broadly, economic recessions and related austerity
central and eastern European countries, has a life measures, as in the 2008 global economic crisis, have been
expectancy between 77 and 80 years. Latvia, Mexico, linked to deteriorating mental health and increased suicide
Lithuania and Hungary have the lowest life expectancy, at rates, but with a less clear-cut impact on overall mortality
less than 76 years in 2017. (Parmar, Stavropoulou and Ioannidis, 2016[3]). What is clear
Among OECD countries, Turkey, Korea and Chile have is that continued gains in longevity should not be taken for
experienced the largest gains since 1970, with increases of granted, with better protection of older people and other at-
24, 20 and 18 years respectively. Stronger health systems risk populations paramount to extending life expectancy.
have contributed to these gains, by offering more accessible Higher national income is generally associated with greater
and higher quality care. Wider determinants of health longevity, particularly at lower income levels. Life
matter too – notably rising incomes, better education and expectancy is also, on average, longer in countries that
improved living environments. Healthier lifestyles, invest more in health systems – although this relationship
influenced by policies within and beyond the health system, tends to be less pronounced in countries with the highest
have also had a major impact (James, Devaux and Sassi, health spending per capita (see Chapter 1 for further
2018[1]). analysis).
In partner countries, life expectancy remains well below the
OECD average except in Costa Rica. Still, levels are
converging rapidly towards the OECD average, with Definition and comparability
considerable gains in longevity since 1970 in India, China,
Brazil, Indonesia, Colombia and Costa Rica. There has been Life expectancy at birth measures how long, on
less progress in the Russian Federation, due mainly to the average, people would live based on a given set of age-
impact of the economic transition in the 1990s and a rise in specific death rates. However, the actual age-specific
risky health behaviours among men. South Africa has also death rates of any particular birth cohort cannot be
experienced slow progress, due mainly to the HIV/AIDS known in advance. If age-specific death rates are
epidemic, although longevity gains over the last decade falling (as has been the case over the past few decades),
have been more rapid. actual life spans will be higher than life expectancy
A closer look at trends in life expectancy at birth shows a calculated with current death rates.
considerable slowdown in gains in recent years. Comparing Data for life expectancy at birth comes from Eurostat
the last five years (2012-17) with a decade earlier (2002-07), for EU countries, and from national sources elsewhere.
27 OECD countries experienced slower gains in life Life expectancy at birth for the total population is
expectancy (Figure 3.2). This slowdown was most marked in calculated by the OECD Secretariat for all OECD
the United States, France, the Netherlands, Germany and countries, using the unweighted average of life
the United Kingdom. Longevity gains were slower for expectancy of men and women.
women than men in almost all OECD countries.
Indeed, life expectancy fell on average across OECD
countries in 2015 – the first time this has happened since
1970. Nineteen countries recorded a reduction, widely References
attributed to a particularly severe influenza outbreak that
[1] James, C., M. Devaux and F. Sassi (2017), “Inclusive Growth
killed many frail elderly people and other vulnerable groups
and Health”, OECD Health Working Papers, No. 103, OECD
(Figure 3.3). Most of these were European countries, with the Publishing, Paris, https://doi.org/10.1787/93d52bcd-en.
exception of the United States and Israel. The largest
[3] Parmar, D., C. Stavropoulou and J. Ioannidis (2016), “Health
reductions were in Italy (7.2 months) and Germany
Outcomes During the 2008 Financial Crisis in Europe:
(6 months).
Systematic Literature Review”, British Medical Journal, p. 354,
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multifaceted (Raleigh, 2019[2]). Principal among them is [2] Raleigh, V. (2019), “Trends in life expectancy in EU and other
slowing improvements in heart disease and stroke. Rising OECD countries: why are improvements slowing?”, OECD
levels of obesity and diabetes, as well as population ageing, Health Working Papers, No. 108, OECD Publishing, Paris,
have made it difficult for countries to maintain previous https://doi.org/10.1787/223159ab-en.

3. HEALTH STATUS
Figure 3.1. Life expectancy at birth, 1970 and 2017 (or nearest year)
1970 2017
Years
100
84.2
83.6
83.4
83.0
82.7
82.7
82.7
82.6
82.6
82.6
82.5
82.2
82.2
82.0
81.9
81.8
81.7
81.7
81.6
81.5
81.4
81.3
81.2
81.1
81.1
80.7
80.2
80.2
90
79.1
78.6
78.2
78.1
77.9
77.3
76.5
75.9
75.7
75.6
75.4
74.8
74.6
72.6
80
69.4
68.9
63.4
70
60
50
40

Figure 3.2. Slowdown in life expectancy gains, 2012-17 and 2002-07
2002-07 2012-17
Gains in months over the 5-year period
45
35
25
15
-5
-15
1. Three-year average.
Figure 3.3. Change in life expectancy at birth, 2014 to 2015

Change in months
6.0
7
5
3.6
3.6
3.6
2.4
2.4
2.4
2.4
2.4
3
1.2
1.2
1.2
1.2
1
0
0
0
0
-1
-1.0
-1.2
-1.2
-3
-2.4
-2.4
-2.4
-2.4
-2.4
-2.4
-3.6
-3.6
-3.6
-3.6
-5
-4.8
-4.8
-4.8
-4.8
-4.8
-7
-6.0
-7.2
-9


67
3. HEALTH STATUS
Women live longer than men do in all OECD and partner less educated, driven mainly by more deaths from
countries. This gender gap averaged 5.3 years across OECD circulatory diseases and cancer (Murtin et al, 2017[1]).
countries in 2017 – life expectancy at birth for women was Higher smoking rates amongst disadvantaged
83.4 years, compared with 78.1 years for men (Figure 3.4). socioeconomic groups is an important contributor to gaps in
The gender gap in life expectancy, though, has narrowed by life expectancy by education or other measures of
one year since 2000, reflecting more rapid gains in life socioeconomic status. Other risk factors are also more
expectancy among men in most countries. prevalent among disadvantaged groups, notably excessive
In 2017, life expectancy at birth for men in OECD countries alcohol consumption among men, and higher obesity rates
ranged from around 70 years in Latvia and Lithuania to for men and women (see indicators in Chapter 4 on “Risk
81 years or higher in Switzerland, Japan, Iceland and factors for health”).
Norway. For women, life expectancy reached 87.3 years in
Japan, but was less than 80 years in Mexico, Hungary and
Latvia. Definition and comparability
Gender gaps are relatively narrow in Iceland, the
Netherlands, Norway, Sweden, New Zealand, Ireland, the Life expectancy at birth measures how long, on
United Kingdom and Denmark – at less than four years. average, people would live based on a given set of age-
However, there are large gender differences in many central specific death rates. Data on life expectancy by sex
and eastern European countries, most notably in Latvia and comes from Eurostat for EU countries, and from
Lithuania (around ten years), Estonia (around nine years) national sources elsewhere.
and Poland (around eight years). In these countries, gains in For life expectancy by education level, data were
longevity for men over the past few decades have been provided directly to the OECD for Australia, Austria,
much more modest. This is partly due to greater exposure to Belgium, Canada, Chile, France, Iceland, Israel, Latvia,
risk factors among men – particularly greater tobacco use, Mexico, Netherlands, New Zealand, Switzerland,
excessive alcohol consumption and less healthy diets – Turkey and the United Kingdom. Data for the
resulting in more deaths from heart diseases, cancer and remaining European countries were extracted from
other diseases. For partner countries, the gender gap is the Eurostat database. The International Standard
around ten years in the Russian Federation, and just over Classification of Education (ISCED) 2011 is the basis for
seven years in Colombia, Brazil and South Africa. China and defining education levels. The lowest education level –
India have small gender gaps, of about three years. ISCED 0-2 – refers to people who have not completed
Socioeconomic inequalities in life expectancy are also their secondary education. The highest education level
evident in all OECD countries with available data (Figure 3.5). – ISCED 6-8 – refers to people who have completed a
On average among 26 OECD countries, a 30-year-old with tertiary education (a university degree or equivalent).
less than an upper secondary education level can expect to Not all countries have information on education as
live for 5.5 fewer years than a 30-year-old with tertiary part of their deaths statistics. In such cases, data
education (a university degree or equivalent). These linkage to another source (e.g. a census) containing
differences are higher among men, with an average gap of information on education is required. Data
6.9 years, compared with an average gap of 4.0 years among disaggregated by education are only available for a
women. subset of the population for Belgium, the Czech
Socioeconomic inequalities are particularly striking among Republic and Norway. In these countries, the large
men in many central and eastern European countries share of the deceased population with missing
(Slovak Republic, Hungary, Poland, Czech Republic, Latvia), information about their education level can affect the
where the life expectancy gap between men with lower and accuracy of the data.
higher education levels is over ten years. Gaps in life
expectancy by education are relatively small in Turkey,
Canada and Sweden.
More deaths amongst prime-age adults (25-64 years) with References
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life expectancy. Mortality rates are almost four times higher in OECD Countries: Insights from New OECD Estimates”,
for less educated prime-age men, and about twice as high OECD Statistics Working Papers, No. 2017/02, OECD Publishing,
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countries). Differences in mortality rates among older men Health Systems, OECD Publishing, Paris, https://doi.org/
and women, while less marked, remain higher among the 10.1787/3c8385d0-en.

3. HEALTH STATUS
Figure 3.4. Life expectancy at birth by sex, 2017 (or nearest year)
Total Men Women

Years
85
75
84.2
83.6
83.4
83.0
82.7
82.7
82.7
82.6
82.6
82.6
82.5
82.2
82.2
82.0
81.9
81.8
81.7
81.7
81.6
81.5
81.4
81.3
81.2
81.1
81.1
80.7
80.2
80.2
79.1
78.6
78.2
78.1
77.9
77.3
76.5
75.9
75.7
75.6
75.4
74.8
65
74.6
72.6
69.4
68.9
63.4
55

Figure 3.5. Gap in life expectancy at age 30 between highest and lowest education level, by sex, latest available year
Women Men
6.9 Slovak Republic 14.4

6.4 Hungary 12.6
5.1 Poland 12.0
3.0 Czech Republic 11.1
8.0 Latvia1 11.0
5.4 Estonia 8.5
5.1 Israel 7.0
4.0 OECD25 6.9
2.6 France1 6.8
5.1 Denmark 6.5
3.5 Australia1 6.3
2.8 Slovenia 6.2
3.0 Austria1 6.2
2.4 Greece 6.0
4.6 Netherlands 5.8
4.4 Belgium1 5.8
3.5 Finland 5.6
2.8 Portugal 5.6
4.5 Mexico 5.2
3.4 Norway 5.0
3.6 Iceland1 4.9
2.9 Italy 4.5
4.0 United Kingdom1 4.4
2.9 Sweden 4.1
2.6 Canada1 4.0
2.1 Turkey 3.1
10 8 6 4 2 0 0 5 10 15 20
Gap in years Gap in years
1. 2010-12 data. All other data are from 2015-17.


69
3. HEALTH STATUS
Over 10 million people died in 2017 across OECD countries, Looking at other specific causes, Alzheimer’s and other
equivalent to about 800 deaths per 100 000 population dementias accounted for 9% of all deaths, and were a more
(Figure 3.6). All-cause mortality rates ranged from under important cause of death among women. Diabetes
600 deaths per 100 000 in Japan to over 1 100 deaths per represented 3% of all deaths across OECD countries. The
100 000 in Latvia, Hungary and Lithuania (age-standardised main causes of death differ between socio-economic groups,
rates). Among partner countries, mortality rates were with social disparities generally larger for the most
highest in South Africa and the Russian Federation (1 940 avoidable diseases (Mackenbach et al., 2015[2]).
and 1 417 per 100 000 deaths respectively).
Age-standardised mortality rates were 50% higher for men
than women across OECD countries (997 per 100 000 Definition and comparability
population for men, compared with 655 for women). In
Lithuania, Latvia and Hungary there were about 1 500 deaths Mortality rates are based on the number of deaths
per 100 000 men. For women, mortality rates were highest in registered in a country in a year divided by the
Hungary, Chile and Latvia. Among partner countries, male population. Rates have been directly age-standardised
mortality rates were around 2 400 deaths per 100 000 in to the 2010 OECD population (available at http://oe.cd/
South Africa and almost 2 000 in the Russian Federation. mortality) to remove variations arising from differences
These countries also had the highest female mortality rates. in age structures across countries and over time. The
Gender gaps are partly due to greater exposure to risk source is the World Health Organization (WHO)
factors – particularly smoking, alcohol consumption and Mortality Database.
less healthy diets – alongside intrinsic gender differences. Deaths from all causes are classified to ICD-10 codes
Accordingly, men had higher death rates from heart A00-Y89, excluding S00-T98. The classification of
diseases, lung cancers and injuries, among other diseases. causes of death defines groups and subgroups. Groups
Diseases of the circulatory system and cancer are the two are umbrella terms covering diseases that are related
leading causes of death in most countries. This reflects the to each other; subgroups refer to specific diseases. For
epidemiological transition from communicable to non- example, the group diseases of the respiratory system
communicable diseases, which has already taken place in comprises four subgroups: influenza, pneumonia,
high-income countries and is rapidly occurring in many chronic obstructive pulmonary diseases and asthma.
middle-income countries (GBD 2017 Causes of Death Charts are based on this grouping, except for
Collaborators, 2018[1]). Across OECD countries, heart Alzheimer’s and other dementias. These were grouped
attacks, strokes and other circulatory diseases caused about together (Alzheimer’s is classified in Chapter G and
one in three deaths; and one in four deaths were related to other dementias in Chapter F).
cancer in 2017 (Figure 3.7). Population ageing largely
explains the predominance of deaths from circulatory
diseases – with deaths rising steadily from age 50 and above.
Respiratory diseases were also a major cause of death, References
accounting for 10% of deaths across OECD countries. [1] GBD 2017 Causes of Death Collaborators (2018), “Global,
Chronic obstructive respiratory disease (COPD) alone regional, and national age-sex-specific mortality for 282
accounted for 4% of all deaths. Smoking is the main risk causes of death in 195 countries and territories, 1980–2017: a
factor for COPD, but occupational exposure to dusts, fumes systematic analysis for the Global Burden of Disease Study
and chemicals, and air pollution in general are also 2017”, The Lancet, Vol. 392/10159, pp. 1736-1788.
important risk factors. [2] Mackenbach, J. et al. (2015), “Variations in the relation
External causes of death were responsible for 6% of deaths between education and cause-specific mortality in 19
European populations: A test of the ‘fundamental causes’
across OECD countries, particularly road traffic accidents
theory of social inequalities in health”, Social Science and
and suicides. Road traffic accidents are a particularly
Medicine, Vol. 127, pp. 51-62.
important cause of death among young adults, whereas
suicide rates are generally higher among middle-aged and
older people.

3. HEALTH STATUS
Figure 3.6. All-cause mortality rates, by gender, 2017 (or nearest year)
Total Men Women

Age-standardised rates per 100 000 population
2 000
1 800
1 600
1 400
1 200
1 000
800
600
400
1000
1001
1052
1054
1142
1114
1150
1417
1940
200
567
630
642
647
654
659
674
675
678
725
690
701
704
710
727
741
730
746
748
753
763
767
769
777
792
799
801
833
908
916
934
941
949
0

Figure 3.7. Main causes of mortality across OECD countries, 2017 (or nearest year)
Stroke Lung Colorectal

cancer cancer
7%
5% 3% Breast
cancer
Ischaemic (female)
heart Diseases of 2%
diseases circulatory Cancers
11% system 25%
31% Prostate
cancer
1%
All deaths
10 866 115
Diseases of the
respiratory COPD
system 4%
10%
Alzheimer's External
and other causes
dementias
6% Pneumonia
9%
3%
Accidents
Suicide
4%
1%
Note: Other causes of death not shown in the figure represent 15% of all deaths.

71
3. HEALTH STATUS
Indicators of avoidable mortality can provide a general 100 000 population for men, compared with 75 for women).
“starting point” to assess the effectiveness of public health Similarly, mortality rates from treatable causes were about
and health care systems in reducing premature deaths from 40% higher among men than women, with a rate of 87 per
various diseases and injuries. However, further analysis is 100 000 population for men compared with 62 for women.
required to assess more precisely different causes of These gender gaps are explained by higher mortality rates
potentially avoidable deaths and interventions to reduce among men, which are in part linked to different exposure
them. to risk factors such as tobacco smoking (see indicator Main
In 2017, almost 3 million premature deaths across OECD causes of mortality).
countries could have been avoided through better
prevention and health care interventions. This amounts to
over one quarter of all deaths. Of these deaths, about
1.85 million were considered preventable through effective Definition and comparability
primary prevention and other public health measures, and
over 1 million were considered treatable through more Based on the 2019 OECD/Eurostat definitions,
effective and timely health care interventions. preventable mortality is defined as causes of death
that can be mainly avoided through effective public
Some cancers that are preventable through public health
health and primary prevention interventions (i.e.
measures were the main causes of preventable mortality
before the onset of diseases/injuries, to reduce
(32% of all preventable deaths), particularly lung cancer
incidence). Treatable (or amenable) mortality is
(Figure 3.8). Other major causes were external causes of
defined as causes of death that can be mainly avoided
death, such as road accidents and suicide (25%); heart
through timely and effective health care interventions,
attack, stroke and other circulatory diseases (19%); alcohol
including secondary prevention and treatment (i.e.
and drug-related deaths (9%); and some respiratory diseases
after the onset of diseases, to reduce case-fatality).
such as influenza and chronic obstructive pulmonary
disease (8%). The two current lists of preventable and treatable
mortality were adopted by the OECD and Eurostat in
The main treatable cause of mortality is circulatory diseases
2019. The attribution of each cause of death to the
(mainly heart attack and stroke), which accounted for 36% of
preventable or treatable mortality category was based
premature deaths amenable to treatment. Effective, timely
on the criterion of whether it is predominantly
treatment for cancer, such as colorectal and breast cancers,
prevention or health care interventions that can
could have averted a further 26% of all deaths from treatable
reduce it. Causes of death that can be both largely
causes. Diabetes and other diseases of the endocrine system
prevented and also treated once they have occurred
(9%) and respiratory diseases such as pneumonia and
were attributed to the preventable category on the
asthma (9%) are other major causes of premature deaths
rationale that if these diseases are prevented, there
that are amenable to treatment.
would be no need for treatment. In cases when there
The average aged-standardised mortality rate from was no strong evidence of predominance of
preventable causes was 133 deaths per 100 000 people across preventability or treatability (e.g. ischaemic heart
OECD countries. Premature deaths ranged from under 96 per disease, stroke, diabetes), the causes were allocated on
100 000 in Israel, Switzerland, Japan, Italy, Spain and a 50%-50% basis to the two categories to avoid double-
Sweden to over 200 in Latvia, Hungary, Lithuania and counting the same cause of death in both lists. The age
Mexico (Figure 3.9). Higher rates of premature death in these threshold of premature mortality is set at 74 years for
countries were mainly due to much higher mortality from all causes (OECD/Eurostat, 2019[1]).
ischaemic heart disease, accidents and alcohol-related
Data come from the WHO Mortality Database and the
deaths, as well as lung cancer in Hungary.
mortality rates are age-standardised to the OECD 2010
The mortality rates from treatable causes across OECD Standard Population (available at http://oe.cd/mortality).
countries was much lower, at 75 per 100 000 population. It
ranged from less than 50 in Switzerland, Iceland, Norway,
Korea, France and Australia, to over 130 deaths per 100 000
people in Latvia, Mexico, Lithuania and Hungary. Ischaemic
heart diseases, strokes and some types of treatable cancers References
(e.g. colorectal and breast cancers) were the main drivers in [1] OECD/Eurostat (2019), “Avoidable mortality: OECD/Eurostat
Latvia, Lithuania and Hungary, countries with some of the lists of preventable and treatable causes of death”, http://
highest treatable mortality rates. www.oecd.org/health/health-systems/Avoidable-mortality-2019-
Joint-OECD-Eurostat-List-preventable-treatable-causes-of-
Preventable mortality rates were 2.6 times higher among death.pdf.
men than among women across OECD countries (197 per

3. HEALTH STATUS
Figure 3.8. Main causes of avoidable mortality, OECD countries, 2017 (or nearest year)
Preventable causes of mortality Treatable causes of mortality

1 856 450 premature deaths 1 051 184 premature deaths
Others,
Respiratory 7%
system, 8% Others,
20% Cancer,
Alcohol and Cancer, 26%
drugs 32%
effects, 9% Respiratory
system, 9%
Circulatory Diabetes / other

system, endocrine
External causes of diseases, 9% Circulatory system,
19%
death, 25% 36%
Note: The 2019 OECD/Eurostat list of preventable and treatable causes of death classifies specific diseases and injuries as preventable and/or treatable.
For example, lung cancer is classified as preventable; whereas breast and colorectal cancers are classified as treatable.
Source: OECD calculations, based on WHO Mortality Database.
Figure 3.9. Mortality rates from avoidable causes, 2017 (or nearest year)
Mortality from preventable causes Mortality from treatable causes
Israel 72 Switzerland 40
Switzerland 85 Iceland 44
Japan 87 Norway 47
Italy 88 Korea 47
Spain 93 France 48
Sweden 93 Australia 49
Iceland 96 Luxembourg 51
Australia 96 Sweden 51
Norway 98 Japan 51
Netherlands 101 Netherlands 52
Luxembourg 102 Spain 53
France 106 Belgium 54
Ireland 107 Italy 55
Portugal 110 Austria 57
Korea 111 Finland 58
New Zealand 112 Denmark 59
Costa Rica 113 Canada 59
Greece 113 Israel 62
Canada 117 Ireland 65
Austria 118 Germany 66
Belgium 119 New Zealand 66
United Kingdom 119 Slovenia 66
Germany 120 United Kingdom 69
Denmark 125 Portugal 69
Finland 126 Greece 75
Chile 128 OECD36 75
OECD36 133 Chile 78
Slovenia 144 Costa Rica 83
Turkey 145 United States 88
Colombia 147 Czech Republic 95
Czech Republic 150 Colombia 97
Poland 169 Poland 99
United States 175 Estonia 103
Slovak Republic 193 Turkey 113
Estonia 194 Slovak Republic 129
Mexico 212 Hungary 136
Lithuania 245 Lithuania 141
Hungary 253 Mexico 155
Latvia 269 Latvia 157
0 50 100 150 200 250 300 0 50 100 150 200
Age-standardised rate per 100 000 population Age-standardised rate per 100 000 population
Source: OECD calculations, based on WHO Mortality Database.


73
3. HEALTH STATUS
Circulatory diseases – notably heart attack and stroke – Lithuania, at over double the OECD average. Rates are also
remain the main cause of mortality in most OECD countries, high in the partner countries such as South Africa and the
accounting for almost one in three deaths across the OECD. Russian Federation (Figure 3.11).
While mortality rates have declined in most OECD countries Mortality rates from stroke have fallen in all OECD and
over time, population ageing, rising obesity and diabetes partner countries since 2000, with an average reduction of
rates may hamper further reductions (OECD, 2015[1]). 47%. Declines have been slower in the Slovak Republic and
Indeed, slowing improvements in heart disease and stroke Chile, however, at less than 15%. For strokes, as for IHD, a
are one of the principal causes of a slowdown in life reduction in certain risk factors – notably smoking – has
expectancy gains in many countries (Raleigh, 2019[2]). contributed to fewer deaths, alongside improved survival
Heart attacks and other ischaemic heart diseases (IHDs) rates following an acute episode, reflecting better quality of
accounted for 11% of all deaths in OECD countries in 2017. care (see indicators on “Mortality following ischaemic
IHDs are caused by the accumulation of fatty deposits lining stroke” and “Mortality following acute myocardial infarction
the inner wall of a coronary artery, restricting blood flow to (AMI)” in Chapter 6).
the heart. Mortality rates are 80% higher for men than
women across OECD countries, primarily because of a
greater prevalence of risk factors among men, such as
smoking, hypertension and high cholesterol. Definition and comparability
Among OECD countries, central and eastern European
countries have the highest IHD mortality rates, particularly Mortality rates are based on numbers of deaths
in Lithuania where there are 383 deaths per 100 000 people registered in a country in a year divided by the size of
(age-standardised). Rates are also very high in the Russian the corresponding population. The rates have been
Federation. Japan, Korea and France have the lowest rates directly age-standardised to the 2010 OECD population
among OECD countries, at about one quarter of the OECD (available at http://oe.cd/mortality) to remove variations
average and less than a tenth of rates in Lithuania and the arising from differences in age structures across
Russian Federation (Figure 3.10). countries and over time. The source is the WHO
Mortality Database.
Since 2000, IHD mortality rates have declined in nearly all
OECD countries, with an average reduction of 42%. Declines Deaths from ischaemic heart disease are classified to
have been most marked in France, Denmark, the ICD-10 codes I20-I25, and cerebrovascular disease to
Netherlands, Estonia and Norway, where rates fell by over I60-I69.
60%. Mexico is the one country where IHD mortality rates
have increased; this is closely linked to increasing obesity
rates and diabetes prevalence. Survival rates following a
heart attack are also much lower in Mexico than in all other References
OECD countries (see indicator on “Mortality following acute
[1] OECD (2015), Cardiovascular Disease and Diabetes: Policies for
myocardial infarction” in Chapter 6).
Better Health and Quality of Care, OECD Publishing, Paris,
Stroke (or cerebrovascular disease) was the underlying http://dx.doi.org/10.1787/9789264233010-en.
cause of 7% deaths across the OECD in 2017. Disruption of [2] Raleigh, V. (2019), “Trends in life expectancy in EU and other
the blood supply to the brain causes a stroke. As well as OECD countries: Why are improvements slowing?”, OECD
causing many deaths, strokes have a significant disability Health Working Papers, No. 108, OECD Publishing, Paris,
burden. Mortality rates are particularly high in Latvia and https://doi.org/10.1787/223159ab-en.

3. HEALTH STATUS
Figure 3.10. Heart attacks and other ischaemic heart disease mortality, 2017 and change 2000-17 (or nearest year)
2017 Change 2000-17

31 Japan -40
35 Korea -24
38 France -85
43 Netherlands -65
50 Belgium -59
51 Spain -46
51 Portugal -42
58 Denmark -66
58 Luxembourg¹ -47
59 Israel -59
66 Norway -62
66 Switzerland -54
74 South Africa -31
76 Italy -33
77 Australia -56
77 Greece -37
82 Chile -23
82 Slovenia -47
84 United Kingdom -57
86 Canada -49
89 Sweden -52
93 Brazil -14
95 Poland -52
97 Iceland¹ -49
102 Germany -47
110 United States -49
112 Costa Rica -32
115 OECD36 -42
116 Ireland -53
120 New Zealand -41
122 Austria -39
138 Finland -48
160 Turkey
165 Mexico 22
176 Colombia -3
182 Estonia -63
207 Czech Republic -24
286 Hungary -16
291 Slovak Republic -33
321 Latvia -32
381 Russian Federation -26
383 Lithuania -19
450 400 350 300 250 200 150 100 50 0 -100 -80 -60 -40 -20 0 20 40
Age-standardised rates per 100 000 population Change in %
Figure 3.11. Stroke mortality, 2017 and change 2000-17 (or nearest year)
2017 Change 2000-17

32.9 Switzerland -46
34.8 France -43
35.1 Canada -45
35.7 Israel -47
39.4 Luxembourg¹ -64
41.0 Spain -54
41.2 Austria -63
41.4 Norway -56
42.0 Australia -49
43.2 Iceland¹ -52
43.2 United States -39
44.8 Belgium -46
46.1 Japan -53
46.1 Germany -50
46.4 Sweden -50
47.2 United Kingdom -56
48.1 Netherlands -46
50.6 Ireland -52
52.1 Denmark -43
53.3 Costa Rica -34
55.5 Estonia -76
56.1 Korea -66
58.5 Mexico -25
59.5 Finland -43
60.9 New Zealand -34
62.2 Italy -41
63.6 OECD36 -47
71.0 Poland -53
72.3 Colombia -36
72.6 Czech Republic -66
77.8 Slovenia -40
78.2 Portugal -64
81.5 Greece -58
88.8 Brazil -28
93.9 Chile -11
97.2 Turkey 0
99.2 Hungary -55
110.8 Slovak Republic -13
140.7 South Africa -29
141.1 Lithuania -21
203.1 Latvia -36
234.4 Russian Federation -46
250 200 150 100 50 0 0 -20 -40 -60 -80 -100
Age-standardised rates per 100 000 population Change in %

75
3. HEALTH STATUS
Cancer is the second leading cause of mortality in OECD in fat and low in fibre, lack of physical activity, obesity,
countries after circulatory diseases, accounting for 25% of all smoking and alcohol consumption all increase the risk of
deaths in 2017. Further, there was an estimated 7.5 million developing the illness.
newly diagnosed cases of cancer across the OECD. Common Breast cancer is the second most common cause of cancer
cancers are lung cancer (21.5%), colorectal cancer (11%), mortality in women (14.5% of deaths). While incidence rates
breast cancer (14.5% among women) and prostate cancer for breast cancer have increased over the past decade,
(9.4% amongst men). These four represent more than 40% of mortality has declined or stabilised, indicative of earlier
all cancers diagnosed in OECD countries. Mortality rates diagnosis and treatment, and consequently higher survival
from cancer have fallen in all OECD countries since 2000, rates (see indicator on “Breast cancer outcomes” in
although across the OECD the decline has been more modest Chapter 6). Prostate cancer is the third most common cause
than for circulatory diseases. of cancer mortality among men, accounting for just over
Cancer incidence rates vary across OECD countries, from 10% of all cancer-related deaths.
over 400 new cases per 100 000 people in Australia and New
Zealand, to around 200 cases or fewer in Mexico and Chile
(Figure 3.12). Cancer incidence is also comparatively low in
all partner countries. Cross-country variations in incidence Definition and comparability
rates, though, reflect differences not only in new cancers
occurring each year but also differences in national cancer Cancer incidence rates are based on numbers of new
screening policies, quality of cancer surveillance and cases of cancer registered in a country in a year divided
reporting. High rates in Australia and New Zealand are by the population. Differences in the quality of cancer
mainly driven by the high incidence of non-melanoma skin surveillance and reporting across countries may affect
cancer. the comparability of data. Rates have been age-
standardised based on Segi’s world population to
Mortality rates from cancer averaged 201 deaths per 100 000 remove variations arising from differences in age
people across the OECD (Figure 3.13). They were highest in structures across countries and over time. Data come
Hungary, the Slovak Republic and Slovenia (above 240); from the International Agency for Research on Cancer
lowest in Mexico, Turkey and Korea (165 or less). Among (IARC), GLOBOCAN 2018. These data may differ from
partner countries with comparable data, cancer mortality national estimates due to differences in methodology.
rates were also comparatively low in Colombia, Costa Rica The incidence of all cancers is classified to ICD-10
and Brazil. codes C00-C97.
Earlier diagnosis and treatment significantly increase Mortality rates are based on numbers of deaths
cancer survival rates. This partly explains why, for example, registered in a country in a year divided by the size of
Australia and New Zealand have below average mortality the corresponding population. The rates have been
rates despite having the highest rates of cancer incidence. In directly age-standardised to the 2010 OECD population
both countries, five-year net survival from common cancers (available at http://oe.cd/mortality). The source is the
is also above the OECD average (see various indicators on WHO Mortality Database.
survival following cancer in Chapter 6).
Deaths from all cancers are classified to ICD-10 codes
Cancer incidence rates are higher for men than women in all C00-C97. The international comparability of cancer
OECD and partner countries; cancer mortality rates are also mortality data can be affected by differences in
higher for men except in Mexico, Iceland, Indonesia and medical training and practices as well as in death
India. Greater prevalence of risk factors among men – certification across countries.
notably smoking and alcohol consumption – drive much of
this gender gap in cancer incidence and mortality.
Lung cancer is the main cause of death for both men and
women, with smoking the main risk factor. It accounts for
25% of cancer deaths among men and 17% among women
References
(Figure 3.14). Colorectal cancer is a major cause of death for [1] GLOBOCAN (2018), Cancer Today, https://gco.iarc.fr/today/home.
men and women (second main cause for men and third for [2] OECD (2013), Cancer Care: Assuring Quality to Improve Survival,
women, accounting for about 10% of cancer-related deaths OECD Health Policy Studies, OECD Publishing, Paris, https://
for each sex). Apart from age and genetic factors, a diet high doi.org/10.1787/9789264181052-en.

3. HEALTH STATUS
Figure 3.12. All cancer incidence by sex, 2018 (estimated)
Total Men Women

600
500
400
300
468
438
200
374
368
352
346
344
340
338
334
334
319
314
313
311
309
305
302
301
298
297
295
291
286
283
280
272
266
260
258
254
248
248
234
225
222
217
214
100
202
198
196
136
143
179
89
Source: International Agency for Research on Cancer (IARC), GLOBOCAN 2018.

Figure 3.13. Cancer mortality, by sex, 2017 (or nearest year)
Total Men Women

400
350
300
250
200
150
275
243
243
237
236
230
230
227
225
221
219
216
216
210
100
204
201
200
199
198
197
197
196
194
194
190
188
187
185
185
185
181
180
173
172
171
172
165
161
161
156
155
120
50
0
Figure 3.14. Main causes of cancer mortality across OECD countries, by sex, 2017 (or nearest year)
Women Men
Lung 17.3% 1.0% Melanoma of skin Lung

24.8%
1.7% Bladder
1.9% Cervix uteri 1.2% Melanoma of skin
3.3% Leukemia 3.5% Leukemia

Breast 14.5%
3.9% Liver Colorectal 10.7% 3.7% Bladder
. .
4.4% Stomach 5.8% Stomach
Colorectal 11.3%
Prostate 9.4%
4.8% Ovary 5.9% Liver
7.8% 6.4%
Pancreas
Pancreas
Note: Proportion of the sums of cancer-related deaths across OECD countries, by sex.

77
3. HEALTH STATUS
Chronic diseases such as cancer, heart attack and stroke,

chronic respiratory problems and diabetes are not only the Definition and comparability
leading causes of death across OECD countries. They also
represent a major disability burden amongst the living. Data on multiple chronic diseases come from three
Many chronic diseases are preventable, by modifying major different sources: Eurostat’s European Health
risk factors such as smoking, alcohol use, obesity and Interview Survey (EHIS-2) for European countries; the
physical inactivity. Medical Panel Expenditures Survey (MEPS) 2016 for the
United States; and the Canadian Community Health
Almost one third of people aged 15 years and over reported
Survey (CCHS) 2015-16 for Canada. The following
living with two or more chronic conditions, on average
chronic diseases and conditions are available in each
across 27 OECD countries (Figure 3.15). In Germany and
survey:
Finland, this figure rises to almost one in two. Multi-
morbidity is far more common among older age groups – on • EHIS-2: asthma (1), chronic bronchitis/COPD/
average, 58% of adults aged 65 or over reported living with emphysema (2), heart attack and chronic
two or more chronic diseases, and this figure rises to 70% or consequences (3), coronary heart disease (4),
more in Portugal, Poland, Hungary, the Slovak Republic and hypertension (5), stroke and chronic consequences
Germany. This compares with 24% for people aged less than (6), arthrosis, low back disorder (7), neck disorder (8),
65 years reporting two or more chronic conditions. diabetes (9), allergy (10), cirrhosis of the liver (11),
urinary incontinence (12), kidney problems (13) and
Socioeconomic disparities are also large: on average across
depression (14).
OECD countries, 35% of people in the lowest income quintile
report two or more chronic conditions, compared with 24% • MEPS and CCHS: (1) – (6), (9) and (14).
of people in the highest income quintile (Figure 3.16). This As fewer conditions are available for both Canada and
income gradient is largest in Hungary, Slovenia and Latvia. the United States, multi-morbidity prevalence is
Diabetes is a chronic condition with a particularly large mechanically lower for these countries, and thus not
disability burden, causing cardiovascular disease, blindness, comparable with European data.
kidney failure and lower limb amputation. It occurs when Sources and methods used by the International
the body is unable to regulate excessive glucose levels in the Diabetes Federation (IDF) are outlined in the Diabetes
blood. In 2017, about 98 million adults – or 6.4% of the adult Atlas, 8th edition (International Diabetes Federation,
population – were living with diabetes across OECD 2017). The IDF produces estimations based on a variety
countries (Figure 3.17). In addition, a further 39 million of sources that met several criteria for reliability. The
adults were estimated to have undiagnosed diabetes majority were national health surveys and peer-
(International Diabetes Federation, 2017[1]). reviewed articles. Age-standardised rates were
Among OECD countries, diabetes prevalence is highest in calculated using the world population based on the
Mexico, Turkey and the United States, with over 10% of distribution provided by the WHO. Adult population
adults living with diabetes (age-standardised data). For here covers those aged between 20 and 79 with Type 1
partner countries, diabetes prevalence is also high in India or Type 2 diagnosed diabetes.
and China, at around 10%.
Age-standardised diabetes prevalence rates have stabilised
in many OECD countries, especially in western Europe, but
have increased markedly in Turkey and most partner References
countries. Such upward trends are due in part to rising rates
[1] International Diabetes Federation (2017), IDF Diabetes Atlas,
of obesity and physical inactivity, and to their interactions
8th edition, International Diabetes Federation, Brussels.
with population ageing (NCD Risk Factor Collaboration,
2016[2]) [2] NCD Risk Factor Collaboration (2016), “Worldwide trends in
diabetes since 1980: a pooled analysis of 751 population-
Diabetes is much more common among older people, and based studies with 4.4 million participants”, Lancet, Vol. 387,
slightly more men than women have the condition. Diabetes pp. 1513-1530, http://dx.doi.org/10.1016/S0140-6736(16)006
also disproportionately affects those from disadvantaged 18-8.
socio-economic groups. The economic burden of diabetes is
substantial. In OECD countries an estimated USD 572 billion
was spent on treating diabetes and preventing
complications (International Diabetes Federation, 2017[1]).

3. HEALTH STATUS
Figure 3.15. People living with two or more chronic diseases, by age, 2014
Total 15-64 65+
%
80
70
60
50
40
30
20
23.2
23.6
23.7
25.2
25.9
27.0
27.5
27.7
29.2
29.4
30.0
30.3
30.7
30.8
31.3
33.2
33.6
34.5
36.7
37.0
38.5
40.5
40.9
42.2
48.1
49.4
10
12.1
15.6
1. Results not directly comparable with those for other countries, due to differences in the variable definition (8 chronic conditions considered instead of
14), resulting in a downward bias.
Source: EHIS-2 2014 and other national health surveys.
Figure 3.16. People living with two or more chronic diseases, by income level, 2014
Total Lowest quintile Highest quintile

%
80
70
60
50
40
30
20
23.2
23.6
23.7
25.2
25.9
27.0
27.5
27.7
29.2
29.4
30.0
30.3
30.7
30.8
31.3
33.2
33.6
34.5
36.7
37.0
38.5
40.5
40.9
42.2
48.1
10
12.1
15.6
1. Results not directly comparable with those for other countries (see note in Figure 3.15).
Source: EHIS-2 2014 and other national health surveys.
Figure 3.17. Type I and II diabetes prevalence among adults, 2017 (or nearest year)
%
13.1
14
12.1
10.8
10.4
12
9.9
9.7
10
8.8
8.5
8.3
8.1
8.1
7.6
7.4
7.4
7.3
7.3
7.2
8
6.8
6.8
6.7
6.4
6.4
6.3
6.4
6.2
5.9
5.8
5.7
5.6
5.5
5.3
5.3
5.3
5.1
4.9
6
4.8
4.8
4.8
4.6
4.4
4.3
4.3
4.0
3.7
3.3
4
2
0
Source: IDF Diabetes Atlas, 8th Edition, 2017.


79
3. HEALTH STATUS
Infant health
Inadequate living conditions, extreme poverty and 2000, most markedly in Korea. Among partner countries,
socioeconomic factors affect the health of mothers and Indonesia and Colombia have a high share.
newborns. However, effective health systems can greatly
limit the number of infant deaths, particularly by addressing
life-threatening issues during the neonatal period. Around
two-thirds of deaths during the first year of life occur before Definition and comparability
an infant reaches 28 days (neonatal mortality), primarily
from congenital anomalies, prematurity and other The infant mortality rate is the number of deaths of
conditions arising during pregnancy. For deaths beyond children under one year of age per 1 000 live births.
these first critical weeks (post-neonatal mortality), there Some of the international variation in infant mortality
tends to be a greater range of causes – the most common rates may be due to variations in registering practices
being Sudden Infant Death Syndrome (SIDS), birth defects, for very premature infants. While some countries
infections and accidents. register all live births including very small babies with
low odds of survival, several countries apply a
Infant mortality rates are low in most OECD countries, at
minimum threshold of a gestation period of 22 weeks
less than five deaths per 1 000 live births in all countries
(or a birth weight threshold of 500 grammes) for babies
except Mexico, Turkey and Chile (Figure 3.18). Within OECD
to be registered as live births (Euro-Peristat, 2018[2]). To
countries, though, infant mortality rates are often higher
remove this data comparability limitation, data
among indigenous populations and other vulnerable groups
presented in this section are based on a minimum
– as observed in Australia, Canada, New Zealand and the
threshold of 22 weeks’ gestation period (or 500 g birth
United States (Smylie et al., 2010[1]). In partner countries,
weight) for a majority of OECD countries that have
infant mortality remains above 20 deaths per 1 000 live
provided these data. However, the data for ten
births in India, South Africa and Indonesia, and above ten
countries (Australia, Canada, Greece, Ireland, Italy,
deaths in Colombia and Brazil. Infant mortality rates have
Lithuania, Luxembourg, Mexico, Norway and Portugal)
fallen in all OECD and partner countries since 2000, with
continue to be based on all registered live births (i.e.
reductions generally largest in countries with historically
with no minimum threshold of gestation period or
the highest rates.
birthweight), resulting in potential over-estimation.
Despite this progress in reducing infant deaths, the
Low birth weight is defined by WHO as the weight of an
increasing numbers of low birthweight infants are a concern
infant at birth of less than 2 500 g (5.5 pounds)
in some OECD countries. On average, one in 15 babies born
irrespective of the gestational age. This threshold is
in OECD countries (6.5% of all births) weighed less than 2 500
based on epidemiological observations regarding the
grammes at birth in 2017 (Figure 3.19). Low birthweight
increased risk of death to the infant. Despite the
infants have a greater risk of poor health or death, require a
widespread use of this 2 500 g limit for low birth
longer period of hospitalisation after birth, and are more
weight, physiological variations in size occur across
likely to develop significant disabilities later in life. Risk
different countries and population groups, and these
factors for low birthweight include maternal smoking,
need to be taken into account when interpreting
alcohol consumption and poor nutrition during pregnancy,
differences (Euro-Peristat, 2018[2]). The number of low
low body mass index, lower socio-economic status, having
weight births is expressed as a percentage of total live
had in-vitro fertilisation treatment and multiple births, and
births.
a higher maternal age. The increased use of delivery
management techniques such as induction of labour and
caesarean delivery, which have contributed to increased
survival rates of low birthweight infants, may also explain
the rise in their numbers. References
Japan, Greece and Portugal have the greatest share of low [2] Euro-Peristat (2018), European Perinatal Health Report: Core
birthweight infants among OECD countries. There are fewer indicators of the health and care of pregnant women and babies in
low birthweight infants in the Nordic (Iceland, Finland, Europe in 2015.
Sweden, Norway, Denmark) and Baltic (Estonia, Latvia, [1] Smylie, J. et al. (2010), “Indigenous birth outcomes in
Lithuania) countries. In 23 of the 36 OECD countries, the Australia, Canada, New Zealand and the United States – an
proportion of low birthweight infants has increased since overview”, Open Womens Health, Vol. 4, pp. 7-17.

3. HEALTH STATUS
Infant health
Figure 3.18. Infant mortality, 2017 (or nearest year)
Deaths per 1 000 live births

35
32.0
28.8
30
25
21.4
16.8
20
13.2
12.1
15
9.1
8.0
7.9
10
6.6
5.6
4.8
4.5
4.5
4.1
3.9
3.8
3.7
3.6
3.5
3.5
3.5
3.3
3.3
3.1
3.1
3.0
3.0
3.0
3.0
2.8
2.8
2.7
2.7
2.7
2.4
2.3
2.3
2.3
2.3
2.3
2.1
5
1.9
1.8
1.7
1. Three-year average (2015-17).

Figure 3.19. Low birthweight infants, 2017 and change 2000-17 (or nearest year)
3.8 Iceland -3
4.2 Finland -2
4.2 Estonia -2
4.4 Latvia -12
4.5 Sweden 2
4.6 Norway -6
4.9 Lithuania 7
4.9 Denmark -2
5.7 Poland 0
5.7 Ireland 19
5.9 Netherlands -14
6.0 Russian Federation -6
6.0 New Zealand -6
6.0 Mexico -38
6.2 Korea 63
6.3 Luxembourg 7
6.3 Chile 26
6.4 Switzerland 7
6.4 Austria 2
6.5 Canada 16
6.5 Australia 3
6.5 OECD36 5
6.6 Slovenia 14
6.6 Germany 3
6.7 Belgium -4
6.9 United Kingdom -8
7.3 Costa Rica 12
7.4 Italy 10
7.4 Czech Republic 28
7.5 Slovak Republic 12
7.6 France 17
7.7 Israel -8
7.8 Spain 20
8.1 Turkey 3
8.3 United States 9
8.3 Hungary -1
8.5 Brazil 4
8.9 Portugal 25
9.3 Greece 15
9.4 Japan 9
9.5 Colombia 9
11.1 Indonesia 23
12 10 8 6 4 2 0 -60 -40 -20 0 20 40 60 80
% of total live births in 2017 Change 2000-17 in %


81
3. HEALTH STATUS
Mental health
Good mental health is vital for people to be able to lead raising awareness of suicide risks. Finland, where a
healthy, productive lives, but an estimated one in two particularly significant decline in suicide was seen in the
people experience a mental health problem in their lifetime early 1990s, has recently moved away from stand-alone
(OECD, 2015[1]). When people are living with a mental health suicide prevention plans and includes suicide reduction in
problem it can have a significant impact on their daily life, broader mental health strategies, focusing on improving
contributing to worse educational outcomes, higher rates of treatment for mental illness, and implementing a network
unemployment, and poorer physical health. Figure 3.22 for coordinating suicide prevention (OECD/EU, 2018[2]).
shows the impact of peoples’ health on their daily activities
and ability to work; people who reported a mental health
problem were significantly more likely to say that their
health had a negative impact on their daily life. In Norway Definition and comparability
and France, more than 50% of respondents who had been
told by a doctor that they had a mental health problem felt The registration of suicide is a complex procedure,
that their ability to work or daily activities were limited. affected by factors such as how intent is ascertained,
More can be done to help people participate in activities that who is responsible for completing the death certificate,
matter to them, even if they have a mental health problem, and cultural dimensions including stigma. Caution is
including promoting timely access to treatment and therefore needed when comparing rates between
integrating mental health and employment services. countries. Age-standardised mortality rates are based
Without effective treatment or support, mental health on numbers of deaths divided by the size of the
problems can have a devastating effect on people’s lives, corresponding population. The source is the WHO
and can even lead to death by suicide. While there are Mortality Database; suicides are classified under
complex social and cultural reasons affecting suicidal ICD-10 codes X60-X84, Y870.
behaviours, suffering from a mental health problem also Figure 3.22 uses data from the Commonwealth Fund
increases the risk of dying from suicide (OECD/EU, 2018[2]). A 2016 International Health Policy Survey of Adults. It is
higher suicide rate also contributes to a significantly higher possible to identify adults who responded “yes” to
rate of overall mortality for people with serious mental “Have you ever been told by a doctor that you have
disorders, as discussed in Chapter 6. In 2017, there were 11.2 depression, anxiety or other mental health problems”
deaths by suicide per 100 000 population in OECD countries. and track their responses to other survey questions.
Figure 3.20 shows that suicide rates were lowest in Turkey This figure shows the rate of responses to the question
and Greece, where there were fewer than five deaths by “Does your health keep you from working full-time or
suicide per 100 000 population in 2017. Korea and Lithuania limit your ability to do housework or other daily
had the highest suicide rate, with 24.6 and 24.4 deaths per activities?”. Respondents who answered “yes” to this
100 000 population, respectively. The rate of suicide was question are identified as “with a mental health
higher among men than women in all countries; in problem” and those who responded “no” as “no mental
Lithuania, the suicide rate among men was more than health problem”. Respondents identified as “no mental
five times higher than that for women. health problem” may have another health problem.
Suicide rates have decreased in almost all OECD countries, The data have shortcomings, including some low
falling by more than 30% between 1990 and 2017. In some response rates and a limited sample size (see also Box
countries, the declines have been significant, including in 2.4 in Chapter 2). Interpretation of questions may be
Finland, Switzerland and Slovenia, where suicide rates have different across countries; further, it is not known
fallen by more than 40%. Other countries such as Chile and whether respondents were living with a mental health
Korea saw suicide peaks in the past decade followed by a problem at the time of responding, and self-reported
decline in more recent years (Figure 3.21). In Switzerland, prevalence can be affected by stigma around mental
suicide has fallen by 48% since 1990; rates of ‘assisted health problems. The rate at which respondents
suicide’ are rising, mainly in older people, but since 2009 reported having been told they had a mental health
assisted suicides have been excluded from overall suicide problem was fairly consistent with national
data, explaining the sharp decline the year the reporting prevalence estimates except for France, where
changed. Switzerland has taken steps to reduce deaths by respondents were significantly less likely to report a
suicide, such as introducing a suicide prevention action plan mental health problem than other national estimates
in 2016 that included providing fast access to mental health suggest.
support, seeking to reduce stigma around suicide, and

3. HEALTH STATUS
Mental health
Figure 3.20. Suicide rates, 2017 (or nearest year)
Total Men Women

40
30
20
10
Figure 3.21. Trends in suicide, selected OECD countries, 1990-2017 (or nearest year)
Canada Finland Slovenia Chile Greece Korea

Switzerland OECD Netherlands OECD
Age-standardised rates per 100 000 population Age-standardised rates per 100 000 population
35 35
30 30
25 25
20 20
15 15
10 10
5 5
0 0
1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 1990 1993 1996 1999 2002 2005 2008 2011 2014 2017

Figure 3.22. People whose health kept them from working full-time or limited their daily activities, 2016
No mental health problem With a mental health problem

%
60
50
40
30
20
10
0
Source: Commonwealth Fund International Health Policy Survey 2016.


83
3. HEALTH STATUS
Self-rated health
How individuals assess their own health provides a holistic

overview of both physical and mental health. By adding Definition and comparability
such a perspective on quality of life, it complements life
expectancy and mortality indicators that only measure Self-rated health reflects an individual’s overall
survival. Further, despite its subjective nature, self-rated perception of his or her health. Survey respondents are
health has proved to be a good predictor of future health typically asked a question such as: “How is your health
care needs and mortality (Palladino et al., 2016[1]). in general?”. Caution is required in making cross-
country comparisons of self-rated health for at least
Most OECD countries conduct regular health surveys that
three reasons. First, self-rated health is subjective, and
include asking respondents how, in general, they would rate
responses may be systematically different across and
their health. For international comparisons, socio-cultural
within countries because of socio-cultural differences.
differences across countries may complicate cross-country
Second, as self-rated health generally worsens with
comparisons of self-assessed health. Differences in the
age, countries with a greater share of older people are
formulation of survey questions, notably in the survey scale,
likely to have fewer people reporting that they are in
can also affect comparability of responses. Finally, since
good health. Third, there are variations in the question
older people generally report poorer health and more
and answer categories used in survey questions across
chronic diseases than younger people do, countries with a
countries. In particular, the response scale used in the
larger proportion of elderly people are likely to have a lower
United States, Canada, New Zealand, Australia and
proportion of people reporting that they are in good health.
Chile is asymmetrical (skewed on the positive side),
With these limitations in mind, almost 9% of adults consider including the response categories: “excellent, very
themselves to be in poor health, on average across OECD good, good, fair, poor”. In most other OECD countries,
countries (Figure 3.23). This ranges from over 15% in Korea, the response scale is symmetrical, with response
Lithuania, Latvia and Portugal to under 4% in New Zealand, categories: “very good, good, fair, poor, very poor”. This
the United States, Canada, Ireland and Australia. However, difference in response categories may introduce a
the response categories used in OECD countries outside comparative bias to a more positive self-assessment of
Europe and Asia are asymmetrical on the positive side, health in those countries that use an asymmetrical
which introduces a comparative bias to a more positive self- scale.
assessment of health (see the box on “Definition and
Self-rated health by income level is reported for the
comparability”). Korea, Japan and Portugal stand out as
first quintile (lowest 20% of income group) and the fifth
countries with high life expectancy, but relatively poor self-
quintile (highest 20%). Depending on the surveys, the
rated health.
income may relate to either the individual or the
People with lower incomes are generally less positive about household (in which case the income is equivalised to
their health than people on higher incomes, in all OECD take into account the number of people in the
countries (Figure 3.24). Almost 80% of adults in the highest household).
income quintile rate their health as good or very good,
compared with just under 60% of adults in the lowest
income quintile, on average across the OECD. Socio-
economic disparities are particularly marked in Latvia,
Estonia, the Czech Republic and Lithuania, with a References
percentage point gap of 40 or more between adults on low [2] Lumsdaine, R. and A. Exterkate (2013), “How survey design
and high incomes. Differences in smoking, harmful alcohol affects self-assessed health responses in the survey of
use and other risk factors are likely to explain much of this health, ageing and retirement in Europe”, European Economic
disparity in these countries. Socio-economic disparities are Review, Vol. 63, pp. 299-307.
relatively low in New Zealand, Greece, Italy, Australia and [1] Palladino, R. et al. (2016), “Associations between
France, at less than 10 percentage points. multimorbidity, healthcare utilisation and health status:
Self-rated health tends to decline with age. In many evidence from 16 European countries”, Age and Ageing,
Vol. 45, pp. 431-435.
countries, there is a particularly marked decline in how
people rate their health when they reach their mid-forties,
with a further decline after reaching retirement age. Men are
also more likely than women to rate their health as good.

3. HEALTH STATUS
Self-rated health
Figure 3.23. Adults rating their own health as bad or very bad, 2017 (or nearest year)
% of population aged 15 years and over
20
17.0
16.4
18
15.5
15.3
14.6
16
14.1
13.6
14
11.9
11.3
10.9
10.7
10.4
12
9.7
9.4
9.3
8.7
10
8.6
8.4
8.3
8.1
7.5
7.2
7.1
8
6.6
6.6
6.4
5.8
5.7
5.7
6
4.6
4.1
3.7
3.4
3.2
4
2.6
2.3
1. Results for these countries are not directly comparable with those for other countries, due to methodological differences in the survey questionnaire
resulting in a bias towards a more positive self-assessment of health.
Source: OECD Health Statistics 2019 (EU-SILC for European countries).
Figure 3.24. Adults rating their own health as good or very good, by income quintile, 2017 (or nearest year)
Total Highest Income Lowest Income
% of population aged 15 years and over reporting to be in good health

100
90
80
70
60
50
40
30
20
88.5
88.2
87.9
85.2
83.2
80.2
77.4
77.0
76.5
76.1
76.1
74.8
74.4
74.2
74.1
74.0
71.7
71.2
71.0
68.8
68.8
68.1
67.4
67.0
65.4
65.3
62.0
60.6
59.7
58.8
52.5
48.8
46.9
43.7
35.5
29.5
10
0
1. Results for these countries are not directly comparable with those for other countries, due to methodological differences in the survey questionnaire
resulting in a bias towards a more positive self-assessment of health.
Source: OECD Health Statistics 2019 (EU-SILC for European countries).

85
4. RISK FACTORS FOR HEALTH
Smoking among adults
Alcohol consumption among adults
Opioids use
Diet and physical activity among adults
Overweight and obesity among adults
Overweight and obesity among children
Air pollution and extreme temperatures
international law.
87
Smoking is a leading cause of multiple diseases, including Raising taxes on tobacco is one of the most effective ways to
cancers, heart attacks and stroke, and respiratory diseases reduce tobacco use. Tobacco prices in most OECD countries
such as chronic obstructive pulmonary disease. Smoking contain more than 50% of taxes. Health warnings on
among pregnant woman increases the risk of low birth packages, bans on promotional and misleading information,
weight and premature delivery. The WHO estimates that and restricted branding are other key tobacco control
tobacco smoking kills 7 million people in the world every policies. Awareness raising and support for smokers,
year, of which more than 1.2 million deaths are due to including nicotine replacement treatment and smoking
second-hand smoke and 65 000 are children (WHO, 2017[1]). cessation advice, also help reduce smoking.
Of these deaths, just over half took place in four countries –
China, India, the United States, and the Russian Federation.
Over recent decades, smoking caused the largest share of Definition and comparability
overall years of healthy life lost in 15 OECD countries, and
ranked second in further 16 OECD countries (Forouzanfar et The proportion of daily smokers is defined as the
al., 2016[2]) percentage of the population aged 15 years and over
Across OECD countries, 18% of adults smoke tobacco daily who report smoking tobacco every day. Other forms of
(Figure 4.1). Smoking rates range from over 25% in Greece, smokeless tobacco products, such as snuff in Sweden,
Turkey, Hungary and France to below 10% in Mexico and are not taken into account. This indicator is more
Iceland. In key partner countries, rates are very high in representative of the smoking population than the
Indonesia (40%) and the Russian Federation (30%); and 10% average number of cigarettes smoked per day. Most
or less in Costa Rica. Men smoke more than women in all countries report data for the population aged 15 and
countries except Iceland – on average across the OECD, 23% older, but there are some exceptions as highlighted in
of men smoke daily compared with 14% among women. The the data source of the OECD Health Statistics database.
gender gap in smoking rates is comparatively high in Korea Data for differences in daily smoking by education
and Turkey, as well as in Indonesia, China and the Russian level comes from the European Health Interview
Federation. Among men, rates are highest in Indonesia Survey in 2014 in EU countries. The United States and
(76%), the Russian Federation (50%), China (48%) and Turkey Canada reported the data respectively from the
(40%); and below 10% in Costa Rica and Iceland. For women, Medical Expenditure Panel Survey (MEPS) in 2016 and
rates are the highest in Austria, Greece, Chile, France and Canadian Community Health Survey (CCHS)
Hungary (over 20%). Less than 5% of women smoke in China, 2015-2016. The latter reflects only daily cigarette
India, Costa Rica, Korea, Mexico and Indonesia. smoking.
Daily smoking rates have decreased in most OECD countries
over the last decade, from an average of 23% in 2007 to 18%
in 2017 (Figure 4.2). In the Slovak Republic and Austria,
though, smoking rates have risen slightly. Smoking rates References
also increased in Indonesia. Greece reduced smoking rates
[2] Forouzanfar, M. et al. (2016), “Global, regional, and national
the most, followed by Estonia, Iceland and Norway.
comparative risk assessment of 79 behavioural,
People with a lower education level are more likely to smoke environmental and occupational, and metabolic risks or
in all countries except Greece, with an average gap of clusters of risks, 1990–2015: a systematic analysis for the
8 percentage points in 2017 (Figure 4.3). Education gaps are Global Burden of Disease Study 2015”, The Lancet,
largest in Estonia and Hungary (about 16 percentage points), Vol. 388/10053, pp. 1659-1724, http://dx.doi.org/10.1016/
and relatively small in Portugal, Bulgaria, Lithuania, and s0140-6736(16)31679-8.
Turkey (less than 2 percentage points). [1] WHO (2017), WHO report on the global tobacco epidemic, 2017.

Figure 4.1. Adult population smoking daily by sex, 2017 (or nearest year)
Total Men Women

80
70
60
50
40
30
20
10
0

Figure 4.2. Adult population smoking daily, 2007 and 2017 (or nearest years)
2007 2017
39.9
45
40
35
24.3
22.9
30
25
30.3
20
24.1
24.5
27.3
26.5
25.8
25.4
24.7
15
22.7
22.1
20.3
19.9
19.1
19.0
18.9
18.9
18.8
10
18.4
18.0
17.7
17.5
17.2
17.2
17.0
16.9
16.9
16.8
16.8
12.0
13.0
14.5
13.8
12.0
10.5
14.0
12.4
10.1
5
11.2
10.4
8.6
4.7
7.6

Figure 4.3. Difference in daily smoking between highest and lowest education level, 2016 (or nearest year)
Lower educated Higher educated

35
30
25
20
15
10
5
0
Source: EHIS 2014 for Europe; MEPS 2016 for the United States; and CCHS 2015-2016 for Canada.

89
Alcohol use is a leading cause of death and disability implemented new forms of pricing policies, such as
worldwide, particularly in those of working age. It accounted minimum pricing of one alcohol unit in Scotland.
for an estimated 7% of male and 2% of female deaths Advertising regulations exist in most OECD countries, but
worldwide in 2016 (Griswold et al., 2018[1]). High alcohol law enforcement and the forms of media included in these
intake is a major risk factor for heart diseases and stroke, regulations (e.g. printed newspapers, billboards, the internet
liver cirrhosis and certain cancers, but even low and and TV) varies. In Norway, Lithuania and Sweden, for
moderate alcohol consumption increases the long-term risk instance, there are complete bans on TV adverts, including
of these diseases. Alcohol also contributes to more accidents on social media, while other countries set partial
and injuries, violence, homicide, suicide and mental health limitations. Controls on the physical availability, drinking
disorders than any other psychoactive substance, age and hours of sale; and drink-driving rules are other
particularly among young people. commonly used policies (OECD, 2015[1]).
Measured through sales data, overall alcohol consumption
averaged 8.9 litres per person across OECD countries in 2017,
down from 10.2 litres in 2007 (Figure 4.4). Lithuania reported Definition and comparability
the highest consumption (12.3 litres), followed by Austria,
France, the Czech Republic, Luxembourg, Ireland, Latvia and Recorded alcohol consumption is defined as annual
Hungary, all with over 11 litres per person. Turkey, Israel sales of pure alcohol in litres per person aged 15 years
and Mexico have comparatively low consumption levels and over (with some exceptions highlighted in the data
(under 5 litres per person). Among key partners, source of the OECD Health Statistics database). The
consumption was relatively high in the Russian Federation methodology to convert alcohol drinks to pure alcohol
(11.1 litres) and low in Indonesia, India, Costa Rica and may differ across countries. Official statistics do not
Colombia (less than 5 litres). Average consumption fell in 27 include unrecorded alcohol consumption, such as
OECD countries between 2007 and 2017, with the largest home production. In some countries (e.g.
reductions in Israel, Estonia, Greece and Denmark (by 3 litres Luxembourg), national sales do not accurately reflect
or more). Consumption also fell markedly in the Russian actual consumption by residents, since purchases by
Federation (by 7 litres). However, alcohol consumption non-residents may create a significant gap between
increased by more than 1 litre per person in China and India, national sales and consumption. Alcohol consumption
and by over 0.5 litres per person in Chile. in Luxembourg is thus estimated as the mean of
alcohol consumption in France and Germany.
While overall consumption per capita helps assess long-
term trends, it does not identify sub-populations at risk from Alcohol dependence is coded as F10.2 in ICD-10 among
harmful drinking patterns. Heavy drinking and alcohol adults aged over 15 years old during a given calendar
dependence account for an important share of the burden of year. The numerator is the number of adults between
disease. On average across OECD countries, 3.7% of adults 18 and 65 years with a diagnosis of F10.2 during a
were alcohol dependent in 2016 (Figure 4.5). In all countries, calendar year. The denominator is the mid-year
men are more likely to be alcohol dependent, with 6% of resident population over 15 years during the same
men and 1.6% of women alcohol dependent on average. calendar year. The WHO also reports alcohol use
Dependence is most common in Latvia, Hungary, and disorders among people aged 15 years and over as a
Russian Federation (more than 9% of adults). In these three prevalence over 12 months, which includes both
counties, gender gaps are also high, with the share of alcohol alcohol dependence and harmful use of alcohol coded
dependent men about five times higher than for women. as F10.1 in ICD-10.
The share of dependent drinkers does not always correlate

with overall alcohol consumption levels, reflecting
differences in consumption patterns and diagnosis of
alcohol dependence. France, for instance, had the third References
highest alcohol consumption in 2017, yet rates of alcohol [2] Griswold, M. et al. (2018), “Alcohol use and burden for 195
dependence below the OECD average. Conversely, the countries and territories, 1990–2016: a systematic analysis
United States has a high share of alcohol dependence in for the Global Burden of Disease Study 2016”, The Lancet,
2016 (7.7%), but recorded consumption is at the OECD Vol. 392/10152, pp. 1015-1035, http://dx.doi.org/10.1016/
average. S0140-6736(18)31310-2.
Policies addressing harmful alcohol use include broad-based [1] OECD (2015), Tackling Harmful Alcohol Use: Economics and Public
strategies and ones that target heavy drinkers. All OECD Health Policy, OECD Publishing, Paris, https://dx.doi.org/
countries apply taxes to alcoholic beverages, but the level of 10.1787/9789264181069-en.
taxes differs greatly. In addition, some countries have [3] WHO (2018), Global status report on alcohol and health.

Figure 4.4. Recorded alcohol consumption among adults, 2007 and 2017 (or nearest year)
2007 2017
Litres per capita (15 years and over)
20
18
16
14
10.6
10.4
12
12.3
8.9
10
11.8
7.9
11.7
11.6
11.3
7.7
11.2
11.1
11.1
11.2
10.9
7.6
10.7
10.3
7.1
10.1
8
9.7
9.7
5.7
9.4
9.2
9.1
8.9
8.8
8.7
8.6
8.4
8.3
8.1
6
4.5
4.4
7.2
7.1
6.5
3.0
6.3
6.0
4
2.6
1.4
2
3.8
0.3

Figure 4.5. Share of dependent drinkers, by sex, 2016
Total Men Women

%
20
15
10
Source: Global Status Report on Alcohol and Health, WHO 2018.


91
Opioids use
Opioids are a narcotic pain medication that have become the diseases and psychosocial interventions. Many countries
cornerstone therapy for treatment of moderate to severe have also implemented harm minimisation interventions
pain in many high-income countries. In parallel, illicit such as overdose reversal medications, needle and syringe
opioid use for nonmedical purposes has created illegal, programmes and medically supervised consumptions
increasingly commercialised global markets. Canada and centres. Research initiatives to boost innovation in pain
the United States have experienced an opioid crisis in recent relief and opioid use disorders treatments have also been
years, fuelled by growth in the consumption of synthetic launched (OECD, 2019[1]).
opioids such as fentanyl and carfentanil. Problematic opioid
use is also spreading in Australia and some European
countries, due to growing prescription rates (see indicator Definition and comparability
on “Safe primary care – prescribing” in Chapter 6) and the
development of a dynamic illegal drug supply market Availability of analgesic opioid is defined as amounts
(OECD, 2019[1]). that each country's competent national authority
For prescription opioids, whilst there is insufficient access in estimates are needed and used annually, including
many low- and middle-income countries, the reality in reporting of medicines destroyed, losses during
OECD countries is quite different, where the availability of manufacture, etc. This information is verified by the
analgesic opioids has been steadily growing. The United International Narcotics Control Board using data from
States has the highest availability of analgesic opioids export and import notifications. The S-DDD is a
among OECD countries, followed by Germany and Canada, technical unit of measurement. It is not a
while Mexico, Chile and Colombia show the lowest recommended prescription dose. It recognises that no
numbers. The sharpest increases occurred in the 2000s: internationally agreed standard doses exist for opioid
between 2002‐04 and 2005‐07 analgesic opioids availability medicines and therefore provides a rough measure to
grew on average by 59% and over the decade by almost 110%. rank opioid use of countries. Levels of use, expressed
More recently, the growth rate dropped to 5.4% on average in S-DDD per million inhabitants per day, are
between 2011‑13 and 2014‑16. In absolute terms, availability calculated with the following formula: annual use
per person increased the most in Israel, the United Kingdom, divided by 365 days, divided by the population in
Germany; the sharpest falls were in the United States, millions of the country or territory during the year,
Denmark and Luxembourg (Figure 4.6). divided by the defined daily dose (Berterame et al.,
2016[2]). Analgesic opioids include codeine,
Opioid-related deaths is a key indicator that reflects the
dextropropoxyphene, dihydrocodeine, fentanyl,
impact of problematic use of the drug, both of legally
hydrocodone, hydromorphone, morphine,
prescribed drugs and illegal drugs (e.g. heroin). On average
ketobemidone, oxycodone, pethidine, tilidine and
across 25 OECD countries for which data are available, there
trimeperidine. It does not include illicit opioids. Those
were 26 opioid-related deaths per million inhabitants in
data do not directly reflect the consumption of
2016 (Figure 4.7). However, death rates were over five times
analgesic opioids in countries, but the general
higher in the United States (131 opioid-related deaths),
availability for different purposes, of which the largest
followed closely by Canada (120). Opioid-related deaths have
component is for medical use.
increased by about 20% since 2011, with large increases in
the United States, Sweden, Canada, England and Wales, and Opioid-related deaths for European countries are
Lithuania. In the United States, almost 400 000 people died collected and shared with the OECD by the European
from an opioid overdose between 1999 and 2017, with the Monitoring Centre for Drugs and Drug Addiction
opioid crisis contributing to the first decline in life (EMCDDA). This was complemented with data
expectancy observed in over half a century. contributed directly from countries to the OECD using
an adapted version of the EMCDDA’s data
Countries are implementing several strategies to address
questionnaire.
the problematic use of opioids, with comprehensive
approaches across different sectors, covering health, social
services, law enforcement, data systems and research.
Countries have aimed to improve opioid prescribing through
evidence-based clinical guidelines, training, surveillance of References
opioid prescriptions, and regulation of marketing and [2] Berterame, S. et al. (2016), “Use of and barriers to access to
financial relationships with opioid manufacturers. opioid analgesics: a worldwide, regional, and national
Educational materials and awareness interventions have study”, The Lancet, Vol. 387/10028, pp. 1644-1656, http://
been developed for both at-risk patients and the general dx.doi.org/10.1016/S0140-6736(16)00161-6.
public. For patients with opioid use disorder, there has been [1] OECD (2019), Addressing Problematic Opioid Use in OECD
increased coverage for long-term medication-assisted Countries, OECD Health Policy Studies, OECD Publishing,
therapy combined with specialised services for infectious Paris, https://dx.doi.org/10.1787/a18286f0-en.

Opioids use
Figure 4.6. Availability of analgesic opioids, 2011-13 and 2014-16
2011-13 2014-16
S-DDDs per million inhabitants per day
50 000
45 000
40 000
35 000
30 000
25 000
20 000
15 000
10 000
5 000
S-DDD: Defined daily doses for statistical purposes.

Source: INCB 2018.
Figure 4.7. Opioid-related deaths, 2011 and 2016 (or nearest year)
2011 2016
Opioid-related deaths per million inhabitants
140
120
100
80
60
40
20
Note: Canada's data corresponds to 2018.

Source: EMCDDA for European countries and country responses to OECD opioid data questionnaire 2018.

93
A healthy diet is associated with improved health outcomes. men are more likely to be physically active than women in
Adults who follow a diet rich in fruits and vegetables and all 23 OECD countries with comparable data.
low in fat, sugars and salt/sodium are at a lesser risk of
developing one or more cardiovascular diseases and certain
types of cancer (Graf and Cecchini, 2017[1]). Healthy diet
may also reduce the likelihood of being overweight or obese. Definition and comparability
In 2017, inadequate fruit and vegetable consumption led to
an estimated 3.9 million deaths worldwide (Global Burden of Fruit and vegetable consumption are defined as the
Disease Collaborative Network, 2018[2]). proportion of adults who consume at least one fruit or
On average across OECD countries, over half (57%) of all vegetable per day, excluding juice and potatoes.
adults consumed at least one piece of fruit per day in 2017 Estimates for fruit and vegetable consumption are
(Figure 4.8). Values for this metric are highest in Australia, derived from national health surveys and are self-
Spain, New Zealand and Italy (greater than 75%). Conversely, reported (with some differences in reporting periods,
Chile, Finland and Latvia recorded values below 40%. In all see country-specific notes in OECD.Stat on definitions,
countries except Spain, women are more likely to consume sources and methods for further details).
fruit daily. This gender gap in fruit consumption was largest Data for Australia, Korea and New Zealand are derived
in Finland and Austria, with over a 20 percentage point from quantity-type questions. Values for these
difference. countries may therefore be overestimated. Most
The share of populations consuming vegetables daily was countries report data for the population aged 15 years
similar: 60% of adults, on average across the OECD. and over, with some exceptions as highlighted in the
Countries with the highest rate of vegetable consumption data source of the OECD Health Statistics database.
are Australia, Korea, New Zealand and the United States, all The indicator of moderate physical activity is defined
of which recorded values greater than 90% (Figure 4.9). At as completing at least 150 minutes of moderate
the other end of the spectrum, this figure fell below 35% in physical activity per week. Estimates of moderate
Germany and the Netherlands. As with fruit consumption, physical activity are based on self-reports from the
women are more likely than men to eat at least one portion European Health Interview Survey 2014, combining
of vegetables per day (65% of women v 54% of men, on work-related physical activity with leisure-time
average). Daily vegetable consumption was higher among physical activity (bicycling for transportation and
women than men in all countries other than Korea and the sport). Walking for transportation is not included.
United States (where gender differences were minimal).
Physical activity is also important for leading a healthy
lifestyle. Regular physical activity is associated with
significant benefits such as improved bone and functional References
health, and reduced risk of various non-communicable
[2] Global Burden of Disease Collaborative Network (2018), Global
diseases and depression (Warburton and Bredin, 2017[3]).
Burden of Disease Study 2017 (GBD 2017) Results, Seattle,
Advances in technology in areas such as transport, United States: Institute for Health Metrics and Evaluation
communication and entertainment have contributed to (IHME).
declines in physical activity (Graf and Cecchini, 2017[1]).
[1] Graf, S. and M. Cecchini (2017), “Diet, physical activity and
About two in three adults (66%) meet the recommended sedentary behaviours: Analysis of trends, inequalities and
guidelines for moderate physical activity, on average across clustering in selected OECD countries”, OECD Health Working
23 OECD countries (Figure 4.10). Adults are most likely to be Papers No. 100, OECD Publishing, Paris, https://doi.org/
sufficiently active in Sweden, Iceland, Norway and Denmark 10.1787/54464f80-en.
(over 75% of adults). Conversely, less than half of the adult [3] Warburton, D. and S. Bredin (2017), “Health benefits of
population in Italy and Spain engage in the recommended physical activity”, Current Opinion in Cardiology, Vol. 32/5,
amount of moderate physical activity. Other than Denmark, pp. 541-556, http://dx.doi.org/10.1097/hco.0000000000000437.

Figure 4.8. Daily fruit consumption among adults by sex, 2017 (or nearest year)
Total Men Women

100
90
80
70
60
50
94.8
84.0
79.7
75.8
40
73.0
70.9
66.5
65.4
64.3
62.8
60.7
59.7
59.1
58.5
58.4
58.3
57.1
56.2
30
55.1
55.0
54.0
53.9
52.2
52.2
51.6
49.8
48.7
47.9
47.4
47.3
46.8
44.3
43.1
39.8
20
30.0
29.7
10
0

Figure 4.9. Daily vegetable consumption amongst adults by sex, 2017 (or nearest year)
Total Men Women

100
90
80
70
60
99.2
98.9
50
95.4
91.8
78.2
40
72.9
67.7
67.7
65.5
63.0
62.2
61.2
61.2
60.9
60.9
59.7
59.6
57.6
57.5
30
55.9
55.7
55.2
55.0
54.8
54.5
52.2
47.5
46.3
44.1
44.0
44.0
43.3
42.2
41.4
20
34.1
34.0
10
0

Figure 4.10. Moderate weekly physical activity among adults by sex, 2014
Total Men Women

90
80
70
60
50
79.5
79.4
78.3
77.6
40
73.6
73.3
72.7
71.2
70.7
69.8
68.0
67.6
66.5
64.5
63.4
62.6
62.5
61.8
60.8
60.7
60.1
57.1
30
47.2
47.1
20
10
0
Source: Eurostat EHIS 2014.


95
Being overweight, including pre-obesity and obesity, is a Initiative in the United States aims to improve access to
major risk factor for various non-communicable diseases healthy foods in underserved areas. Despite these efforts,
including diabetes, cardiovascular diseases and certain the overweight epidemic has not been reversed,
cancers. High consumption of calories-dense food and highlighting the issue’s complexity (OECD, 2019[3]).
increasingly sedentary lifestyles have contributed to
growing global obesity rates. The rate of growth has been
highest in early adulthood and has affected all population
groups, in particular women and those with lower levels of Definition and comparability
education (Afshin et al., 2017[1]). High body mass index (BMI)
has been estimated to cause 4.7 million deaths worldwide Overweight is defined as abnormal or excessive
(Global Burden of Disease Collaborative Network, 2018[2]) accumulation of fat, which presents a risk to health.
Based on measured data, 58% of adults were overweight or The most frequently used measure is body mass index
obese in 2017 on average across 23 OECD countries with (BMI), which is a single number that evaluates an
comparable data (Figure 4.11). For Chile, Mexico and the individual’s weight in relation to height (weight/
United States this figure exceeds 70%. Conversely, in Japan height2, with weight in kilograms and height in
and Korea, less than 35% of adults were overweight or obese. metres). Based on WHO classifications, adults over age
The remaining 13 OECD countries include self-reported 18 with a BMI greater than or equal to 25 are defined as
data, with rates ranging from 42% in Switzerland to 65% in pre-obese, and those with a BMI greater than or equal
Iceland. These estimates, though, are less reliable and to 30 as obese. Data come from national sources – in a
typically lower than those based on measured data. For both few instances these may differ from data shown in the
measured and self-reported data, men are more likely than OECD 2019 report on obesity, which uses data from the
women to be overweight. WHO Global Health Observatory, with age-
standardised estimates and other methodological
The proportion of overweight adults has been gradually
differences. Overweight includes both pre-obesity and
increasing in most OECD countries since the early 2000s,
obesity. BMI measurements are the same for both
including in countries where rates are relatively low
genders and adults of all ages. Data for BMI can also be
(Figure 4.12). In Japan and Korea, this proportion has
collected using self-reported estimates of height and
increased by 2.1 and 4.2 percentage points, respectively,
weight. BMI estimates based on self-reported data are
between 2000 and 2017. In countries with relatively high
typically lower and less reliable than those based on
rates of adults overweight, this figure ranged from
measured data.
2.3 percentage points in Canada to 11.9 in Chile.
For Figure 4.13, the lowest level of education refers to
Adults with a low level of education are more likely to be
people with less than a high-school diploma, while the
overweight than those with a tertiary education level or
highest refers to people with a university or other
above in all 27 OECD countries examined (Figure 4.13). The
tertiary diploma.
difference in the proportion of overweight adults by
education level was greatest in Luxembourg, Spain and
France, where the gap was greater than 15 percentage
points.
OECD member countries have implemented a suite of References
regulatory and non-regulatory initiatives to reduce [1] Afshin, A. et al. (2017), “Health Effects of Overweight and
overweight population rates. Prominent examples include Obesity in 195 Countries over 25 Years.”, The New England
mass media campaigns to promote the benefits of healthy Journal of Medicine, http://dx.doi.org/10.1056/NEJMoa1614362.
eating; promotion of nutritional education and skills; ‘sin’ [2] Global Burden of Disease Collaborative Network (2018), Global
taxes on energy-dense food and drink items to discourage Burden of Disease Study 2017 (GBD 2017) Results, Seattle,
consumption; food labelling to communicate nutritional United States: Institute for Health Metrics and Evaluation
value; and agreements with the food industry to improve (IHME).
the nutritional value of products. Policymakers are also [3] OECD (2019), The Heavy Burden of Obesity: The Economics of
exploring initiatives that address the social determinants of Prevention, OECD Publishing, Paris, https://doi.org/
being overweight. For example, the Healthy Food Financing 10.1787/67450d67-en.

Figure 4.11. Overweight including obesity among adults by sex, measured and self-reported, 2017 (or nearest year)
Total Men Women OECD36

80
70
60
50
40
74.2
72.5
71.0
67.6
67.6
66.6
65.4
65.2
64.4
64.3
62.3
62.0
60.0
59.1
58.2
58.1
30
55.6
55.0
55.0
54.6
53.3
53.3
53.0
51.5
51.3
51.0
51.0
50.9
49.0
48.2
47.3
46.7
46.0
46.0
41.8
20
33.7
25.9
10
0
Note: Left- and right-hand side estimates utilise measured and self-reported data, respectively. OECD36 average includes both data types.
Figure 4.12. Evolution of overweight including obesity in selected countries, measured, 2000-17 (or nearest year)
United States United Kingdom

Korea Japan France Chile Canada
% of population aged 15 years and over % of population aged 15 years and over
80 80
70 70
60 60
50 50
40 40
30 30
20 20
10 10
0 0
2000 2005 2010 2015 2000 2005 2010 2015
Note: Linear interpolation was used to impute values where data was missing.
Figure 4.13. Difference in overweight including obesity by education level, self-reported, 2014
Lowest education level Highest education level
80
70
60
50
59.8
56.2
53.3
40
48.6
48.5
48.5
48.4
48.3
48.2
48.1
48.0
46.6
45.6
44.9
44.5
44.0
43.2
30
41.0
40.8
40.5
40.0
39.9
39.1
37.7
37.3
35.1
35.1
34.9
20
10
0
Source: EHIS2 and OECD estimates based on national health survey data.

97
Childhood overweight rates, including pre-obesity and Childhood obesity is a complex issue and its causes are
obesity, have been growing worldwide. Environmental multi-faceted. Consequently, the response has been to
factors, lifestyle preferences, genetic makeup and culture all implement a suite of complementary policies involving
can cause children to be overweight. Obese children are at government, community leaders, schools, health
greater risk of developing hypertension and metabolic professionals and industry. Commonly used policies to alter
disorders. Psychologically, obesity can lead to poor self- individual behaviours or the obesogenic environment
esteem, eating disorders and depression. Further, obesity include tightened regulation of advertising of unhealthy
may act as a barrier for participating in educational and foods and drinks targeted at children; improved access to
recreational activities. Childhood obesity is particularly parks and playgrounds; food reformulation policies; and
concerning as it is a strong predictor of obesity in adulthood, price interventions to promote a healthy lifestyle (OECD,
which is linked to diabetes, heart disease and certain types 2019[2]).
of cancer (Bösch et al., 2018[1]; OECD, 2019[2]).
Almost one-third (31%) of children aged 5-9 years living in
OECD countries are overweight (Figure 4.14). In the United
Definition and comparability
States, Italy, New Zealand and Greece this figure exceeds
40%. Conversely, in Japan, Estonia, Lithuania, Switzerland Childhood overweight and obesity rates were
and Latvia, rates are below 25%. The proportion of calculated using body mass index (BMI). BMI is
overweight boys exceeds that of girls in 38 of the 43 OECD calculated by dividing weight in kilograms by height in
and partner countries examined. Countries with the metres squared.
greatest disparity between genders are China, Korea,
A child is considered overweight if their BMI is one
Poland, the Czech Republic and the Slovak Republic (above a
standard deviation above the median, according to the
10 percentage point difference). The gap between boys and
World Health Organization child growth standards. A
girls is small in Portugal and the United Kingdom (less than
child whose BMI is two standard deviations above the
1 percentage point).
median is classified as obese.
The rate of overweight children increased from 20.5% to
31.4% across 35 OECD countries between 1990 and 2016
(Figure 4.15). Only in Belgium did this rate fall, albeit
marginally. Growth was greatest in Hungary, Poland,
Turkey, Slovenia and the Slovak Republic whose rates References
increased by more than 100%. At the other end of the [1] Bösch, S. et al. (2018), Taking Action on Childhood Obesity, World
spectrum, Sweden, Israel, Iceland, Japan and Denmark Health Organization & World Obesity Federation, Geneva,
recorded growth rates at or below 25%. Similar trends were https://apps.who.int/iris/bitstream/handle/10665/274792/WHO-
found in non-OECD countries. Growth in these countries NMH-PND-ECHO-18.1-eng.pdf?ua=1.
was typically higher, which reflects their relatively low [2] OECD (2019), The Heavy Burden of Obesity: The Economics of
starting value. For example, the proportion of overweight Prevention, Organisation for Economic Cooperation and
and obese children in Indonesia, South Africa and India Development, Paris, https://doi.org/10.1787/67450d67-en.
grew by over 600%; however, their starting values were just [3] OECD (2017), Obesity Update, OECD, Paris, https://
2.4%, 2.3%, and 1%, respectively. www.oecd.org/els/health-systems/Obesity-Update-2017.pdf.

Figure 4.14. Overweight including obesity among 5-9 year olds by sex, 2016
Total Boys Girls

%
60
50
40
30
43.0
42.0
41.8
41.0
20
38.3
37.9
37.7
37.7
37.1
36.0
34.6
34.6
33.9
33.9
32.7
32.5
32.4
32.4
31.8
31.4
31.4
30.9
30.5
30.0
29.5
29.5
29.2
28.7
28.1
27.6
26.9
26.2
25.7
25.6
25.5
25.2
23.5
23.0
22.9
22.9
22.8
10
17.6
17.5
8.0
Source: WHO Global Health Observatory.

Figure 4.15. Change in overweight including obesity among 5-9 year olds, 1990-2016
1990 2016
%
50
43.0
42.0
41.8
41.0
38.3
37.9
37.7
37.7
37.1
36.0
40
34.6
34.6
33.9
33.9
32.7
32.5
32.4
32.4
31.8
31.4
31.4
30.9
30.5
30.0
29.5
29.5
29.2
28.7
28.1
27.6
26.9
26.2
25.7
25.6
25.5
25.2
30
23.5
23.0
22.9
22.9
22.8
17.6
17.5
20
8.0
10
Source: WHO Global Health Observatory.


99
Climate change is one of the biggest challenges of present vehicles and industries would lower ambient air pollution.
and future generations. It is linked to different types of Health systems can also contribute, by preparing for new
environment distress, including air pollution and extreme diseases that can develop with new climate conditions;
temperatures. Air pollution is already a major cause of death promoting consumption of sustainably grown and sourced
and disability today, and its future impact is likely to be even food; and reducing the carbon footprint of health facilities.
greater without adequate policy action. Projections have In addition, health providers can reduce the environmental
estimated that outdoor air pollution may cause 6 to 9 million footprint in hospitals and in nursing homes by encouraging
premature deaths a year worldwide by 2060, and cost 1% of healthier food consumption, waste reduction and efficient
global GDP as a result of sick days, medical bills and reduced energy use (Landrigan et al., 2018[2]; OECD, 2017[3]).
agricultural output (OECD, 2015[1]).
Among OECD countries, ambient (outdoor) and household
(indoor) air pollution caused about 40 deaths per 100 000
people in 2016 (Figure 4.16). Death rates ranged from over 80 Definition and comparability
deaths per 100 000 in Latvia, Hungary and Lithuania, to 15
deaths or less in New Zealand and Canada. In partner Household (indoor) air pollution results from polluting
countries, death rates were particularly high in India and fuel used mainly for cooking. Ambient (outdoor) air
China (around 140 deaths per 100 000 people), and also pollution results from emissions from industrial
higher than most OECD countries in the Russian Federation activity, households, cars and trucks, which are
and Indonesia. complex mixtures of air pollutants, many of which are
harmful to health. Of all of these pollutants, fine
Extreme temperatures are also a consequence of climate
particulate matter has the greatest effect on human
change. Both extreme heat and cold can cause health
health. Polluting fuels include solid fuels such as wood,
problems and lead to death, as has been experienced in
coal, animal dung, charcoal, crop wastes and kerosene.
some OECD countries in recent decades. Extreme cold has
Attributable mortality is calculated by first combining
generally had a greater impact on mortality than heatwaves,
information on the increased (or relative) risk of a
particularly in Eastern Europe and Nordic countries. Still,
disease resulting from exposure, with information on
heatwaves have caused significant numbers of deaths in
how widespread the exposure is in the population (e.g.
certain years. For instance, the record warm summer of 2003
the annual mean concentration of particulate matter
caused around 80 000 deaths in Europe and the heatwaves in
to which the population is exposed). Applying this
the summer of 2015 caused more than 3 000 deaths in France
fraction to the total burden of disease (e.g.
alone.
cardiopulmonary disease expressed as deaths or
Death rates due to cold extreme temperatures are far higher DALYs), gives the total number of deaths that results
in Lithuania, Latvia and Estonia than other OECD countries, from exposure to household or ambient air pollution.
with over 1 400 deaths per million people since 2000
Data on fatalities due to extreme temperature events
(Figure 4.17). Although these high death rates are clearly
come from national registries on deaths by cause
linked to the naturally cold climates in these countries, they
collected in the WHO Mortality Database. Deaths due
should not be viewed as inevitable – for example, Canada,
to exposure to excessive natural heat (ICD code X30)
Iceland and Norway had less than 80 deaths per million
and exposure to excessive natural cold (X31) were
people over the same period. Evidence suggests that these
selected.
deaths might be also linked to excessive alcohol use. For
instance, in Finland among the deaths due to extreme cold Note that for both air pollution and deaths from
in 2015-2017, 46% of men and 24% of women were alcohol- extreme temperatures, data are based on WHO
intoxicated. estimates, which may differ from national data.
Extreme heat caused 82 deaths per million people in Japan,

followed by rates of 39 in France, 28 in Belgium and 21 in the
United States since 2000. Whilst the total number of deaths
due to cold temperatures has remained relatively stable References
since 2000, deaths from extreme heat have been on an [2] Landrigan, P. et al. (2018), “The Lancet Commission on
upward trend, with two peaks in 2003 and 2010 (Figure 4.18). pollution and health”, The Lancet, Vol. 391/10119, pp. 462-512,
Inter-sectoral policies are needed to address the impact of http://dx.doi.org/10.1016/s0140-6736(17)32345-0.
climate change. Countries can start planning to address [3] OECD (2017), Healthy people, healthy planet – The role of health
pollution and its impacts on health, for instance, by creating systems in promoting healthier lifestyles and a greener future,
partnerships with various international, national and local Organisation for Economic Cooperation and Development,
stakeholders, including local city authorities and ministries OECD, Paris, http://www.oecd.org/health/healthy-people-
of industry, environment, transport, and agriculture. Bottled healthy-planet.htm.
gas, for instance, can be used to replace solid fuels for [1] OECD (2015), The Economic Consequences of Climate Change,
cooking in order to address indoor pollution deaths. OECD Publishing, Paris, https://dx.doi.org/
Reducing crop burning and lowering emissions from motor 10.1787/9789264235410-en.

Figure 4.16. Ambient and household air pollution attributable death rate, 2016
Death rate per 100 000 population
160
141
140
140
120
98
86
100
83
82
81
77
76
64
80
61
60
59
57
49
46
45
60
43
40
39
39
35
35
34
33
32
31
31
30
28
27
27
25
25
24
40
23
23
20
19
19
18
17
17
15
14
20
0
Source: Global Health Observatory data repository, WHO.

Figure 4.17. Cumulative death rate due to extreme heat and extreme cold temperatures, 2000-17
Extreme heat Extreme cold

Death rate per 1 000 000 population
500
400
1480
1536
1708
227
331
422
211
208
300
203
164
200
95
80
77
73
63
59
58
52
49
36
100
34
31
27
27
26
21
18
17
16
14
12
10
8
5
1
Note: Lithuania, Latvia and Estonia show cumulative death rates higher than 500 per 1 000 000. The graph is truncated at this level to allow better
comparability.
Source: WHO Mortality Database.
Figure 4.18. Number of deaths due to extreme heat and extreme cold temperatures in OECD36, 2000‑16
Extreme heat Extreme cold Linear (Extreme heat) Linear (Extreme cold)
Number of deaths
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Source: WHO Mortality Database.


101
5. ACCESS TO CARE
Population coverage for health care
Extent of health care coverage
Use of primary care services
Unmet need for health care
Financial hardship and out-of-pocket expenditure
Geographic distribution of doctors
Waiting times for elective surgery
international law.
103
5. ACCESS TO CARE
The share of a population covered for a core set of health in Ireland and Australia. In the United States, 8% of the
services offers an initial assessment of access to care and population has complementary private health insurance.
financial protection. However, it is only a partial measure of This is in addition to the 55% of the population with primary
accessibility and coverage, focusing on the number of private health insurance.
people covered. Universal health coverage also depends on Over the last decade, the population covered by additional
the range of services covered and the degree of cost sharing private health insurance has increased in 18 of 27 OECD
for these services. Such services also need to be of sufficient countries with comparable data, though these increases
quality. Indicators in this chapter focus on access and have often been small. Changes have been most marked in
different dimensions of coverage, while Chapter 6 provides Korea, Denmark, Slovenia and Finland (Figure 5.3). Note that
indicators on quality and outcomes of care. in Slovenia increases were mainly due to one insurance
Most OECD countries have achieved universal (or near- company adding free supplementary health insurance to its
universal) coverage for a core set of health services, which insurance portfolio. Several factors determine how
usually include consultations with doctors, tests and additional private health insurance evolves, notably the
examinations, and hospital care (Figure 5.1). National health extent of gaps in access to publicly financed services and
systems or social health insurance have typically been the government interventions directed at private health
financing schemes for achieving universal health coverage. insurance markets.
A few countries (the Netherlands, Switzerland) have
obtained universality through compulsory private health
insurance – supported by public subsidies and laws on the
scope and depth of coverage. In Greece, a new law in 2016 Definition and comparability
closed the coverage gap for the 10% of the population who
were previously uninsured. Population coverage for health care is defined here as
Population coverage for core services remains below 95% in the share of the population eligible for a core set of
seven OECD countries, and is lowest in Mexico, the United health care services – whether through public
States and Poland. Mexico has expanded coverage since programmes or primary private health insurance. The
2004, but gaps remain. In the United States, the uninsured set of services is country-specific but usually includes
tend to be working-age adults with lower education or consultations with doctors, tests and examinations,
income levels – the share of people uninsured decreased and hospital care. Public coverage includes both
sharply from about 13% in 2013 to 9% in 2015 (United States national health systems and social health insurance.
Census Bureau, 2018[1]), but has remained relatively On national health systems, most of the financing
unchanged since then. In Poland, the majority of uninsured comes from general taxation, whereas in social health
are citizens living abroad. In Ireland, though coverage is insurance systems, financing typically comes from a
universal, less than half of the population are covered for combination of payroll contributions and taxation.
the cost of GP visits. Financing is linked to ability-to-pay. Primary private
health insurance refers to insurance coverage for a
In some countries, citizens can purchase additional health
core set of services, and can be voluntary or mandatory
coverage through voluntary private insurance. This can
by law (for some or all of the population). Additional
cover any cost sharing left after basic coverage
private health insurance is always voluntary. Private
(complementary insurance), add further services
insurance premiums are generally not income-related,
(supplementary insurance) or provide faster access or larger
although the purchase of private coverage may be
choice of providers (duplicate insurance). Eight OECD
subsidised by government.
countries have additional private insurance coverage for
over half of the population (Figure 5.2). In France, nearly all
of the population (96%) have complementary insurance to
cover cost sharing in the social security system – with public
subsidies making it free or at reduced rates for poor References
households. Complementary insurance is also widely used [3] OECD (2016), OECD Reviews of Health Systems: Mexico, OECD
in Belgium, Slovenia and Korea. Israel and the Netherlands Publishing, Paris, https://doi.org/10.1787/9789264230491-en.
have the largest supplementary market (over 80% of the
[2] OECD/European Observatory on Health Systems and Policies
population), whereby private insurance pays for dental care,
(forthcoming), Greece, Ireland, Poland, Country Health Profiles
physiotherapy, certain prescription drugs and other services 2019, State of Health in the EU.
not publicly reimbursed. Duplicate private health insurance,
[1] United States Census Bureau (2018), Health Insurance Coverage
providing faster private sector access to medical services
in the United States.
where there are waiting times in public systems, are largest

5. ACCESS TO CARE
Figure 5.1. Population coverage for a core set of services, Figure 5.2. Voluntary private health insurance coverage by
2017 (or nearest year) type, 2017 (or nearest year)
Total public coverage

Complementary Supplementary Duplicate
Primary private health coverage
Australia 100 France 96
Canada 100
Czech Republic 100 Slovenia 72 10 3
Denmark 100
Finland 100 Israel 85
Ireland 100 Belgium 84
Italy 100
Korea 100 Netherlands 84
New Zealand 100
Norway 100 Korea 68
Portugal 100 Canada 67
Slovenia 100
Switzerland 100 Australia 55
United Kingdom 100
Sweden 100 Ireland 45
Latvia 100 Austria 37
Japan 100
Israel 100 Chile 35
Greece 100
Iceland 99.5 0.5 Denmark 29
Germany 89.4 10.6 Switzerland 29
Netherlands 99.9
France 99.9 New Zealand 28
Austria 99.9
Spain 99.0 0.9 Portugal 27
Russian Federation 99.7 Germany 24
Turkey 99.2
Belgium 98.7 Finland 22
Lithuania 98.1
Colombia 94.9 Spain 16
Slovak Republic 94.6 Greece 12
Estonia 94.1
Hungary 94.0 United Kingdom 10
Chile 75.6 18.4 Mexico 9
Poland 92.6
United States 35.9 54.9 United States 8
Costa Rica 90.0
Mexico 89.3 Sweden 6
0 20 40 60 80 100 0 20 40 60 80 100
Percentage of total population Percentage of total population
Source: OECD Health Statistics 2019. Note: Private health insurance can be both duplicate and supplementary
StatLink 2 https://doi.org/10.1787/888934015619 in Australia; complementary and supplementary in Denmark and Korea;
and duplicate, complementary and supplementary in Israel and Slovenia.
In the United States, 55% of the population also has primary private
health insurance.
Figure 5.3. Trends in private health insurance coverage, 2007 and 2017 (or nearest year)
2007 2017
Percentage of total population
100 96
84 85 86
80 67 68 84
55
60
37
40 27 29
24 24 45
22
17
20 7 8 8 9 29 29
1 1
16 16
0 10


105
5. ACCESS TO CARE
In addition to the share of the population entitled to core (frequently limited to children) and higher levels of cost-
health services, the extent of health care coverage is defined sharing. On average only around 30% of dental care costs are
by the range of services included in a publicly defined borne by government schemes or compulsory insurance.
benefit package and the proportion of costs covered. More than half of dental spending is covered in only three
Figure 5.4 assesses the extent of overall coverage, as well as OECD countries (Japan, Germany and the Slovak Republic).
coverage for selected health care services, by computing the In Greece and Spain, dental care costs for adults without any
share of expenditure covered under government schemes or specific entitlement are not covered. Voluntary health
compulsory health insurance. Differences across countries insurance may play an important role in providing financial
in the extent of coverage can be due to specific goods and protection when dental care is not comprehensively covered
services being included or excluded in the publicly defined in the benefit package (e.g. the Netherlands).
benefit package (e.g. a particular drug or medical treatment); Coverage for pharmaceuticals is also typically less
different cost-sharing arrangements; or some services only comprehensive than for inpatient and outpatient care:
being covered for specific population groups in a country across the OECD, around 57% of pharmaceutical costs are
(e.g. dental treatment). covered by government or compulsory insurance schemes.
On average across OECD countries, almost three-quarters of This share is less than 40% in Lithuania, Iceland, Poland,
all health care costs were covered by government or Canada and Latvia. Coverage is most generous in Germany
compulsory health insurance schemes. This share rose (84%), followed by France (80%) and Ireland (78%). Over-the-
above 80% in ten countries (Norway, Germany, Japan, counter medications – which by their nature are not usually
Denmark, Luxembourg, Sweden, France, the Czech covered by public schemes – play an important role in some
Republic, Iceland, the Netherlands). However, in Mexico, countries (see indicator “Pharmaceutical Expenditure” in
Latvia and Korea less than 60% of all costs are covered by Chapter 10).
publicly mandated schemes. Coverage is also comparatively
low in the Russian Federation.
Inpatient services in hospitals are more comprehensively Definition and comparability
covered than any other type of care. Across the OECD, 88% of
all inpatient costs are borne by government or compulsory Health care coverage is defined by the share of the
insurance schemes. In many countries, patients have access population entitled to services, the range of services
to free acute inpatient care or only have to make a small co- included in a benefit package and the proportion of
payment. As a result, coverage rates are near 100% in costs covered by government schemes and
Sweden, Norway, Iceland and Estonia. Only in Korea, compulsory insurance schemes. Coverage provided by
Mexico, Greece, Australia and Ireland is the financial voluntary health insurance and other voluntary
coverage for the cost of inpatient care 70% or lower. In some schemes such as charities or employers is not
of those countries, patients frequently choose treatment in considered. The core functions analysed here are
private facilities where coverage is not (fully) included in the defined based on definitions in the System of Health
public benefit package. Accounts 2011. Hospital care refers to inpatient
curative and rehabilitative care in hospitals,
More than three-quarters of spending on outpatient medical
outpatient medical care to all outpatient curative and
care in OECD countries are borne by government and
rehabilitative care excluding dental care,
compulsory insurance schemes (77%). Coverage ranged
pharmaceuticals to prescribed and over-the-counter
from under 60% in Korea and Italy, to over 90% in the Slovak
medicines including medical non-durables.
Republic, Denmark and the Czech Republic. Outpatient
primary and specialist care are generally free at the point of Comparing the shares of the costs covered for different
service, but user charges may still apply for specific services types of services is a simplification. For example, a
or if non-contracted private providers are consulted. This is country with more restricted population coverage but
for example the case in Denmark, where 92% of total costs a very generous benefit basket may display a lower
are covered but user charges exist for visits to psychologists share of coverage than a country where the entire
and physiotherapists, and the United Kingdom (85%), where population is entitled to services but with a more
care provision outside of NHS commissioned services are limited benefit basket.
not covered.
Public coverage for dental care costs is far more limited
across the OECD due to restricted service packages

5. ACCESS TO CARE
Figure 5.4. Extent of coverage in OECD countries, 2017 (or nearest year)
Government and compulsory insurance spending as proportion of total health spending by type of care
All services Outpatient

Hospital care Dental care Pharmaceuticals
medical care
OECD32 73% 88% 77% 29% 57%
Australia 69% 68% 81% 23% 53%
Austria 74% 87% 78% 45% 68%
Belgium 77% 76% 76% 39% 71%
Canada 70% 91% 87% 6% 36%
Czech Republic 82% 95% 90% 48% 58%
Denmark 84% 91% 92% 19% 43%
Estonia 75% 98% 84% 25% 53%
Finland 75% 91% 82% 30% 55%
France 83% 96% 77% N/A 80%
Germany 84% 96% 89% 68% 84%
Greece 61% 66% 62% 0% 54%
Hungary 69% 91% 61% 36% 50%
Iceland 82% 99% 78% 24% 35%
Ireland 73% 70% 74% N/A 78%
Israel 63% 94% 62% 2% N/A
Italy 74% 96% 58% N/A 62%
Japan 84% 93% 85% 78% 72%
Korea 59% 65% 58% 33% 54%
Latvia 57% 80% 61% 18% 37%
Lithuania 67% 91% 77% 16% 34%
Luxembourg 84% 92% 88% 43% 68%
Mexico 52% 66% 85% 7% N/A
Netherlands 82% 91% 84% 11% 68%
Norway 85% 99% 86% 29% 56%
Poland 69% 93% 67% 24% 36%
Portugal 66% 85% 63% N/A 55%
Slovak Republic 80% 87% 98% 53% 71%
Slovenia 72% 86% 76% 50% 51%
Spain 71% 91% 76% 1% 58%
Sweden 84% 99% 86% 40% 53%
Switzerland 64% 84% 62% 6% 55%
United Kingdom 79% 94% 85% N/A 66%
Costa Rica 75% 88% 59% 11% 42%
Russian Federation 57% 82% 55% N/A 12%


107
5. ACCESS TO CARE
Primary care services are the main entry point into health performance. Countries offering nationwide population-
systems. Indicators on the use of such services therefore based screening programmes have more equal access, as
provide a critical barometer of accessibility, with data compared with countries where cancer screening happens
disaggregated by income illustrating the degree of in a more ad-hoc manner (Palencia, 2010[2])
inequalities in access. Such observed problems in accessing health services,
In terms of access to a doctor, on average just under 80% of particularly for the less well-off, occur despite most OECD
individuals aged 15 or over reported visiting a doctor in the countries having universal or near-universal coverage for a
past year, adjusting for need (Figure 5.5). Note that need is core set of services (see indicator on “Population coverage
modelled, rather than measured directly (see definition and for health care”). Part of the explanation are high cost
comparability box). Furthermore, the probability of visiting a sharing, exclusion of some services from benefit packages or
doctor may be lower in some countries because people make implicit rationing of services. Limitations in health literacy,
greater use of other types of health professionals, such as imperfect communication strategies, and low quality of care
nurses. Notwithstanding these issues, cross-country are also contributing factors.
differences in utilisation are large, with need-adjusted
probabilities of visiting a doctor ranging from around 65% in
Sweden and the United States to 89% in France.
Socioeconomic inequalities in accessing a doctor are evident Definition and comparability
within almost all OECD countries. Excepting Denmark and
the Slovak Republic, wealthier individuals are more likely to The health care module of the European Health
see a doctor than individuals in the lowest income quintile, Interview Survey (EHIS) and of national surveys allows
for a comparable level of need. Pro-rich inequalities in respondents to report on their utilisation of health care
doctor access are highest in Finland and the United States services, whether they have visited a GP, specialist or
(over 15 percentage-points difference) but practically non- dentist in the past year, as well as their use of various
existent in the United Kingdom, Ireland and the
screening services.
Netherlands. Income inequalities in accessing doctors are
much more marked for specialists than for general The probability of visiting a doctor is defined as having
practitioners (OECD, 2019 [1]). seen a GP or a specialist in the past year. However, the
For dental care, only 63% of individuals aged 15 or over volume of care a person receives in itself does not
reported visiting a dentist in the past year, on average across accurately measure access, as people have varying
27 OECD countries (Figure 5.6). This is partly due to benefit health care needs. Need is not measured directly.
design: public coverage for dental care is much lower than Rather, predicted needs are modelled, and then the
for hospital care or doctor consultations in many OECD probability of visiting a doctor is adjusted by this value
countries (see indicator on “Extent of health care coverage”). (see O’Donnell (2008[3]) for further methodological
Overall access to dental care ranged from 41% of people details). Here, four categorical variables are used to
visiting a dentist in the United States, to 93% in Ireland. model predicted need: age, sex, self-rated health and
Socioeconomic disparities are large – on average, there is an activity limitations.
almost 20 percentage-point difference in visits between high
and low-income groups (72% of wealthier individuals visited Cervical cancer screening is defined as the proportion
a dentist, compared with 54% among those from the lowest of women aged 20-69 who have undergone a Pap
income quintile). Inequalities are largest in Canada, Portugal smear test in the past 3 years.
and the United States (over 30 percentage-point difference);
but almost zero in Ireland.
Uptake of cancer screening is also lower amongst the less
well-off. This is despite most OECD countries providing References
screening programmes at no cost. For example, on average
79% of wealthier women had a Pap smear test for cervical [4] Moreira, L. (2018), “Health literacy for people-centred care:
cancer, as compared with 65% amongst women from the Where do OECD countries stand?”, OECD Health Working
lowest income quintile (Figure 5.7). Wealthier people also Papers, No. 107, OECD Publishing, Paris, https://doi.org/
10.1787/d8494d3a-en.
have greater access to screening for both breast and
colorectal cancer, though inequalities are less marked than [3] O’Donnell, O. (2008), Analyzing Health Equity Using Household
for cervical cancer. Screening for cervical cancer is Survey Data: A Guide to Techniques and Their Implementation,
disproportionately low among the bottom income group in World Bank Group, Washington D.C., http://dx.doi.org/
Sweden and Norway (over 30 percentage-point gap between 10.1596/978-0-8213-6933-3.
income quintiles), but relatively equal in Ireland, Chile and [1] OECD (2019), Health for everyone? Social Inequalities in Health and
Iceland. Overall uptake of cervical cancer screening ranged Health Systems, OECD Health Policy Studies, OECD
from just under 50% in the Netherlands, to over 85% in the Publishing, Paris, https://doi.org/10.1787/3c8385d0-en.
Czech Republic and Austria. This applies to women aged 20
to 69 with a screening interval of three years. Note that some [2] Palencia, L. (2010), “Socio-economic inequalities in breast and
cervical cancer screening practices in Europe: influence of
countries (e.g. the Netherlands) offer screening amongst a
the type of screening program”, International Journal of
narrower age group and less frequently. This may result in
Epidemiology, Vol. 39/3, pp. 757-765.
lower screening rates but not necessarily worse

5. ACCESS TO CARE
Figure 5.5. Need-adjusted probability of visiting a doctor, by income, 2014

%
100
90
80
70
60
71.3
74.1
74.2
74.7
75.0
75.2
75.3
75.5
76.0
76.3
76.3
76.4
76.9
78.6
79.8
80.2
80.8
83.9
84.0
85.5
85.6
85.6
85.7
86.4
88.3
88.9
64.0
65.0
50
Source: OECD estimates based on EHIS-2 and other national survey data.
Figure 5.6. Share of the population who visited a dentist, by income, 2014

%
100
90
80
70
60
50
40
46.9
48.0
50.2
52.9
55.0
57.0
59.4
59.7
63.0
65.5
70.5
70.9
71.7
74.1
74.8
75.8
78.2
78.6
79.1
80.5
82.0
92.9
30
49.0
46.0
46.0
48.9
41.0
47.0
20
Figure 5.7. Share of women aged 20-69 screened for cervical cancer, by income, 2014

%
100
90
80
70
60
50
57.9
61.9
63.4
64.0
66.2
68.5
69.0
69.0
69.2
70.8
71.2
71.7
71.9
72.3
75.5
75.6
76.1
77.7
78.4
79.3
80.0
80.1
80.6
80.7
82.1
84.0
86.6
87.3
40
49.1
30

109
5. ACCESS TO CARE
People should be able to access health services when they among older people, on average (14% compared to 17%
need to, irrespective of their socio-economic circumstances. across the OECD) and in most countries (17 out of 23).
This is a fundamental principle underpinning all health Income inequalities are also less marked among older
systems across the OECD. Yet a quarter of individuals aged individuals. Although older people from the top income
18 or older report unmet need (defined as forgoing or quintile report similar levels of forgone care to the overall
delaying care) because limited availability or affordability of top quintile (8% and 9% respectively), older people from the
services compromise access, on average across 23 OECD bottom income quintile report significantly lower levels on
countries. People may also forgo care because of fear or average (20% compared to 27%).
mistrust of health service providers. Strategies to reduce
unmet need, particularly for the less well-off, need to tackle
both financial and non-financial barriers to access (OECD,
2019[1]).
Looking specifically at availability of services, just over 20% The health care module of the European Health
of respondents reported unmet need due to waiting times Interview Survey (EHIS) and of national surveys allows
and/or transportation difficulties (Figure 5.8). The share of respondents to report on their utilisation of health care
the population delaying or forgoing care is comparatively services, as well as potential barriers experienced
high in Luxembourg, Italy, Ireland and Iceland (above 30%); when trying to access these services. The probability of
but much lower in Norway (5%) and the Slovak Republic reporting an unmet need due to availability issues is
(7%). In response to this accessibility constraint, based on two of the available variables: unmet need
telemedicine initiatives are becoming more popular in many due to long waiting lists or to physical accessibility
OECD countries (Hashiguchi Cravo Oliveira, forthcoming[2]). (distance or transportation). The probability to report
Socioeconomic disparities are significant: on average, 23% of forgone care due to financial reasons aggregates
people from the lowest income quintile report availability- unmet need for four different types of service (medical,
related unmet need compared with 18% for richer dental and mental health services, and prescription
individuals. This income gradient is largest in Finland, Italy drugs). Respondents who reported not having a health
and Portugal. In Slovenia, Poland and Estonia, richer care need in the past 12 months were excluded from
individuals report slightly more unmet need than the less the sample. Probabilities thus reflect the proportion of
well-off, with results driven by the better-off being more people reporting an unmet need, among individuals
likely to report waiting times as a cause of unmet need. that have reported a need, satisfied or not (rather than
In terms of affordability, 17% of respondents delayed or did the total population surveyed). This leads to higher
not seek needed care because the costs were too high for estimates than surveys where unmet needs are
them (Figure 5.9). Across countries, unmet need due to such calculated as a share of the total population – as is
financial reasons ranged from less than 7% of the population done, for example, with the EU-SILC survey.
in the Netherlands, the Czech Republic, the United Kingdom
and Norway, to over 30% in Estonia, Ireland and Latvia.
Affordability-related inequalities are more marked than
inequalities related to availability of services. On average, References
28% of people in the lowest income quintile forgo care for
[2] Hashiguchi Cravo Oliveira, T. (forthcoming), “Is telemedicine
financial reasons compared with 9% for richer individuals.
leading to more cost-effective, integrated and people-
That is, the least well-off are three times more likely than centred care in the OECD?”, OECD Health Working Papers,
the better-off to have unmet need for financial reasons. OECD Publishing, Paris.
Amongst people aged 65 or older, affordability constraints [1] OECD (2019), Health for Everyone? Social inequalities in health and
are slightly less marked than for the population as a whole. health systems, OECD Publishing, Paris, https://doi.org/
The proportion of cost-related reported unmet need is lower 10.1787/3c8385d0-en.

5. ACCESS TO CARE
Figure 5.8. Population forgoing or postponing care because of limited availability, by income, 2014

% of population who reported a health need
50
40
30
20
10
12.4
12.4
14.0
14.2
14.5
16.7
17.0
18.1
19.0
20.6
21.1
21.5
21.7
25.5
26.2
26.5
26.7
28.1
30.8
31.3
32.0
32.9
5.0
7.1
Source: OECD estimates based on EHIS-2 and other national health survey data.
Figure 5.9. Population forgoing care because of affordability, by income, 2014

60
50
40
30
20
10
13.4
13.9
15.6
16.1
16.9
17.2
17.2
17.4
19.9
20.1
20.9
25.6
28.6
31.7
34.4
34.7
5.7
6.1
6.5
6.5
7.4
8.9
9.9
Source: OECD estimates based on EHIS-2.

Figure 5.10. Adults over 65 forgoing or postponing care because of affordability, by income, 2014

50
40
30
20
10
10.4
10.4
10.5
11.5
12.0
12.3
14.3
14.6
19.0
19.4
25.2
25.8
28.8
35.0
35.0
6.7
7.5
7.8
8.4
8.7
Source: OECD estimates based on EHIS-2.


111
5. ACCESS TO CARE
Where health systems fail to provide adequate financial choices are also important, particularly around coverage
protection, people may not have enough money to pay for policy (WHO Regional Office for Europe, 2018[2]). Population
health care or meet other basic needs. As a result, lack of entitlement to publicly financed health care is a prerequisite
financial protection can reduce access to health care, for financial protection, but not a guarantee of it. Countries
undermine health status, deepen poverty and exacerbate with a low incidence of catastrophic spending on health are
health and socio-economic inequalities. On average across also more likely to exempt poor people and frequent users of
OECD countries, just over a fifth of all spending on health care from co-payments; use low fixed co-payments instead
care comes directly from patients through out-of-pocket of percentage co-payments, particularly for outpatient
(OOP) payments (see indicator “Financing of health care”). medicines; and cap the co-payments a household has to pay
People experience financial hardship when the burden of over a given time period (e.g. Austria, the Czech Republic,
such OOP payments is large in relation to their ability to pay. Ireland and the United Kingdom).
Poor households and those who have to pay for long-term
treatment such as medicines for chronic illness are
particularly vulnerable.
The share of household consumption spent on health care Definition and comparability
provides an aggregate assessment of the financial burden of
OOP expenditure. Across OECD countries, about 3% of total Out-of-pocket (OOP) payments are expenditures borne
household spending was on health care goods and services, directly by a patient where neither public nor private
ranging from around 2% in France, Luxembourg and insurance cover the full cost of the health good or
Slovenia, to more than 5% in Korea and nearly 7% in service. They include cost-sharing and other
Switzerland (Figure 5.11). expenditure paid directly by private households and
should also ideally include estimations of informal
Health systems in OECD countries differ in the degree of
payments to health providers.
coverage for different health goods and services (see
indicator “Extent of health care coverage”). Household Catastrophic health spending is an indicator of
spending on pharmaceuticals and other medical goods was financial protection used to monitor progress towards
the main health care expense for people, followed by universal health coverage (UHC). It is defined as OOP
spending on outpatient care (Figure 5.12). These two payments that exceed a predefined percentage of the
components typically account for almost two-thirds of resources available to a household to pay for health
household spending on health care. Household spending on care. Household resources available can be defined in
dental care and long-term health care can also be high, different ways, leading to measurement differences. In
averaging 14% and 11% of OOP spending on health the data presented here, these resources are defined as
respectively. Inpatient care plays only a minor role (9%) in household consumption minus a standard amount
the composition of OOP spending. representing basic spending on food, rent and utilities
(water, electricity, gas and other fuels). The threshold
The indicator most widely used to measure financial
used to define households with catastrophic spending
hardship associated with OOP payments for households is
is 40%. Microdata from national household budget
the incidence of catastrophic spending on health (Cylus et
surveys are used to calculate this indicator.
al., 2018[1]). This varies considerably across OECD countries,
from fewer than 2% of households experiencing
catastrophic health spending in France, Sweden, the United
Kingdom, Ireland, the Czech Republic and Slovenia, to over
8% of households in Portugal, Poland, Greece, Hungary, References
Latvia and Lithuania (Figure 5.13). Across all countries, [1] Cylus, J., Thomson, S., Evetovits, T (2018), “Catastrophic
poorer households (i.e. those in the bottom consumption health spending in Europe: equity and policy implications of
quintile) are most likely to experience catastrophic health different calculation methods”, Bulletin of the World Health
spending, despite the fact that many countries have put in Organization, Vol. 96 No. 9, http://dx.doi.org/10.2471/
place policies to safeguard financial protection. BLT.18.209031.
Countries with comparatively high levels of public spending [2] WHO Regional Office for Europe (2019). “Can people afford to
on health and low levels of OOP payments typically have a pay for health care? New evidence on financial protection in
lower incidence of catastrophic spending. However, policy Europe”, WHO Regional Office for Europe, Copenhagen.

5. ACCESS TO CARE
Figure 5.11. Out-of-pocket spending as share of final household consumption, 2017 (or nearest year)
%
8
6.9
7
5.6
6
4.5
4.2
4.2
4.2
5
4.0
4.0
3.9
3.9
3.8
3.7
3.7
3.6
3.6
3.5
3.4
3.3
3.3
3.1
4
3.1
3.1
3.0
2.8
2.8
2.8
2.8
2.7
2.6
2.6
2.6
2.6
2.4
2.3
2.3
2.2
3
2.0
2.0
2.0
2
1
0
Source: OECD Health Statistics 2019, OECD National Accounts Database.

Figure 5.12. Out-of-pocket spending on health, by type of services, 2017 (or nearest year)
Medical Goods Outpatient Dental Inpatient LTC Other

% 1 2
100 1
3 3 7 6 4 2 2 2 7 7 9 1 1 4 11 2 2 2 3 9 3
11 11 12 11 12 16 15 12
90 20 17 14 8 17 19 6
2
16 2 2 17 17
31 5
17 20 8 22 23
19 9 9 30 2 34
80 9 7 22 2 8 29 20 6 7 36 13 15 28 39
12 31 22 7 3
70 2
16 13 14 11
30
27 19 14 19
22
17 26
3 13
5
14
60 26 30 7 14 47 22 16 56
9 18 14 21 28 3 14 11 5
22 23
50 14 17 15 22 19 18 19 24
38
12 13 22
40 69
22 28 34
30 63 63 60 59 55 52 50 49 48 48 47 46
20 44 43 41 41 39 39 39 38 37 37 37 36 36 34 34 33 31 30 28
10 23
0
Note: The “Medical Goods” category includes pharmaceuticals and therapeutic appliances. The "Other" category includes preventive care,
administrative services and services unknown.
Figure 5.13. Share of households with catastrophic health spending by consumption quintile, latest year available
Richest 4th Quintile 3rd Quintile 2nd Quintile Poorest

%
15.8
20
15.2
18
12.9
16
11.6
14
9.7
12
8.6
8.1
8.0
7.5
7.4
7.4
10
5.8
5.5
5.2
8
4.3
3.9
3.5
3.2
3.2
3.1
6
2.6
2.4
1.9
1.8
1.4
1.2
1.1
1.0
4
2
0
Source: WHO Regional Office for Europe, 2019.


113
5. ACCESS TO CARE
Access to medical care requires an adequate number and financial incentives for doctors to work in underserved
equitable distribution of doctors in all parts of the country. areas; 2) increasing enrolments in medical education
Concentration of doctors in one region and shortages in programmes of students coming from specific social or
others can lead to inequities in access such as longer travel geographic backgrounds or decentralising the location of
or waiting times. The uneven distribution of doctors and the medical schools; 3) regulating the choice of practice location
difficulties in recruiting and retaining doctors in certain of doctors (for new medical graduates or foreign-trained
regions is an important policy issue in most OECD countries, doctors); and 4) re-organising service delivery to improve the
especially in countries with remote and sparsely populated working conditions of doctors in underserved areas.
areas, and those with deprived rural and urban regions. Many OECD countries provide different types of financial
The overall number of doctors per capita varies widely incentives to attract and retain doctors in underserved
across OECD countries from around two per 1 000 areas, including one-time subsidies to help them set up their
population in Turkey, Korea and Poland, to five or higher in practice and recurrent payments such as income guarantees
Portugal, Austria and Greece (see indicator on “Doctors” in and bonus payments. A number of countries have also
Chapter 8). Beyond these cross-country differences, the introduced measures to encourage students from under-
number of doctors per capita also varies widely across served regions to enrol in medical schools. The effectiveness
regions within the same country. The density of physicians and cost of different policies to promote a better distribution
is consistently greater in urban regions, reflecting the of doctors can vary significantly, with the impact depending
concentration of specialised services such as surgery, and on the characteristics of each health system, the geography
physicians’ preferences to practice in urban settings. of the country, physician behaviours, and the specific policy
Differences in the density of doctors between urban regions and programme design. Policies should be designed with a
and rural regions are highest in the Slovak Republic, clear understanding of the interests of the target group in
Hungary and Portugal, notwithstanding differential order to have any significant and lasting impact (Ono,
definition of urban and rural regions across countries. The Schoenstein and Buchan, 2014[1]).
distribution of physicians between urban and rural regions
was more equal in Japan and Korea, but there are generally
fewer doctors in these two countries (Figure 5.14). Growing
urbanisation will likely further widen existing geographic Definition and comparability
disparities in access to doctors.
Within predominantly urban areas, capital cities are Regions are classified in two territorial levels. The
typically capturing most of the physician supply higher level (Territorial Level 2) consists of large
(Figure 5.15). This is particularly evident in Austria, the regions corresponding generally to national
Czech Republic, Greece, Portugal, the Slovak Republic and administrative regions. These broad regions may
the United States. Differences between the capital region contain a mix of urban, intermediate and rural areas.
and the second region with highest density are largest in the The lower level is composed of smaller regions
United States and the Slovak Republic, with Washington classified as predominantly urban, intermediate or
D.C. and the Bratislava region having nearly twice as many rural regions, although there are variations across
physicians per capita as Massachusetts and East Slovakia countries in the classification of these regions. Note
(the second most dense), respectively. This usually results in that overseas territories are generally excluded from
higher dispersion between small regions for these countries, calculations. All data on geographic distributions come
with the United States showing a nearly five-fold difference from the OECD Regional Database.
in physician density; and almost three-fold differences for
the Slovak Republic and Greece. In contrast, Australia,
Belgium and Korea show only around a 20% difference in
physician densities between regions. References
Doctors may be reluctant to practice in rural regions due to [2] OECD (2016), Health Workforce Policies in OECD Countries: Right
concerns about their professional life (including their Jobs, Right Skills, Right Places, OECD Health Policy Studies,
income, working hours, opportunities for career OECD Publishing, Paris, https://dx.doi.org/
development, isolation from peers) and social amenities 10.1787/9789264239517-en.
(such as educational options for their children and [1] Ono, T., M. Schoenstein and J. Buchan. (2014), “Geographic
professional opportunities for their spouse). A range of Imbalances in Doctor Supply and Policy Responses”, OECD
policy levers can be used to influence the choice of practice Health Working Papers, No. 69, OECD Publishing, Paris, http://
location of physicians. These include: 1) the provision of dx.doi.org/10.1787/5jz5sq5ls1wl-en.

5. ACCESS TO CARE
Figure 5.14. Physician density, rural vs urban areas, 2016 (or nearest year)
Predominantly urban Predominantly rural

Density per 1 000 population
7
5.7
5.6
6
6.7
5.1
6.3
4.7
5
4.4
4.4
4.4
4.3
4.2
4.2
3.9
3.9
3.8
3.8
3.6
4
3.4
3.3
2.8
2.8
2.7
2.7
2.7
2.6
3
2.5
2.4
2.3
2.3
2.2
2.0
1.9
2
1.3
1.0
1
0
Source: OECD Regional Statistics Database 2019.

Figure 5.15. Physician density across localities, by level 2 regions, 2016 (or nearest year)
Australia
Austria Vienna
Belgium Brussels
Canada
Chile
Czech Republic Prague
Denmark Copenhagen
Estonia
Finland Helsinki
France
Germany Hamburg
Greece Athens Region
Hungary
Israel
Italy
Japan
Korea
Latvia
Luxembourg
Mexico Nuevo Leon
Netherlands
New Zealand
Norway Oslo Region
Poland
Portugal Lisbon
Slovak Republic Bratislava
Slovenia
Spain
Sweden
Switzerland
Turkey Ankara
United Kingdom
United States Massachusetts District of Columbia
China Beijing
Colombia Bogota
Lithuania
Russian Federation St. Petersburg
0 1 2 3 4 5 6 7 8 9 10
Density per 1 000 population
Source: OECD Regional Statistics Database 2019.


115
5. ACCESS TO CARE
Long waiting times for elective (non-emergency) surgery Denmark has used maximum waiting times, together with
cause dissatisfaction for patients, because they postpone patient choice of provider, to reduce waiting times since the
the expected benefits of treatment, and pain and disability late 2000s. The maximum waiting time guarantee was
remain. Waiting times are the result of a complex reduced from two months to one month in 2007, combined
interaction between the demand and supply of health with free choice of provider. Under this scheme, if the
services, with doctors playing a critical role on both sides. hospital can foresee that the guarantee will not be fulfilled,
Demand for health services and elective surgeries is the patient can choose another public or private hospital. If
determined by the health status of the population, progress the treatment is outside of the region’s own hospitals, the
in medical technologies (including the simplification of expenses are covered by the region where the patient lives.
many procedures, such as cataract surgery), patient In Hungary, waiting times for many elective surgeries have
preferences, and the burden of cost-sharing for patients. also been reduced in recent years. Specific objectives were
However, doctors play a crucial role in the decision to set to reduce waiting times to under 60 days for minor
operate on a patient or not. On the supply side, the surgery and under 180 days for major surgery, for all
availability of surgeons, anaesthetists and other staff in patients. To achieve this, the government adopted new laws
surgical teams, as well as the supply of the required medical and regulations on the management of waiting lists,
equipment, affect surgical activity rates. developed an online waiting list system at the national level
The measure reported here refers to the waiting time from to monitor the situation in real-time, provided additional
when a medical specialist adds a patient to the waiting list payment to reduce waiting times in selected areas or
for the procedure, to the moment the patient receives hospitals, and encouraged a reallocation of patients from
treatment. Both mean and median waiting times are providers with longer waiting times to those with shorter
reported. Since a number of patients wait for very long waiting times.
times, the median is consistently and considerably lower
than the mean, and might therefore represent a better
measure for the central tendency of this indicator. The Definition and comparability
significant difference between the two measures, especially
in countries such as Chile, Estonia, and Poland, highlights Two different measures of waiting times for elective
the presence of problematic groups of patients who wait procedures are commonly used: 1) measuring the
significantly longer than others to receive treatment. waiting times for patients treated in a given period; or
In 2017, the median waiting time for cataract surgery was 2) measuring waiting times for patients still on the list
less than 50 days in Italy, Hungary, Denmark, and Sweden at a point in time. The data reported here relate to the
(Figure 5.16). Countries with the largest waiting times first measure (data on the second measure are
include Estonia and Poland, with median waits of about available in the OECD Health Database). Data come
seven months and over a year respectively. Over the past from administrative databases rather than surveys.
decade, waiting times increased in some countries, such as Waiting times are reported in terms of both the mean
Canada and Portugal; in Spain waits decreased, while in and the median. The median is the value that
New Zealand they remained relatively stable. separates a distribution in two equal parts (i.e. half the
For hip replacement, the median waiting time was less than patients have longer waiting times, the other half have
50 days in Denmark and Italy (Figure 5.17). There were very shorter waiting times). Compared with the average
long median waiting times of eight months or more in (mean), the median minimises the influence of
Estonia, Poland and Chile. Over the past five years, some outliers, i.e. patients with very long waiting times.
countries, such as Finland, Hungary and Denmark, observed Waiting times are over-estimated in Norway because
a decline in median waiting times for hip replacement, they start from the data when a doctor refers a patient
while Estonia saw a sharp increase. for specialist assessment up to the treatment, whereas
in other countries they start only when a specialist has
Waiting times for knee replacement follows the patterns of
assessed the patient and decided to add the person on
hip replacement but with higher waiting times on average,
the waiting list up to the treatment.
with Estonia, Poland and Chile also having by far the longest
waiting times (Figure 5.18). The median waiting time across
the OECD sample is 114 days, more than 30 days above those
of cataract surgery and 20 days above those of hip
replacement. In Australia, median waiting times slightly References
increased over time to reach 200 days, while Portugal [2] National Research Council (US); Institute of Medicine (US)
remained relatively unchanged since 2007. Hungary and (2013), U.S. Health in International Perspective, National
Denmark saw reductions in the past decade. Academies Press, Washington, D.C., http://dx.doi.org/
10.17226/13497.
Waiting time guarantees have become the most common
policy tool to tackle long waiting times in several countries, [1] Siciliani, L., M. Borowitz and V. Moran (eds.) (2013), Waiting
but these guarantees are only effective if well enforced Time Policies in the Health Sector: What Works?, OECD Health
(Siciliani, Borowitz and Moran, 2013[1]). Policy Studies, OECD Publishing, Paris, https://dx.doi.org/
10.1787/9789264179080-en.

5. ACCESS TO CARE
Figure 5.16. Cataract surgery waiting times, averages and selected trends, 2017
Median Mean Canada New Zealand

Days Days Portugal Spain
500 160
458
450 140
386
400
349
120
350
300 100
219
250 80
200
132
129
129
60
123
121
119
108
106
106
103
150
86
92
76
78 40
77
77
76
75
63
n.a. 66
62
61
100
57
48
44
43
37
34
21
50 20
n.a.
n.a.
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Figure 5.17. Hip replacement waiting times, averages and selected trends, 2017
Denmark Estonia
Days Median Mean Days Finland Hungary
500 350
433
419
450
391
300
400
350 250
286
300
246
240
200
250
162
161
150
134
200
130
119
130
109
105
104
114
99
150
111
100
95
95
90
82
81
78
75
85
73
100
56
55
51
49
n.a. 39
50
29
50
n.a.
n.a.
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Figure 5.18. Knee replacement waiting times, averages and selected trends, 2017
Median Mean Australia Denmark

Hungary Portugal
Days Days
1000 250
861
900
842
800 200
700
564
535
600 150
442
500
335
400 100
227
211
201
198
300
160
192
145
n.a. 129
133
157
117
117
141
114
101
200
80
50
98
90
90
83
95
65
53
75
45
33
41
100
n.a.
n.a.
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017


117
6. QUALITY AND OUTCOMES OF CARE
Safe primary care – prescribing
Safe acute care – surgical complications and health care-associated

infections
Safe acute care – obstetric trauma
Avoidable hospital admissions
Diabetes care
Mortality following ischaemic stroke
Mortality following acute myocardial infarction (AMI)
Hip and knee surgery
Care for people with mental health disorders
Breast cancer outcomes
Screening and survival for colorectal cancer
Survival for other major cancers
Vaccinations
Patient experiences of ambulatory care
international law.
119
Prescribing can be used as an indicator of health care

quality, supplementing consumption and expenditure Definition and comparability
information (see Chapter 10). The overuse, underuse or
misuse of prescription medicines can cause significant Defined daily dose (DDD) is the assumed average
hazards to health and lead to wasteful expenditure. This is, maintenance dose per day for a drug used for its main
for example, the case for opioids and antibiotics. indication in adults. For instance, the DDD for oral
aspirin equals 3 grammes, the assumed maintenance
Opioids are often used to treat acute pain and pain
daily dose to treat pain in adults. DDDs do not
associated with cancer, and over the last decade have been
necessarily reflect the average daily dose actually used
increasingly used to treat chronic pain, despite the risk of
in a given country. For more detail, see http://
dependence, dose increase, shortness of breath and death.
www.whocc.no/atcddd.
Opioid use is now causing an alarming and rising epidemic
of overdose deaths in some OECD countries, such as the Data for Austria, Latvia, Estonia, Portugal, Spain and
United States and Canada (OECD, 2019[1]) (see indicator on Sweden include data for primary care physicians only.
“Opioids use” in Chapter 4). Data for Canada, Finland, Italy, Korea and Norway
include outpatient care. Data for the Netherlands
Figure 6.1 indicates that, across OECD countries, the average
include prescriptions by primary care doctors and
volume of opioids prescribed in primary care in 2017 was
medical specialists in outpatient clinics. Data for
more than 16 defined daily doses (DDDs) per 1 000
Denmark, Ireland and Slovenia include primary care,
population per day. Iceland and Luxembourg report
outpatient care and nursing homes. Data for Belgium
volumes more than twice the OECD average; Turkey and
and Turkey include primary care, nursing and
Korea report the lowest volumes. While these numbers
residential facilities. Data for Iceland include data for
measure prescriptions in primary care, they may reflect
primary care, outpatient care, specialists in private
conditions on the supply side, as the mean availability of
practice and nursing homes. Data relate to reimbursed
opioids is also low in Turkey (see indicator on “Opioids use”
prescriptions, with the exception of Iceland, Slovenia
in Chapter 4). On average, more than 2% of the adult
and the Netherlands (for benzodiazepines only), which
population across OECD countries were chronic users of
include non-reimbursed medicines. Data for Denmark,
opioids in 2017 (Figure 6.2). Korea and Italy report the lowest
Canada, Finland, Luxembourg, Portugal, the
and Iceland reports the highest proportion by a large
Netherlands and Sweden relate to medicines
margin. The large variation can be explained in part by
dispensed in community pharmacies. Data for
differences in clinical practice in pain management, as well
Germany are based on prescription data of statutory
as differences in regulation, legal frameworks for opioids,
health insurance for the outpatient area. Data for
prescribing policies and treatment guidelines.
Australia are sourced from the Pharmaceutical
Antibiotics should be prescribed only where there is a need Benefits Scheme dataset. Denominators comprise the
that is clearly supported by evidence, to reduce the risk of population held in the national prescribing database,
resistant strains of bacteria (OECD, 2018[2]). For example, rather than the general population. Further
quinolones and cephalosporins are considered second-line information on sources and methods is at OECD.Stat.
antibiotics in most prescribing guidelines, which should Other data in OECD Health Statistics on antibiotics
generally be used only when first-line antibiotics are may differ due to differences in data sources and
ineffective. Total volume of antibiotics prescribed and coverage.
second-line antibiotics as a proportion of total volume have
For opioids, “chronic users” is defined as the number of
been validated as markers of quality in the primary care
adults in the prescribing database with two or more
setting (OECD, 2017[3]), while overall antibiotic consumption
prescriptions for at least 90 days.
and antimicrobial resistance across OECD countries has
been increasing (OECD, 2018[2]).
Figure 6.3 shows the volume of all antibiotics prescribed in
primary care in 2017, including second-line antibiotics. Total
volumes vary more than three-fold across countries, with References
the United Kingdom, Estonia and Sweden reporting the [1] OECD (2019), Addressing Problematic Opioid Use in OECD
lowest volumes, and Italy and Greece reporting the highest. Countries, OECD Health Policy Studies, OECD Publishing,
Volumes of second-line antibiotics vary more than 24-fold Paris, https://dx.doi.org/10.1787/a18286f0-en.
across countries. The Scandinavian countries and the [2] OECD (2018), Stemming the Superbug Tide: Just A Few Dollars
United Kingdom report the lowest volumes of second-line More, OECD Health Policy Studies, OECD Publishing, Paris,
antibiotics, whereas Greece and Korea report the highest. https://dx.doi.org/10.1787/9789264307599-en.
Variation is likely to be explained, on the supply side, by
[3] OECD (2017), Tackling Wasteful Spending on Health, OECD
differences in the guidelines and incentives that govern Publishing, Paris, https://dx.doi.org/10.1787/9789264266414-
primary care prescribers and, on the demand side, by en.
differences in attitudes and expectations regarding optimal
treatment of infectious illness.

Figure 6.1. Overall volume of opioids prescribed, 2017 (or nearest year)
DDDs per 1 000 population, per day
40.2
45
39.0
40
35
30
22.5
23.3
21.1
20.4
25
17.6
17.3
17.0
16.5
15.4
15.3
13.3
20
12.7
10.7
15
5.8
10
4.2
0.9
0.1
5
0
Note: Data exclude products used in the treatment of addiction. 1. Three-year average.
Source: OECD Health Statistics 2019 and Third Australian Atlas of Healthcare Variation 2018.
Figure 6.2. Proportion of chronic opioid users in the adult population, 2017 (or nearest year)
% of population aged 18 and over
12
9.6
10
8
6
3.0
4
2.6
2.3
2.3
2.1
1.8
1.4
1.4
1.1
1.1
2
0.6
0.2
Note: Data exclude products used in the treatment of addiction. 1. Three-year average.
Figure 6.3. Overall volume of antibiotics prescribed, 2017 (or nearest year)
All - 2017 2nd line

DDDs per 1000 population, per day
35
30
25
20
15
10
5
0
1. Three-year average. 2. Data from European Centre for Disease Prevention and Control as OECD Health Statistics data are not available.

121
Safe acute care – surgical complications and health care-associated
infections
Patient safety remains one of the most pressing health

issues for public education and further policy action. Over Definition and comparability
15% of hospital expenditure and activity in OECD countries
can be attributed to treating patients who experience a Indicators using unlinked data rely on information
safety event, many of which are preventable (Slawomirski, from a patient’s admission to the hospital where
Auraaen and Klazinga, 2018[1]). The World Health Assembly surgery occurred to calculate rates. The number of
recently endorsed the establishment of an annual World discharges with International Classification of
Patient Safety Day to further strengthen awareness and Diseases (ICD) codes for the relevant complication in
galvanise concerted action for safer care. any secondary diagnosis field is divided by the total
number of discharges for patients aged 15 and older.
Patient safety problems may be categorised as “sentinel” or
The linked data approach expands beyond the surgical
“never” events: events that should never or very rarely
admission to include all subsequent related re-
occur; and “adverse” events: events that cannot be fully
admissions to any hospital within 30 days after
avoided, but whose incidence could be considerably
surgery.
reduced.
Variations in definitions and medical recording
Figure 6.4 illustrates rates for a never event – a foreign body
practices between countries can affect calculation of
left in during a procedure – using both linked and unlinked
rates and limit data comparability in some cases.
data (see the “Definition and comparability” box). The most
Higher adverse event rates may signal more developed
common risk factors for this never event are emergencies,
patient safety monitoring systems and a stronger
unplanned changes in procedure, patient obesity and
patient safety culture rather than worse care.
changes in the surgical team. Preventive measures include
checklists, counting instruments, methodical wound HAI data are based on results of point prevalence
exploration and effective communication among the studies conducted by the Centers for Disease Control
surgical team. and Prevention (CDC) and the European Centre for
Disease Prevention and Control (ECDC) between 2015
Figure 6.5 illustrates rates for an adverse event – the
and 2017 (Magill et al., 2018[2]; Suetens et al., 2018[3]).
percentage of hospital inpatients with health care-
HAI rates are unadjusted and may not reflect rates
associated infections (HAIs) – in OECD countries, together
published elsewhere owing to differences in the
with the proportion of bacteria causing these infections that
infections included. See Suetens et al. (2018[3]) and
are resistanct to antibiotics. HAIs are the single most deadly
Magill et al. (2018[2]) for more details regarding specific
and costly adverse event, representing up to 6% of public
inclusions and exclusions. Country estimates may
hospital budgets (Slawomirski, Auraaen and Klazinga,
reflect different levels of variability based on sampling
2018[1]). This impact is increased by antibiotic-resistant
differences.The HAI rate is presented, along with the
bacteria, which can make HAIs difficult or even impossible
proportion of patients recruited from intensive care
to treat.
units (ICUs). ICU patients may be at greater risk of
On average, across OECD countries, just under 4.9% of developing an HAI. Antibiotic resistance data are based
hospital patients had an HAI in 2015-17. This proportion was on a composite antibiotic resistance indicator
5.2% in 2011-12. The observed proportion of patients was developed by the ECDC (Suetens et al., 2018[3]).
lowest in Lithuania, Latvia and Germany (around 3%) and
highest in Portugal, Greece and Iceland (more than 7%).
Antibiotic resistance rates ranged from 0% in Iceland to
nearly 70% in Latvia, although these rates should be
interpreted with caution due to small sample sizes in some References
cases. [2] Magill, SS. et al. (2018), “Changes in Prevalence of Health
Figure 6.6 shows rates for two related adverse events – Care-Associated Infections in U.S. Hospitals.” New England
pulmonary embolism (PE) and deep vein thrombosis (DVT) Journal of Medicine, 1;379(18):1732-1744. doi: http://
dx.doi.org/10.1056/NEJMoa1801550.
after hip or knee replacement surgery – using both unlinked
and linked data definitions (see the “Definition and [1] Slawomirski, L., A. Auraaen and N. Klazinga (2018), “The
comparability” box). PE and DVT cause unnecessary pain Economics of Patient Safety: Strengthening a value-based
and in some cases death, but they can be prevented by approach to reducing patient harm at national level,” OECD
Health Working Papers, No. 96, OECD Publishing, Paris, https://
anticoagulants and other measures. The large variations
doi.org/10.1787/5a9858cd-en.
observed, including an over 25-fold variation in DVT rates,
may be explained in part by differences in diagnostic [3] Suetens, C. et al. (2018), “Prevalence of healthcare-associated
practices across countries. infections, estimated incidence and composite
antimicrobial resistance index in acute care hospitals and
long-term care facilities: results from two European point
prevalence surveys, 2016 to 2017”, Eurosurveillance, http://
dx.doi.org/10.2807/1560-7917.es.2018.23.46.1800516.

Safe acute care – surgical complications and health care-associated infections
Figure 6.4. Foreign body left in during procedure, 2017 (or nearest year)
Per 100 000 hospital discharges

14 12.3
12 10.9
9.8
10 8.2 8.3
7.2 7.2 7.5 7.6
8 6.3 6.8
5.2
6 4.4 4.7 3.8 4.4
4.6
4 2.8
3.5 3.1 3.3 3.5
1.1 1.7
1.8 2.0 2.1 1.6 1.9 2.1 2.2
2 0.3 0.8
0
Spain
Finland
Spain
OECD19
Finland
Lithuania
OECD12
Sweden
Sweden
Poland
Israel
Netherlands
Australia
Israel
Netherlands
Latvia
Italy
Ireland
Slovenia
Norway
Ireland
Slovenia
Norway
Canada
Germany
United Kingdom
Italy
United States
Belgium
Switzerland
Portugal
New Zealand
Portugal
Using unlinked data Using linked data

Figure 6.5. Percentage of hospitalised patients with at least one health care-associated infection and proportion of
bacteria isolated from these infections resistant to antibiotics, 2015-17
Prevalence of HAI % % resistant

% HAI % resistant
9 90
8 80
7 70
6 60
5 50
4 40
3 30
2 20
1 10
0 0
Note: No resistance data available for Iceland, Norway and the United States.
1. Under 5% of patients from ICUs. 2. Over 5% of patients from ICUs.
Source: ECDC 2016-17 Point prevalence survey. CDC 2015 point prevalence study.
Figure 6.6. Adverse events in hip and knee surgeries: post-operative pulmonary embolism (PE) or deep vein thrombosis
(DVT), 2017 (or nearest year)
PE DVT
Per 100 000 hospital discharges
1800
1600
267
1400
535
1200
1000
357
171
800
339
357
1328
357
267
Estonia 219 148
287
402
311
United States 421 446
OECD12 203 295
Canada 272 554

Israel 328 535
Germany 419 340
600
Belgium 149 255
Sweden 103 344
Finland 358 443

Italy 164 153
Norway 196 177
Israel 279 551
1006
Portugal 99 183
Netherlands 53 211
Ireland 279 372
Netherlands 35 175
Portugal 24 168
New Zealand 153 152

Sweden 66 193
Spain 69 121
Lithuania 32 99
Poland 52 15
Spain 69 84
400
Italy 90 54
Ireland 427
200
Norway 260
Slovenia 200
Switzerland 237
Slovenia 157
Finland 110
United Kingdom 198

OECD21 260
Latvia 44
0
Australia
France
Using unlinked data Using linked data


123
A woman’s safety during childbirth can be assessed by trend is evident in the overall rates of obstetric trauma over
looking at potentially avoidable tearing of the perineum the five-year period: the OECD average remained relative
during vaginal delivery. Tears that extend to the perineal static for vaginal deliveries both with and without
muscles and bowel wall require surgery. Possible instrument. In some countries, including Estonia, Italy and
complications include continued perineal pain and Slovenia, rates appear to have deteriorated.
incontinence. It is not possible to prevent these types of tear In Canada there has been limited action to address the high
in all cases, but they can be reduced by appropriate labour rates of reported obstetric trauma. One initiative was the
management and high-quality obstetric care. Hospital Harm Improvement Resource: Obstetric Trauma by the
The proportion of deliveries involving higher-degree Canadian Patient Safety Institute to complement
lacerations is considered a useful indicator of the quality of measurement of obstetric trauma by the Canadian Institute
obstetric care. Nevertheless, differences in the consistency for Health Information. It links measurement and
with which obstetric units report these complications may improvement by providing evidence-informed resources
make international comparison difficult. that support patient safety improvement efforts across the
Rates of obstetric trauma may be influenced by other care health system.
processes, including the overall national rate of caesarean
births, assisted vaginal births (i.e. using forcepts or a
vacuum) and episiotomy (i.e. surgical incision of the Definition and comparability
perineum performed to widen the vaginal opening for
delivery of an infant); these remain issues of ongoing The two obstetric trauma indicators are defined as the
research. For example, while the World Health Organization proportion of instrument-assisted/non-assisted
(WHO) (2018[1]) does not recommend routine or liberal use vaginal deliveries with third- and fourth-degree
of episiotomy for women undergoing spontaneous vaginal obstetric trauma codes (ICD-10 codes O70.2-O70.3) in
birth, selective use of episiotomy to decrease severe perineal any diagnosis and procedure field.
lacerations during delivery remains a matter of debate. Several differences in data reporting across countries
Figure 6.7 shows rates of obstetric trauma with instrument may influence the calculated rates of obstetric patient
(referring to deliveries using forceps or vacuum extraction) safety indicators. These relate primarily to differences
and Figure 6.8 shows rates of obstetric trauma after vaginal in coding practices and data sources. Some countries
delivery without instrument. As the risk of a perineal report obstetric trauma rates based on administrative
laceration is significantly increased when instruments are hospital data and others based on obstetric register
used to assist the delivery, rates for this patient population data.
are reported separately. Careful interpretation of obstetric trauma for
High variation in rates of obstetric trauma is evident across instrument-assisted delivery rates over time is
countries. Reported rates of obstetric trauma with required, since the very low number of trauma cases in
instrument vary from below 2% in Poland, Israel, Italy, some countries is likely to give rise to significant year-
Slovenia and Lithuania to more than 10% in Denmark, on-year variation.
Sweden, the United States and Canada. The rates of Data for 2012 are not available for Latvia and not
obstetric trauma after vaginal delivery without instrument presented for Belgium, Portugal, Spain and the United
vary from below 0.5 per 100 deliveries in Poland, Lithuania, States due to a break in the series. Rates for Denmark,
Portugal, Latvia and Israel to over 2.5 per 100 deliveries in the Netherlands and Norway are based on registry
Denmark, the United Kingdom and Canada. data.
While the average rate of obstetric trauma with instrument
(5.5 per 100 instrument-assisted vaginal deliveries) across
OECD countries in 2017 was nearly four times the rate
without instrument (1.4 per 100 vaginal deliveries without References
instrument assistance), there are indications of a
[2] Canadian Patient Safety Institute (2018), Hospital Harm
relationship between the two indicators, with Israel,
Improvement Resource: Obstetric Trauma.
Lithuania, Portugal and Poland reporting among the lowest
rates and Canada, Denmark and New Zealand reporting [1] WHO (2018), WHO recommendation on episiotomy policy.
among the highest rates for both indicators.
Rates for both indicators reveal noticeable improvements in
Denmark and Norway between 2012 and 2017, but no clear

Figure 6.7. Obstetric trauma, vaginal delivery with instrument, 2012 and 2017 (or nearest year)
2012 2017
Crude rate per 100 instrument-assisted vaginal deliveries
18
16
16.4
14
11.1
12
10 11.1 11.0 8.5

7.4 7.1
8
6 6.8 4.9 4.5

6.2 6.0 5.5 3.4 2.9
4 2.3
3.7 1.9 1.9 1.7
3.7 1.3
2 2.8 0.7

Figure 6.8. Obstetric trauma, vaginal delivery without instrument, 2007 and 2017 (or nearest year)
2012 2017
Crude rate per 100 vaginal deliveries without instrument assistance
4
3.5
3 3.1
3.0 2.5 2.5 2.4
2.5
2.5
2.3
2 2.1 1.7
1.5
1.5 1.4 1.0
1.4 0.9 0.9 0.9
1 1.2 0.7 0.7
0.5 0.5
0.4 0.3
0.5 0.2


125
Primary care is expected to serve as the first point contact of lowest rates, while Poland, Lithuania and the Slovak
people with health systems, and its functions include health Republic report rates over twice the OECD average.
promotion and disease prevention, managing new health Figure 6.11 reveals that in Korea, Lithuania, Mexico and
complaints, treating the majority of uncomplicated cases, Sweden steady reductions in admission rates for asthma
managing long-term conditions and referring patients to and COPD combined and for CHF have been achieved in
hospital-based services when appropriate. A key aim of recent years, whereas in the Slovak Republic, while rates of
primary care is to keep people well by providing a consistent admission for asthma and COPD have fallen, rates of
point of care over the longer term, treating the most admission for CHF have increased. While observed
common conditions, tailoring and co-ordinating care for improvements in some countries may represent advances
those with multiple health care needs and supporting the in the quality of primary care, recent reviews undertaken by
patient in self-education and self-management. Good the OECD indicate that investment in primary care may still
primary care has, therefore, the potential to improve health, not be happening quickly enough (OECD, 2017[2]),
reduce socio-economic inequalities in health and make potentially resulting in wasteful spending on hospital care
health care systems people-centred, while making better (OECD, 2017[3]).
use of health care resources (OECD, forthcoming [1]).
Asthma, chronic obstructive pulmonary disease (COPD) and
congestive heart failure (CHF) are three widely prevalent Definition and comparability
long-term conditions. Both asthma and COPD limit the
ability to breathe: asthma symptoms are usually The indicators are defined as the number of hospital
intermittent and reversible with treatment, while COPD is a admissions with a primary diagnosis of asthma, COPD
progressive disease that mainly affects current or prior or CHF among people aged 15 years and over per
smokers. CHF is a serious medical condition in which the 100 000 population. Rates are age-sex standardised to
heart is unable to pump enough blood to meet the body’s the 2010 OECD population aged 15 and over.
needs. CHF is often caused by hypertension, diabetes or Admissions resulting from a transfer from another
coronary heart disease. hospital and where the patient dies during admission
Common to all three conditions is the fact that the evidence are excluded from the calculation, as these are
base for effective treatment is well established, and much of considered unlikely to be avoidable.
it can be delivered by primary care. A high-performing Disease prevalence and availability of hospital care
primary care system, where accessible and high-quality may explain some, but not all, variations in cross-
services are provided, can reduce acute deterioration in country rates. Differences in coding practices among
people living with asthma, COPD or CHF. This can avoid the countries may also affect the comparability of data. For
need for hospital admissions to treat these conditions, example, the exclusion of “transfers” cannot be fully
which are used as a marker of quality and access in primary complied with by some countries. Differences in data
care. coverage of the national hospital sector across
Figure 6.9 shows hospital admission rates for asthma and countries may also influence rates.
COPD together, given the physiological relationship
between the two conditions. Admission rates specifically for
asthma vary 12-fold across OECD countries, with Mexico,
Italy and Colombia reporting the lowest rates and Latvia, References
Turkey and Poland reporting rates over twice the OECD
[1] OECD (forthcoming), Doing Things Differently: Towards better
average. International admission rates specifically for COPD
primary care in the 21st century, OECD Publishing, Paris.
vary 15-fold across OECD countries, with Japan, Italy and
Mexico reporting the lowest and Hungary, Turkey and [2] OECD (2017), Caring for Quality in Health: Lessons Learnt from 15
Reviews of Health Care Quality, OECD Reviews of Health Care
Australia the highest rates. A lower 7-fold variation across
Quality, OECD Publishing, Paris, https://dx.doi.org/
countries is seen for the two respiratory conditions
10.1787/9789264267787-en.
combined.
[3] OECD (2017), Tackling Wasteful Spending on Health, OECD
Hospital admission rates for CHF vary 13-fold, as shown in Publishing, Paris, https://dx.doi.org/10.1787/9789264266414-
Figure 6.10. Costa Rica, Mexico and Colombia have the en.

Figure 6.9. Asthma and COPD hospital admission in adults, Figure 6.10. Congestive Heart Failure (CHF) hospital
2017 (or nearest year) admission in adults, 2017 (or nearest year)
Asthma COPD CHF
Hungary 428 Poland 511

Turkey 425 Lithuania 503
Australia 403 Slovak Republic 479
New Zealand 363 Hungary 441
Ireland 329 Germany 389
Denmark 325 United States 371
Belgium 291 Czech Republic 354
Germany 289 Finland
United Kingdom 281 286
United States 268 France 266
Lithuania 263 Italy 250
Korea 263 Estonia 249
Canada 253 Austria 236
Austria 248 Sweden 234
Norway 244 OECD34 233
Latvia 242 Australia 227
Netherlands 236 Israel 226
Poland 236 Slovenia 224
OECD35 225 New Zealand 216
Israel 214
Spain 210 Belgium 189
Slovak Republic 209 Switzerland 174
Luxembourg¹ 203 Canada 169
Iceland¹ 201 Norway 164
Finland 182 Iceland¹ 163
Czech Republic 174 Netherlands 153
Sweden 169 Spain 143
France 150 Denmark 140
Switzerland 138 Turkey 126
Colombia 132 Ireland 117
Slovenia 128 Portugal
Costa Rica 126 111
Estonia 122 United Kingdom 99
Chile 98 Chile 96
Portugal 90 Korea 88
Mexico 85 Colombia 61
Italy 64 Mexico 57
Japan 58 Costa Rica 39
0 100 200 300 400 500 0 100 200 300 400 500
Age-sex standardised rates per 100 000 population Age-sex standardised rates per 100 000 population
1. Three-year average. 1. Three-year average.

Source: OECD Health Statistics 2019. Source: OECD Health Statistics 2019.
StatLink 2 https://doi.org/10.1787/888934016113 StatLink 2 https://doi.org/10.1787/888934016132
Figure 6.11. Trends in hospital admission in adults, selected countries 2007‑17 (or nearest year)
Asthma and COPD CHF
Korea Lithuania Mexico Slovak Republic Sweden

Age-sex standardised rates per 100 000 population Age-sex standardised rates per 100 000 population
750 750
500 500
250 250
0 0
2012 2013 2014 2015 2016 2017 2012 2013 2014 2015 2016 2017


127
Diabetes care
Effective management of diabetes remains a public health

priority, with over 425 million people living with the Definition and comparability
condition worldwide. Diabetes is a chronic disease that
occurs when the body’s ability to regulate excessive glucose Diabetes avoidable admission is based on the sum of
levels in the blood is diminished. It is a leading cause of three indicators: admissions for short-term and long-
cardiovascular disease, blindness, kidney failure and lower term complications and for uncontrolled diabetes
limb amputation. Diabetes caused 4 million deaths in 2017, without complications. The indicator is defined as the
and it is projected that by 2045 over 629 million adults will number of hospital admissions with a primary
have the condition (IDF, 2017[1]). diagnosis of diabetes among people aged 15 years and
over per 100 000 population.
Ongoing management of diabetes usually involves a
considerable amount of self-care; therefore, advice and The denominator of people with diabetes who have
education are central to the primary care of people with recommended antihypertensive medication
diabetes (OECD, 2019[2]). Effective control of blood glucose prescriptions is based on people with diabetes (i.e. who
levels through routine monitoring, dietary modification and are long-term users of glucose-regulating medication)
regular exercise can reduce the onset of serious who also have one or more prescriptions per year from
complications and the need for hospitalisation (Wolters, a range of medications often used in the management
Braspenning and Wensing, 2017[3]). Management of other of hypertension. The numberator is the number of
key risk factors such as smoking, blood pressure and lipid these people who have one or more prescriptions of an
levels is also important in reducing complications of angiotensin converting enzyme inhibitor (ACE-I) or
diabetes. angiotensin receptor blocker (ARB).
Figure 6.12 shows avoidable hospital admissions for Major lower extremity amputation in adults with
diabetes. While admissions have fallen in many countries diabetes is defined as the number of discharges of
over time, a more than 5-fold variation in the rates is still people aged 15 years and over per 100 000 population.
evident across countries. Iceland, Italy and Spain report the Rates for these indicators have been directly age-
lowest rates, with Mexico and Korea reporting rates nearly standardised to the 2010 OECD population.
twice the OECD average. Prevalence of diabetes may explain Differences in data definition, coding practices and
some of this variation. A positive relationship can be indicator calculation methods between countries may
demonstrated between overall hospital admissions and affect comparability of data. Differences in data
admissions for diabetes, providing some indication that coverage of the national hospital sector across
access to hospital care can also play a role in explaining countries may also influence indicator rates.
international variation (OECD, 2015[4]).
In all instances, national data are reported. Variations
In diabetic individuals with hypertension, angiotensin- in the coverage and national representativeness of the
converting enzyme inhibitors (ACE-Is) or angiotensin indicators for countries are documented in the sources
receptor blockers (ARBs) are recommended in most national and methods information in OECD.Stat.
guidelines as first-line medications to reduce blood
pressure. Figure 6.13 reveals broad consistency in the
proportion of diabetic patients on recommended
antihypertensive medications: only Finland, Belgium and
Korea have rates lower than 80%.
References
Hospital admissions for major lower extremity amputation [1] IDF (2017), IDF Diabetes Atlas Eighth Edition 2017, International
Diabetes Federation, http://www.diabetesatlas.org.
reflect the long-term quality of diabetes care. Figure 6.14
shows the rates of amputations among adults with diabetes. [2] OECD (2019), “Realising the Full Potential of Primary Health
The international variation is over 20-fold, with Iceland, Care”, OECD, Paris, http://www.oecd.org/health/health-
Italy, Korea and the United Kingdom reporting rates lower systems/OECD-Policy-Brief-Primary-Health-Care-May-2019.pdf.
than 3 per 100 000 general population and Costa Rica, Israel, [4] OECD (2015), Cardiovascular Disease and Diabetes: Policies for
Mexico and Austria reporting rates above 13 per 100 000. Better Health and Quality of Care, OECD Health Policy Studies,
OECD Publishing, Paris, https://dx.doi.org/10.1787/9789264
The relationship between the nature, frequency and
233010-en.
duration of primary care for diabetes and the rate of
admissions to hospital for related complications is complex [3] Wolters, R., J. Braspenning and M. Wensing (2017), “Impact of
and still not well understood. In its ongoing attempts to primary care on hospital admission rates for diabetes
patients: A systematic review”, Diabetes Research and Clinical
contribute to reductions in knowledge gaps, the OECD is
Practice, Vol. 129, pp. 182-196, http://dx.doi.org/10.1016/
working to establish an international survey of patients with j.diabres.2017.05.001.
chronic conditions, including diabetes, to capture their self-
reported health outcomes and better understand their
primary care context. This survey is central to the Patient-
Reported Indicators Surveys (PaRIS) initiative (https://
www.oecd.org/health/paris.htm).

Diabetes care
Figure 6.12. Diabetes hospital admission in adults, 2012 and 2017 (or nearest year)
2012 2017
Age-sex standardised rates per 100 000 population
400
350
300
250
200
249
245
222
219
218
150
210
209
170
100
165
73
162
156
151
148
144
42
139
129
119
119
117
50
108
102
98
96
96
77
66
59
74
78
62
52
79
43
45
Figure 6.13. People with diabetes prescribed recommended antihypertensive medication in the past year, 2017 (or nearest year)
% of patients with diabetes

100 88.7 89.2 89.6 89.9 90.3
82.5 82.9 83.6 84.8 85.0 85.1 85.5 86.1
90 80.5 80.6 80.9 82.0
78.0
80 73.0
70 60.1
60
50
40
30
20
10
0
Figure 6.14. Major lower extremity amputation in adults with diabetes, 2012 and 2017 (or nearest year)
2012 2017
Age-sex standardised rates per 100 000 population
25
20.0
20
15
16.8
10 8.7 13.2 13.7
7.4 7.8
10.4
3.0 3.1 3.6 4.4
5 1.6
7.1 7.8 8.2
0.9
4.1 4.3 5.7 5.9 5.9 6.0 6.4 6.4 6.5
2.1 3.1 3.4 3.9 3.9 3.9
0

129
Stroke is the second leading global cause of death behind based medical interventions and access to high-quality
heart disease and accounted for over 10% of total deaths specialised facilities such as stroke units (OECD, 2015[3]).
worldwide in 2013 (American Heart Association, 2017[1]). A Timely care is particularly important, and advances in
stroke occurs when the blood supply to a part of the brain is technology are leading to new models of care to deliver
interrupted, leading to necrosis (cell death) of the affected reperfusion therapy in an even more speedy and efficient
part. Of the two types of stroke, about 85% are ischaemic manner, whether through pre-hospital triage via telephone
(caused by clotting) and 15% are haemorrhagic (caused by or administering the therapy in the ambulance (Chang and
bleeding). Prabhakaran, 2017[4]).
Figure 6.15 shows the case-fatality rates within 30 days of
hospital admission for ischaemic stroke where the death
occurred in the same hospital as the initial admission Definition and comparability
(unlinked data). Figure 6.16 shows the case-fatality rate
where deaths are recorded regardless of where they National case-fatality rates are defined in indicator
occurred, including in another hospital or outside the “Mortality following acute myocardial infarction”.
hospital where the stroke was first recorded (linked data). Hospital-level stroke mortality rates use a different
The indicator using linked data is more robust because it methodology from national rates. Hospital rates are
captures fatalities more comprehensively than the same- adjusted for age, sex, co-morbidity, stroke severity and
hospital indicator, but it requires a unique patient identifier previous stroke (linked data only). The reference
and linked data, which are not available in all countries. population for hospital rates is constructed from data
Across OECD countries, 7.7% of patients in 2017 died within from participating countries. The hospital-level
30 days of hospital admission for ischaemic stroke using ischaemic stroke definition also differs from the
unlinked data (Figure 6.15). The case-fatality rates were national indicator, using only ICD-10 code I63 (cerebral
highest in Slovenia, Poland, Lithuania and Latvia, all with infarction).
mortality rates over 12%. Rates were less than 4% in Norway, Figure 6.17 is a turnip plot that graphically represents
Korea, Japan and Costa Rica. Low rates in Japan are due in the relative dispersion of rates. A limitation of this type
part to recent efforts dedicated to improving the treatment of representation is the inability to detect statistically
of stroke patients in hospitals, through systematic blood significant variations. Countries are ordered according
pressure monitoring, major material investment in to ascending level of dispersion as measured by the
hospitals and establishment of stroke units (OECD, 2015[2]). interquartile range (between the 25th and 75th
Across the 23 countries that reported linked data rates, percentile) of rates. Hospitals with fewer than 50
12.3% of patients died within 30 days of being admitted to ischaemic stroke admissions were excluded from both
hospital for stroke (Figure 6.16). This figure is higher than figures to improve data reliability.
the same-hospital indicator because it only counts each
patient once and captures all deaths.
Treatment for ischaemic stroke has advanced dramatically
over the last decade, with systems and processes now in References
place in many OECD countries to identify suspected [1] American Heart Association (2017), Heart Disease and Stroke
ischaemic stroke patients as early as possible and to deliver Statistics 2017 at-a-Glance.
acute reperfusion therapy quickly. Between 2007 and 2017,
[4] Chang, P. and S. Prabhakaran (2017), “Recent advances in the
case-fatality rates for ischaemic stroke decreased management of acute ischemic stroke”, F1000Research,
substantially across OECD countries: from 10.1% to 7.7% for http://dx.doi.org/10.12688/f1000research.9191.1.
unlinked data rates and from 14.6% to 12.6% for linked data
rates.
Better Health and Quality of Care, OECD Health Policy Studies,
National measures of ischaemic stroke are affected by OECD Publishing, Paris, https://dx.doi.org/
within-country variations in performance at the hospital 10.1787/9789264233010-en.
level. Reducing this variation is key to providing equitable [2] OECD (2015), OECD Reviews of Health Care Quality: Japan
care and reducing overall mortality rates. Figure 6.17 2015: Raising Standards, OECD Reviews of Health Care
presents the dispersion of ischaemic stroke 30-day case- Quality, OECD Publishing, Paris, https://dx.doi.org/
fatality rates across hospitals within countries, using both 10.1787/9789264225817-en.
unlinked and linked data.
Reducing this variation requires high-quality stroke care for
all, including timely transportation of patients, evidence-

Figure 6.15. Thirty-day mortality after admission to hospital for ischaemic stroke based on unlinked data, 2007 and 2017
(or nearest year)
2007 2017
Age-sex standardised rate per 100 admissions of adults aged 45 years and over
30
25
20.4
15.6
20
15
12.8
10
12.2
3.0
10.1
2.8
9.6
9.4
8.8
9.0
8.3
8.3
8.3
8.7
8.0
5
7.9
8.0
7.7
7.7
7.1
6.2
6.3
6.0
6.1
6.0
5.9
5.3
5.7
5.4
4.1
3.7
4.2
4.2
4.1
3.2
Figure 6.16. Thirty-day mortality after admission to hospital for ischaemic stroke based on linked data, 2007 and 2017 (or
nearest year)
2007 2017
Age-sex standardised rate per 100 patients aged 45 years and over
30
28.2
25
20
20.5
15
17.3
16.4
15.8
14.8
14.0
10
12.3
12.0
12.2
11.6
11.4
10.2
10.3
10.3
10.0
9.8
9.4
9.3
9.3
8.7
8.5
5
6.2
5.7
1. Three-year average. 2. Results for Canada do not include deaths outside acute care hospitals.
Figure 6.17. Variations across hospitals in 30-day mortality after admission for ischaemic stroke using linked and
unlinked data, 2015-17
Note: The width of each line in the figure represents the number of hospitals (frequency) with the corresponding rate.
Source: OECD Hospital Performance Data Collection 2019.

131
Mortality due to coronary heart disease has declined

substantially since the 1970s (see indicator “Mortality from Definition and comparability
circulatory diseases” in Chapter 3). Important advances in
both prevention policies, such as for smoking (see indicator The case-fatality rate measures the percentage of
“Smoking among adults” in Chapter 4), and treatment of people aged 45 and over who die within 30 days
cardiovascular diseases have contributed to these declines following admission to hospital for a specific acute
(OECD, 2015[1]). A good indicator of acute care quality is the condition. Rates based on unlinked data only consider
30-day AMI case-fatality rate. The measure reflects the deaths occurring in the same hospital as the initial
processes of care, including timely transport of patients and admission. Rates based on linked data consider deaths
effective medical interventions. that occurred anywhere including in or outside
hospital. While the linked data-based method is
Figure 6.18 shows the case-fatality rates within 30 days of
considered more robust, it requires a unique patient
admission for AMI where the death occurs in the same
identifier to link the data across the relevant datasets,
hospital as the initial AMI admission. This method of
which is not available in all countries.
calculating the indicator is influenced by not only the
quality of care provided in hospitals but also differences in National rates are age-sex standardised to the 2010
hospital transfers and average length of stay. The lowest OECD population aged 45 and over admitted to
rates are found in Iceland, Denmark, Norway, the hospital for AMI (ICD-10 codes I21-I22) and ischaemic
Netherlands, Australia and Sweden (all 4% or less). The stroke (ICD-10 codes I63-I64).
highest rates are in Latvia and Mexico, suggesting that AMI Hospital-level AMI mortality rates use a different
patients do not always receive recommended care in these methodology from national rates. Hospital rates are
countries. In Mexico, the absence of a co-ordinated system adjusted for age, sex, co-morbidity and previous AMI
of care between primary care and hospitals may contribute (linked data only). The reference population for
to delays in reperfusion and low rates of angioplasty hospital rates is constructed from data from
(Martínez-Sánchez et al., 2017[2]). participating countries (Padget, forthcoming[4]).
Figure 6.19 shows 30-day case-fatality rates where fatalities Figure 6.20 is a turnip plot that graphically represents
are recorded regardless of where they occur (including after the relative dispersion of rates. A limitation of this type
transfer to another hospital or after discharge). This is a of representation is the inability to detect statistically
more robust indicator because it records deaths more widely significant variations. Countries are ordered according
than the same-hospital indicator, but it requires a unique to ascending level of dispersion as measured by the
patient identifier and linked data, which are not available in interquartile range (between the 25th and 75th
all countries. The AMI case-fatality rate in 2017 ranged from percentile) of rates. Hospitals with fewer than 50 AMI
4.0% in the Netherlands to 16.5% in Latvia. admissions were excluded from both figures to
Case-fatality rates for AMI decreased substantially between improve data reliability.
2007 and 2017 (Figure 6.18 and Figure 6.19). Across OECD
countries, case fatalities fell from 9.5% to 6.9% when
considering same-hospital deaths and from 12.5% to 9.1%
when considering deaths in and out of hospital. References
Variations in AMI 30-day case-fatality rates at the national
[4] Padget, M. (forthcoming), “OECD Hospital Performance
level are influenced by the dispersion of rates across Project: Methodological Development of International
hospitals within countries, as represented in Figure 6.20. Measurement of Acute Myocardial Infraction 30-Day
The interquartile range of rates within countries varies Mortality Rates at the Hospital Level”, OECD Health Working
markedly. The differences between the upper and lower Papers, OECD Publishing, Paris.
rates are 1.9 deaths per 100 admissions for Sweden and 4.1 [3] Lalloué, B. et al. (2019), “Does size matter? The impact of
deaths per 100 admissions for Korea (based on linked data). caseload and expertise concentration on AMI 30-day
Multiple factors contribute to variations in outcomes of care, mortality-A comparison across 10 OECD countries.”, Health
including hospital structure, processes of care and policy (Amsterdam, Netherlands), Vol. 123/5, pp. 441-448, http://
dx.doi.org/10.1016/j.healthpol.2019.03.007.
organisational culture. Recent research points to higher
total numbers of hospital patients as being significantly [2] Martínez-Sánchez, C. et al. (2017), “Reperfusion therapy of
related to higher performance; this may support national myocardial infarction in Mexico: A challenge for modern
movements towards concentration of care services (Lalloué cardiology.”, Archivos de cardiologia de Mexico, Vol. 87/2,
pp. 144-150, http://dx.doi.org/10.1016/j.acmx.2016.12.007.
et al., 2019[3]).
Better Health and Quality of Care, OECD Health Policy Studies,
OECD Publishing, Paris, https://dx.doi.org/
10.1787/9789264233010-en.

Figure 6.18. Thirty-day mortality after admission to hospital for AMI based on unlinked data, 2007 and 2017 (or nearest year)
2007 2017
Age-sex standardised rate per 100 admissions of adults aged 45 years and over
30
27.5
25
20
15
13.4
10
9.6
9.7
9.6
8.6
8.5
5
8.5
8.2
8.0
6.8
6.9
6.5
6.8
7.0
7.3
6.2
6.2
5.9
5.6
3.2
5.5
4.8
2.3
5.0
5.6
4.7
3.5
3.9
5.4
5.4
3.8
3.5
4.1
4.1
Figure 6.19. Thirty-day mortality after admission to hospital for AMI based on linked data, 2007 and 2017 (or nearest year)
2007 2017
Age-sex standardised rate per 100 patients aged 45 years and over
30
25
20
15
16.5
13.6
10
13.1
12.6
12.3
12.0
11.1
10.8
10.1
8.8
9.1
8.6
7.7
5
8.0
7.9
7.0
7.5
7.5
7.6
7.0
7.3
6.9
7.2
7.2
7.2
7.0
4.0
1. Three-year average. 2. Results for Canada do not include deaths outside acute care hospitals.
Figure 6.20. Variations across hospitals in 30-day mortality after admission for AMI using linked and unlinked data, 2015-17
Note: The width of each line in the figure represents the number of hospitals (frequency) with the corresponding rate.
Source: OECD Hospital Performance Data Collection 2019.

133
Hip and knee replacement surgeries can be effective The biggest improvement was observed in Israel (from 68%
treatments for patients with chronic conditions such as to 89%). Targeted policies that effectively incentivise timely
osteoarthritis (OA). Surgeries to repair hip fractures are also surgery following hip fracture admission could partly
common and effective. Ageing and a loss of skeletal strength explain this result. Iceland, the Czech Republic, Portugal and
from osteoporosis are the main risk factors associated with Latvia reported a decline in the proportion over this period,
a hip fracture, typically sustained during a fall. In most suggesting a need for policy interventions.
instances, surgical intervention is required to repair or
replace the fractured hip joint.
Treatment of patients with hip and knee OA aims to reduce Definition and comparability
the patient’s joint pain and improve their function, mobility
and quality of life (QoL). Surgery is generally recommended The PROM results are based on data from adult
if symptoms substantially affecting QoL persist after patients undergoing elective hip or knee replacement
exhausting non-surgical treatment (NICE, 2014[1]). Age- with a principal diagnosis of OA, who completed an
standardised hip and knee replacement rates have risen Oxford Hip/Knee Score and/or H/KOOS questionnaire
over the past decade, and vary up to five-fold within and pre- and post-operatively (OECD, forthcoming[5]). On
between countries (OECD, 2014[2]). both scales, a higher score denotes better outcomes.
Figure 6.21 shows the crude mean scores submitted by Data collection at 6 months versus 12 months
patients before and at 6 or 12 months after elective hip influences the results. The size of participating
replacement surgery for OA in a set of national or sub- programmes varied from entire countries to single
national joint replacement programmes using the Oxford hospitals. For further details of the methodological
Hip Score and HOOS-PS, which are validated patient- approach and issues regarding comparability, refer to
reported outcome measures (PROMs) that have been Chapter 2.
developed specifically for hip and knee pain. In all Hip fracture indicator is defined as the proportion of
programmes, the average patient reported a higher score patients aged 65 years and over admitted to hospital in
following surgery, suggesting a positive outcome on a specified year with a diagnosis of upper femur
average. fracture, who had surgery initiated within two
Figure 6.22 shows the crude mean scores submitted by calendar days of their admission to hospital. The
patients before and 6 or 12 months after elective knee capacity to capture time of admission and surgery in
replacement surgery for OA in national and sub-national hospital administrative data varies across countries,
programmes using the Oxford Knee Score and KOOS-PS resulting in the inability to precisely record surgery
instruments. On average, knee replacement patients also within 48 hours in some countries.
reported improvement after surgery in all programmes. The While cases where the hip fractures occurred during
amount of improvement for knee replacement was, on the admission to hospital should be excluded, not all
average, more modest than that reported by hip countries have a ‘present on admission’ flag in their
replacement patients. However, patients recovering from datasets to enable them to identify such cases
knee arthroplasty may take longer to recover. Further accurately.
results and analysis of these measures are provided in
Chapter 2.
While a hip replacement for OA is an elective procedure, hip
fracture repair is usually an emergency procedure. Evidence References
suggests that early surgical intervention improves patient
[3] National Clinical Guideline Centre (2011), The management of
outcomes and minimises the risk of complication. There is hip fracture in adults, National Clinical Guideline Centre,
general agreement that surgery should occur within two London, http://www.ncgc.ac.uk.
days (48 hours) of hospital admission (National Clinical
[1] NICE (2014), Osteoarthritis: care and management, The
Guideline Centre, 2011[3]).
National Institute for Health and Care Excellence.
Time-to-surgery (TTS) is considered a clinically meaningful
[2] OECD (2014), Geographic Variations in Health Care: What Do We
process indicator of the quality of acute care for patients
Know and What Can Be Done to Improve Health System
with hip fracture. However, TTS is influenced by many Performance?, OECD Health Policy Studies, OECD Publishing,
factors, including hospitals’ surgical theatre capacity, flow Paris, https://dx.doi.org/10.1787/9789264216594-en.
and access, and targeted policy interventions, including
[5] OECD (forthcoming), “Patient-reported outcome indicators in
public reporting and monitoring of performance (Siciliani,
joint replacement and breast cancer surgery”, OECD Health
Borowitz and Moran, 2013[4]). Working Papers, OECD Publishing, Paris.
In 2017, on average across OECD countries, over 80% of [4] Siciliani, L., M. Borowitz and V. Moran (eds.) (2013), Waiting
patients admitted for hip fracture underwent surgery within Time Policies in the Health Sector: What Works?, OECD Health
two days (Figure 6.23) This represents a modest increase of Policy Studies, OECD Publishing, Paris, https://dx.doi.org/
2.7 percentage points (from 78.2% to 80.9%) since 2012. 10.1787/9789264179080-en.

Figure 6.21. Crude mean pre- and post-operative Oxford Hip Score and HOOS-PS, 2013-16 (or nearest year)
mean pre-op mean post-op mean pre-op mean post-op

48 100
44 44.4
42.8 41.4 42.2 90
40 40.0 86.7
80 82.0
36
32 70
28 60
24 50 52.2 53.5
23.3
20 19.8 40
18.1 18.5
16 15.9 30
12
Oxford hip score 20 HOOS-PS
8
4 10
0 0
Australia-ACORN¹ Canada-Manitoba England¹ Finland-Coxa Netherlands Netherlands Italy-Galeazzi¹
1. Post-operative measurement at six months.

Figure 6.22. Crude mean pre- and post-operative Oxford Knee Score and KOOS-PS, 2013-16 (or nearest year)
mean pre-op mean post-op mean pre-op mean post-op

48 100
44 90
40 41.1
38.4 37.7 39.2 80
36 35.7
70 70.7 71.9
32 66.5
28 60
24 23.6 50 47.8 49.2
21.4 21.6 46.5
20 18.6 19.5 40
16
30
12
8 20
Oxford Knee Score KOOS-PS
4 10
0 0
Australia-ACORN¹ England¹ Finland-Coxa Canada-Manitoba Netherlands Sweden Italy-Galeazzi¹ Netherlands
1. Post-operative measurement at six months.

Figure 6.23. Hip fracture surgery initiation within two days of admission to hospital, 2012 and 2017 (or nearest year)
2012 2017
% of patients aged 65 years and over being operated on within 2 days
100 91.4 90.8 88.7 88.6 88.5 86.8
90 80.9
80 96.9 96.0 96.0 94.9 92.8 92.4 69.5
90.7 87.0
70 85.6 84.0
80.5 53.2 51.9
60 70.8
50 37.3
40
30 43.5 40.6
20
10 24.9
0


135
The burden of mental illness is substantial, affecting an In addition, in several countries including Australia, Sweden
estimated one in five people among the population of OECD and France, people diagnosed with a mental health problem
countries at any given time, and one in two across the life are more likely to have received conflicting information
course (see indicator “Mental health” in Chapter 3). The total from different health care professionals (see Chapter 2). This
cost of mental ill health is estimated at between 3.5% and 4% suggests that there is a room to improve the quality of care
of GDP in OECD countries (OECD, 2018[1]). High-quality, for people with mental health problems.
timely care has the potential to improve outcomes and may
help reduce suicide and excess mortality for individuals
with mental disorders. Definition and comparability
High-quality care for mental disorders in inpatient settings
is vital, and inpatient suicide is a “never” event, which The inpatient suicide indicator is composed of a
should be closely monitored as an indication of how well denominator of patients discharged with a principal
inpatient settings are able to keep patients safe from harm. diagnosis or first two secondary diagnosis code of
Most countries report inpatient suicide rates below 10 per mental health and behavioural disorders (ICD-10 codes
10 000 patients, but Denmark is an exception, with rates of F10-F69 and F90-99) and a numerator of these patients
over 10 (Figure 6.24). Steps to prevent inpatient suicide with a discharge code of suicide (ICD-10 codes X60-
include identification and removal of likely opportunities for X84). Data should be interpreted with caution due to a
self-harm, risk assessment of patients, monitoring and very small number of cases. Reported rates can vary
appropriate treatment plans. While inpatient suicide should over time, so where possible a three-year average has
be considered a never event, some practices that reduce risk been calculated to give more stability to the indicator,
of inpatient suicide – such as use of restraints – may impede except for New Zealand.
high-quality care. Suicide within 30 days and within one year of
Suicide rates after hospital discharge can indicate the discharge is established by linking discharge following
quality of care in the community, as well as co-ordination hospitalisation with a principal diagnosis or first two
between inpatient and community settings. Across OECD listed secondary diagnosis code of mental health and
countries, suicide rates among patients who had been behavioural disorders (ICD-10 codes F10-F69 and
hospitalised in the previous year was as low as 10 per 10 000 F90-99) with suicides recorded in death registries
patients in Iceland and the United Kingdom but higher than (ICD-10 codes X60-X84).
50 per 10 000 in the Netherlands, Slovenia and Lithuania For the excess mortality indicators, the numerator is
(Figure 6.25). Patients with a psychiatric illness are the overall mortality rate for persons aged between 15
particularly at risk immediately following discharge from and 74 diagnosed with schizophrenia or bipolar
hospital, but it is known that suicide in the high-risk days disorder. The denominator is the overall mortality rate
following discharge can be reduced by good discharge for the general population in the same age group. The
planning and follow-up, and enhanced levels of care relatively small number of people with schizophrenia
immediately following discharge. or bipolar disorder dying in any given year can cause
Individuals with a psychiatric illness have a higher mortality substantial variations from year to year, so three-year
rate than the general population. An “excess mortality” averages were presented.
value that is greater than one implies that people with For information on patient experience monitoring see
mental disorders face a higher risk of death than the rest of the 2016 Commonwealth Fund International Health
the population. Figure 6.26 shows the excess mortality for Policy Survey of Adults. Differences between countries
schizophrenia and bipolar disorder, which is above two in should be interpreted with care, given the
most countries. In order to reduce their high mortality, a heterogeneity in nature and the size of country
multifaceted approach is needed for people with mental samples.
disorders, including primary care prevention of physical ill
health, better integration of physical and mental health
care, behavioural interventions and changing professional
attitudes (OECD, 2014[2]).
References
Patient experiences can also shed light on the quality of care
[1] OECD (2018), Health at a Glance: Europe 2018: State of Health in
provided to individuals diagnosed with a mental problem.
the EU Cycle, OECD Publishing, Paris/European Union,
On average across OECD countries, patients diagnosed with Brussels, https://dx.doi.org/10.1787/health_glance_eur-2018-en.
a mental health problem are less likely to report that they
[2] OECD (2014), Making Mental Health Count: The Social and
were treated with courtesy and respect by doctors and
Economic Costs of Neglecting Mental Health Care, OECD Health
nurses during hospitalisation than hospitalised patients
Policy Studies, OECD Publishing, Paris, https://dx.doi.org/
never diagnosed with a mental health problem (Figure 6.27). 10.1787/9789264208445-en.

Figure 6.24. Inpatient suicide among patients with a Figure 6.25. Suicide following hospitalisation for a
psychiatric disorder, 2015-17 (or nearest year) psychiatric disorder, within 30 days and one year of
discharge, 2017 (or nearest year)
Within 30 days of discharge Within one year of discharge

Age-sex standardised rate per 10 000 patients Age-sex standardised rate per 10 000 patients
25 120
8.6
20 100
11.1
53.1
80
52.7
15
5.3
6.6
48.0
40.3
37.6
7.7
37.9
60
6.4
35.5
4.4
34.3
32.9
10
26.7
6.1
25.8
17.5
21.1
19.7
40
2.7
15.8
2.5
13.5
2.8
15.7
12.2
13.8
3.5
12.4
12.0
10.7
10.2
1.5
2.1
5
1.7
1.9
6.1
101.6
1.1
7.9
0.6
0.6
6.8
0.7
6.0
20
0.4
1.0
0.3
1.0
0.0
2.5
1.8
0 0
Note: H lines show 95% confidence intervals. 1. Three-year average.

Figure 6.26. Excess mortality from bipolar disorder and schizophrenia, 2015-17
Bipolar disorders Schizophrenia

Ratio
7
6.1
5.3
6
4.8
4.7
4.6
4.4
4.3
4.2
4.0
4.0
3.7
3.7
3.4
3.1
4
2.9
2.7
2.7
2.6
2.5
2.1
1.9
1.9
1.8
1.3
2
1
0
Note: Data represent a three-year average except for the Netherlands (two-year average).
Figure 6.27. Share of people who were treated with courtesy and respect by doctors and nurses during hospitalisation, 2016
People with mental health problem People without mental health problem
%
100
90
80
70
60
50
40
30
20
88.3
81.9
87.3
82.5
81.0
90.0
80.4
94.4
80.1
91.5
78.6
93.6
77.5
81.5
76.7
89.1
75.2
89.1
61.2
87.1
10
0
Germany New Zealand Sweden Netherlands Switzerland Australia United States OECD9 Norway Canada
Note: H lines show 95% confidence intervals.

Source: Commonwealth Fund International Health Policy Survey 2016.

137
Breast cancer is the cancer with the highest incidence

among women in all OECD countries, and the second most Definition and comparability
common cause of cancer death among women (see indicator
“Cancer incidence and mortality” in Chapter 3). The stage at diagnosis for breast cancer is categorised
according to the Tumour, Nodes, Metastasis (TNM)
During 2010-14, an average of 51.5% of women with breast
staging system. In this analysis, “early or localised
cancer were diagnosed at an early stage of disease in OECD
stages” refers to tumours without lymph node
countries, while 8.6% of women were diagnosed at an
involvement or metastasis (T1-3, N0, M0),
advanced stage (Figure 6.28). Countries with a high
“intermediate stage” refers to tumours with lymph
proportion of women diagnosed at an early stage, such as
node involvement but no metastasis (T1-3, N1-3, M0),
the United States and Japan, have a correspondingly low
and “advanced stage” refers to large tumours with
proportion of women diagnosed at an advanced stage. Since
ulceration or involvement of the chest wall, and those
the 1980s, most OECD countries have adopted breast cancer
that have metastasised to other organs (T4, any N, M0
screening programmes as an effective way of detecting the
or M1).
disease early (OECD, 2013[1]). This has contributed to higher
proportions of women being diagnosed at an early stage. Five-year net survival refers to the cumulative
probability that the cancer patients would have lived
In most OECD countries, five-year net survival for women
five years after diagnosis if the cancer was the only
with breast cancer has improved in recent years, reflecting
possible cause of death. The period approach is used to
overall improvement in the quality of cancer care (Allemani
allow estimation of five-year survival where five years
et al., 2018[2]). In all OECD countries, for women diagnosed
of follow-up are not available. Cancer survival
at early or localised stage, the cumulative probability of
estimates are age-standardised with the International
surviving their cancer for at least five years is 90% and the
Cancer Survival Standard weights.
international variation is small (Figure 6.29). However, net
survival for women diagnosed at an advanced stage is still Cancer patient data were provided by national or
low and ranges widely, from about 30% in Austria and regional cancer registries. Quality control and analysis
Lithuania to over 50% in Israel and Finland. for stage distribution and age-standardised five-year
net survival were performed centrally as part of
Motivated providers and patients across OECD countries are
CONCORD, the global programme for the surveillance
increasingly using patient-reported outcome measures
of cancer survival, led by the London School of Hygiene
(PROMs) for breast cancer to help inform difficult clinical
and Tropical Medicine (Allemani et al., 2018[2]).
decisions. Figure 6.30 presents crude outcome scores at
6-12 months following breast surgery (breast-conserving See Box 2.3 in Chapter 2 for more details regarding the
therapy and breast reconstruction) for 11 clinical sites from BREAST-Q breast satisfaction scale used to measure
eight countries. Outcomes were measured using the the breast cancer PROMs. Data are only presented for
relevant post-operative breast satisfaction scales from the selected sites and are not representative for each
BREAST-Q tool, an internationally validated instrument country. Note that measurement extended beyond
used to measure breast surgery outcomes reported by 12 months after surgery for sites in Sweden and
patients (Pusic et al., 2009[3]). Further results and analysis of Switzerland.
this measure are provided in Chapter 2.
Figure 6.31 presents the proportion of women undergoing
implant and autologous reconstruction surgery in the
sample from each site. Consolidated crude scores from the References
participating sites indicate that women are about 10%
[2] Allemani, C. et al. (2018), “Global surveillance of trends in
(6 percentage points) more satisfied with their breasts after cancer survival 2000–14 (CONCORD-3): analysis of individual
autologous reconstruction surgery than after implant records for 37 513 025 patients diagnosed with one of 18
reconstruction (see Figure 2.9 in Chapter 2). This outcome cancers from 322 population-based registries in 71
aligns with existing evidence (Matros et al., 2015[4]) and can countries”, The Lancet, Vol. 391/10125, pp. 1023-1075, http://
be an important consideration if choice of surgical dx.doi.org/10.1016/s0140-6736(17)33326-3.
intervention is possible. [4] Matros, E. et al. (2015), “Cost-Effectiveness Analysis of
These PROMs results are not representative for each country Implants versus Autologous Perforator Flaps Using the
but do show the capacity for metrics of this kind to be BREAST-Q”, Plastic and Reconstructive Surgery, Vol. 135/4,
pp. 937-946, http://dx.doi.org/10.1097/prs.0000000000001134.
reported internationally. Some OECD countries are now
scaling up efforts to measure breast cancer PROMs as their [1] OECD (2013), Cancer Care: Assuring Quality to Improve Survival,
utility becomes more fully appreciated. For example, in the OECD Health Policy Studies, OECD Publishing, Paris, https://
Netherlands, breast cancer has been identified as a possible dx.doi.org/10.1787/9789264181052-en.
priority area as part of a current national policy effort to [3] Pusic, A. et al. (2009), “Development of a New Patient-
measure PROMs systematically. Reported Outcome Measure for Breast Surgery: The BREAST-
Q”, Plastic and Reconstructive Surgery, Vol. 124/2, pp. 345-353,
http://dx.doi.org/10.1097/prs.0b013e3181aee807.

Figure 6.28. Breast cancer stage distribution, 2010-14
Early or localised stages Intermediate stage Advanced stage Unknown

%
100
90
80
70
60
50
40
30
20
63.1
60.8
60.5
59.3
58.5
57.4
57.2
55.5
53.2
53.1
52.9
52.6
52.5
52.0
51.5
51.2
50.7
50.5
47.9
47.7
47.3
46.3
45.9
45.7
44.3
44.2
43.2
42.0
41.3
41.1
10
0
1. Data represent coverage of less than 100% of the national population. 2. Data for 2004-09.
Figure 6.29. Breast cancer five-year net survival by stage of breast cancer at diagnosis, 2010-14
Early or localised stages Advanced stage All stages

100
90
80
70
60
50
40
30
98.7
99.5
99.0
98.7
98.0
98.5
99.0
98.7
98.9
98.7
96.8
96.8
98.6
99.1
98.9
99.0
95.1
97.4
97.1
92.9
96.9
95.8
95.2
96.8
94.5
94.6
89.5
95.3
95.7
20
10
0
Note: H line shows 95% confidence intervals. 1. Coverage is less than 100% of the national population for stage-specific survival estimates. 2. Coverage is
less than 100% of the national population. 3. Survival estimates for advanced stage are not age-standardised. 4. Data for 2004-09.
Figure 6.30. Self-reported satisfaction with breast surgery: Figure 6.31. Type of breast reconstruction surgery,
crude scores 6-12 months after surgery, 2017-18 (or proportion of total, 2017-18 (or nearest year)
nearest year)
Autologous reconstructions without implant
Breast Conserving Therapy Reconstruction following mastectomy
Mean score Total breast reconstructions
100 100%
80
57%
19%
25%
38%
24%
100%
100%
80%
60 60%
40 40%
100%
n=100
n=113
n=106
n=641
43%
81%
75%
63%
76%
n=29
n=46
n=16
n=29
n=50
n=49
n=54
n=13
n=48
n=39
n=24
20 20%
0 0%
AUS - FRA - DEU - NLD - SWE - CHE - GBR - USA - USA - AUS - DEU - NLD - SWE - CHE - GBR - USA - USA -
Site/s Site/s Site/s Site/s Site/s Site/s Site/s Site 1 Site 2 Site/s Site/s Site/s Site/s Site/s Site/s Site 1 Site 2
Note: H line shows 95% confidence intervals. Data labels at the base of the Source: PaRIS Breast Cancer PROMs pilot data collection 2019.
histogram refer to the sample size at each site. StatLink 2 https://doi.org/10.1787/888934016531
Source: PaRIS Breast Cancer PROMs pilot data collection 2019.

139
Colorectal cancer is the third most commonly diagnosed Czech Republic, Latvia, Poland, the Slovak Republic and
cancer after breast and prostate cancers in OECD countries, Turkey. In recent years, some of these countries have made
and the third most common cause of death from cancer (see progress in strengthening their systems to reduce the
indicator “Cancer incidence and mortality” in Chapter 3) burden of colorectal cancer. For example, in 2013, Chile
(GLOBOCAN, 2018[1]). Several factors increase the risk of included treatment for colorectal cancer as part of its
developing colorectal cancer, including older age, ulcerative guaranteed health care coverage plan (OECD, 2019[4]).
colitis, previous colorectal polyps or a family history of In order to tackle poor outcomes for other cancers (see
colorectal cancer, as well as lifestyle factors such as a diet indicator “Survival for other major cancers”), several OECD
high in fat and low in fibre, lack of physical activity, obesity countries have taken a more comprehensive approach to
and tobacco and alcohol consumption. Incidence is strengthening their cancer care systems. In Latvia, cancer
significantly higher for men than women in most countries. care delivery has been centralised and expertise
Rectal cancer is often more difficult to treat than colon concentrated in specialised institutions to improve both
cancer due to a higher probability of spreading to other quality and efficiency of care delivery. A national plan was
tissue, recurrence and post-operative complications. also adopted in 2017 to improve cancer care through
A growing number of OECD countries have introduced free prevention, better access to early diagnosis and optimal
population-based screening, targeting men and women in treatment, as well as rehabilitation and palliative care
their 50s and 60s at either the national or regional levels (OECD/European Observatory on Health Systems and
(OECD, 2013[2]). In most countries that offer the faecal occult Policies, 2017[6]).
blood test, screening is available every two years. The
screening/follow-up periodicity schedule is less frequent
with colonoscopy and flexible sigmoidoscopy – generally Definition and comparability
every ten years. These differences complicate international
comparisons of screening coverage. Net survival is defined in indicator “Breast cancer
In 2014, an average 40.4% of people aged between 50 and 74 outcomes”. Survival estimates are based on cancer
in OECD countries had had a faecal occult blood test at least patient records with ICD-10 codes C18-C19
once in their life (Figure 6.32), and 18.4% of people of all ages (International Classification of Diseases for Oncology,
had undergone colonoscopy at least once in their life. third edition) for colon cancer and ICD-10 codes C20-
Population coverage of screening for colorectal cancer is still C21 for rectal cancer.
much lower than for breast and cervical cancer in many
OECD countries.
Advances in the diagnosis and treatment of colorectal
cancer – including improved surgical techniques, radiation References
therapy and combined chemotherapy, combined with wider
and more timely access to treatments – have contributed to cancer survival 2000–14 (CONCORD-3): analysis of individual
higher survival over the last decade in OECD countries. On records for 37 513 025 patients diagnosed with one of 18
average, age-standardised five-year net survival for patients cancers from 322 population-based registries in 71
diagnosed during 2010-14 reached 62.1% for colon cancer countries”, The Lancet, Vol. 391/10125, pp. 1023-1075, http://
and 60.6% for rectal cancer (Figure 6.33 and Figure 6.34). dx.doi.org/10.1016/s0140-6736(17)33326-3.
Some countries have shown a considerable improvement [1] GLOBOCAN (2018), Cancer Today, https://gco.iarc.fr/today/home.
over the last 10 years, including Denmark, Korea and
[3] OECD (2019), OECD Reviews of Public Health: Chile: A Healthier
Lithuania for colon cancer, and the Czech Republic,
Tomorrow, OECD Publishing, Paris, https://dx.doi.org/
Denmark, Korea, Ireland, Latvia, Lithuania and Slovenia for 10.1787/9789264309593-en.
rectal cancer.
[2] OECD (2013), Cancer Care: Assuring Quality to Improve Survival,
International variation in age-standardised five-year net OECD Health Policy Studies, OECD Publishing, Paris, https://
survival for cancers of the colon and rectum between OECD dx.doi.org/10.1787/9789264181052-en.
countries is very wide. For example, five-year net survival is
[4] OECD/European Observatory on Health Systems and Policies
much higher in Korea than in Chile, for both colon cancer (2017), Latvia: Country Health Profile 2017, State of Health in
(71.8% versus 43.9%) and rectal cancer (71.1% versus 32.7%). the EU, OECD Publishing, Paris/European Observatory on
Countries where survival from colon cancer is low also tend Health Systems and Policies, Brussels, https://dx.doi.org/
to have low survival for rectal cancer, including Chile, the 10.1787/9789264283466-en.

Figure 6.32. People aged 50-74 years who have had faecal occult blood test at least once in their life, 2014
%
90
70.0
80 63.4
60.2
70
50.6
49.4
49.1
48.5
48.3
47.6
46.5
60
40.8
40.4
37.6
35.2
50
34.1
31.2
30.0
40
24.8
22.6
19.2
18.3
18.2
17.2
30
14.5
14.4
20
81.0
77.9
10
0
Source: European Health Interview Survey 2014.

Figure 6.33. Colon cancer five-year net survival, 2010-14

67.3
67.9
67.8
80
67.0
64.9
64.9
64.9
64.9
64.8
64.2
64.0
63.7
63.7
63.3
63.1
62.1
61.9
61.6
60.9
60.5
60.1
60.0
58.4
57.6
56.9
56.1
70
55.2
38.9
52.9
51.8
48.8
48.3
43.9
60
44.9
34.5
50
40
12.3
30
20
71.8
71.7
70.7
68.2
10
0
Note: H line shows 95% confidence intervals. 1. Data represent coverage of less than 100% of the national population. 2. Survival estimates are
considered less reliable: see Allemani et al. (2018) for more information.
Figure 6.34. Rectal cancer five-year net survival, 2010-14

63.0
67.8
67.3
67.1
80
66.6
66.0
65.3
64.8
64.8
64.7
64.4
64.2
64.1
62.5
62.3
61.7
61.3
60.9
60.6
60.3
59.6
59.5
54.8
53.9
70
56.9
52.7
52.6
52.3
49.5
48.6
48.4
60
42.6
41.9
38.0
30.0
32.7
50
40
9.1
30
20
71.0
68.3
71.1
10
0
considered less reliable. 3. Survival estimates are not age-standardised.

141
Lung cancer is the main cause of cancer death for both men Leukaemia is the most common cancer among children
and women in OECD countries (see indicator “Cancer aged 0-14; it accounts for over 30% of all cancers diagnosed
incidence and mortality” in Chapter 3). The main risk factors in children worldwide (GLOBOCAN, 2018[2]). The causes of
for lung cancer are smoking; passive smoking; exposure to leukaemia are not well known, but some known risk factors
radon and/or certain chemicals and substances such as include inherited factors, such as Down syndrome and a
arsenic, asbestos, beryllium, cadmium, coal and coke fumes, family history of leukaemia, and non-inherited factors, such
silica and nickel; air pollution; and a family history of lung as exposure to ionising radiation. There are different types
cancer. Following the declining trend of smoking in recent of leukaemia but about three-quarters of cases among
decades (see indicator “Smoking among adults” in Chapter children are acute lymphoblastic leukaemia (ALL). The
4), incidence rates of lung cancer have declined across OECD prognosis for leukaemia depends on various factors
countries. However, together with ischaemic heart disease, including age, initial white blood cell count, gender, initial
road accidents and alcohol-related deaths, lung cancer reaction to induction treatment and type of leukaemia.
continues to be one of the main causes of preventable Children with acute leukaemia who are free of the disease
mortality in OECD countries. for five years are considered to have been cured, as
Compared to other cancers such as breast and colorectal remission after five years is rare.
cancers (see indicators “Breast cancer outcomes” and Age-standardised five-year net survival for ALL among
“Screening and survival for colorectal cancer”), lung cancer children was on average 83.7% during 2010-14 in OECD
continues to be associated with very poor survival. On countries (Figure 6.37), and it improved over the period,
average in OECD countries, for patients diagnosed with lung mainly due to progress in chemotherapy and stem cell
cancer, the cumulative probability of surviving their cancer transplantation technology. However, countries have not
for at least five years is less than 20% (Figure 6.35). Across benefited equally from progress in medical technologies.
OECD countries, age-standardised five-year net survival Survival estimates are high in Finland and Denmark but low
ranged from 32.9% in Japan to 4.6% in Chile in 2010-14, and is in Chile and Mexico. Chile is making progress in improving
low in Lithuania, the Czech Republic, the Slovak Republic, access and quality of care for childhood cancer – for
Finland and the United Kingdom. In recent years, age- example, by including access to care for childhood cancer as
standardised five-year net survival has increased part of its guaranteed health care coverage plan (OECD,
substantially in Denmark, Ireland, Korea and France. Lung 2019[4]).
cancer screening is not common in OECD countries, but in
Japan, an annual chest X-ray is recommended for people
aged 40 and over, and sputum cytology is also recommended Definition and comparability
for smokers aged 50 and over who have smoked more than
600 cigarettes over their lifetime (OECD, 2019[1]) while the Net survival is defined in indicator “Screening and
English National Health Service is launching its Targeted survival for breast cancer”.
Lung Health Checks Programme.
Stomach cancer is another commonly diagnosed cancer and
fifth highest cause of cancer death in OECD countries
(GLOBOCAN, 2018[2]). The main risk factors for stomach References
cancer include age, gender, smoking, Helicobacter pylori
infection, diet, genetic predisposition, pernicious anaemia,
cancer survival 2000–14 (CONCORD-3): analysis of individual
peptic stomach ulcer and stomach surgery. WHO records for 37 513 025 patients diagnosed with one of 18
recommends that countries with a high burden of stomach cancers from 322 population-based registries in 71
cancer should explore the introduction of population-based countries”, The Lancet, Vol. 391/10125, pp. 1023-1075, http://
H. pylori screening and treatment based on local contexts, dx.doi.org/10.1016/s0140-6736(17)33326-3.
such as health priorities and cost–effectiveness (IARC, [2] GLOBOCAN (2018), Cancer Today, https://gco.iarc.fr/today/home.
2014[3]). Incidence of stomach cancer is high in some OECD
[3] IARC (2014), Helicobacter pylori Eradication as a Strategy for
countries, such as Chile, Korea and Japan; in these countries,
Preventing Gastric Cancer.
stomach cancer screening is available for people in certain
age groups (OECD, 2019[1]; OECD, 2019[4]). [4] OECD (2019), OECD Reviews of Public Health: Chile: A Healthier
Age-standardised five-year net survival for stomach cancer 10.1787/9789264309593-en.
is particularly high in Korea and Japan (60% or higher), while
it ranges between 20% and 40% in other OECD countries [1] OECD (2019), OECD Reviews of Public Health: Japan: A Healthier
(Figure 6.36). Net survival is low in Chile, suggesting that
10.1787/9789264311602-en.
there is room to improve stomach cancer screening
strategies through stronger stakeholder engagement, better
communication strategies to increase public awareness and
better access to cancer screening (OECD, 2019[4]).

Figure 6.35. Lung cancer five-year net survival, 2010-14

32.9
40
35
26.6
15.0
25.1
20.2
30
20.1
21.3
21.2
20.4
19.8
19.7
19.5
19.4
18.3
18.3
18.2
18.1
16.9
25
17.5
17.3
17.3
16.6
17.2
15.9
15.7
15.3
14.9
14.8
14.4
13.7
13.5
13.3
13.0
20
11.2
10.6
9.9
8.1
8.7
15
4.6
3.7
10
5
0
Note: H line shows 95% confidence intervals.1. Data represent coverage of less than 100% of the national population. 2. Survival estimates are considered
less reliable: see Allemani et al. (2018) for more information.
Figure 6.36. Stomach cancer five-year net survival, 2010-14

68.9
80
60.3
70
25.6
60
40.6
37.5
35.9
50
35.4
28.1
33.5
33.1
32.3
32.2
32.2
31.8
30.5
29.8
29.7
29.2
28.8
27.6
27.2
27.0
26.7
26.2
40
25.7
25.7
25.1
24.8
24.6
21.1
21.0
20.9
20.7
20.6
20.5
19.9
25
17.1
16.7
30
8.9
20
10
0
considered less reliable. 3. Survival estimates are not age-standardised.
Figure 6.37. Childhood acute lymphoblastic leukaemia five-year net survival, 2010-14
Age-standardised five-year net surival (%)
100
90
80
70
60
50
40
30
20
95.2
94.0
93.0
92.4
92.2
91.4
91.1
90.8
90.7
90.4
90.3
89.8
89.5
89.0
88.6
88.3
88.2
87.9
87.8
87.7
87.6
87.0
86.9
83.7
84.7
84.4
84.2
84.1
83.0
80.9
80.0
76.9
74.7
68.9
66.6
63.9
57.7
52.7
10
0
Note: H line shows 95% confidence intervals. 1. Data represent coverage of less than 100% of the national population. 2. Survival estimates are not age-
standardised.

143
Vaccinations
Vaccines are an effective and cost-effective tool for against influenza among the elderly population decreased
protecting against infectious diseases. The WHO estimates among OECD countries from 49% to 42%. Large decreases
that vaccines prevent between 2 million and 3 million can be seen in Germany, Slovenia and Italy. Some countries
deaths each year worldwide through direct protection of did show increased vaccination over this period, including
those vaccinated and prevention of the spread of disease to Mexico, Israel, the United States, Portugal, Denmark, Greece
those unvaccinated. and New Zealand. Only Korea attained the 75% target, with
Figure 6.38 shows vaccination coverage for diphtheria, coverage of 83%.
tetanus and pertussis (DTP), measles and hepatitis B at 1
year of age. Across OECD countries, vaccination levels are
high, with around 95% of children receiving the Definition and comparability
recommended DTP or measles vaccinations and 91%
receiving the recommended hepatitis B vaccination. Vaccination rates reflect the percentage of people that
receive the respective vaccination in the
Despite high overall rates, however, nearly half of countries
recommended timeframe. The age of complete
fall short of attaining the minimum immunisation levels
immunisation differs across countries due to different
recommended by the WHO to prevent the spread of measles
immunisation schedules. For those countries
(95%) and nearly 15% of countries fail to meet this target for
recommending the first dose of a vaccine after 1 year
DTP (90%). Furthermore, high national coverage rates may
of age, the indicator is calculated as the proportion of
not be sufficient to stop disease spread, as low coverage in
children less than 2 years of age who have received
local populations can lead to outbreaks. In the United States,
that vaccine. Thus, these indicators are based on the
1 123 individual cases of measles were reported for the
actual policy in a given country.
period 1 January to 11 July 2019 – the highest number since
1992. Between March 2018 and February 2019 OECD Some countries administer combination vaccines (e.g.
countries in Europe reported 10 564 cases of measles. (CDC, DTP), while others administer the vaccinations
2019[1]; ECDC, 2019[2]). separately. Some countries ascertain whether a
vaccination has been received based on surveys and
Over the last decade, rates of vaccination across OECD have
others based on encounter data, which may influence
increased by six percentage points for hepatitis B and by half
the results. In Canada, only four provinces and three
a percentage point for measles, but have decreased by one
territories include vaccination against hepatitis B in
percentage point for DTP. Some countries, however, have
their infant immunisation programmes. Other
experienced important reductions. Coverage for DTP has
Canadian jurisdictions do this at school age.
decreased by four or more percentage points in Mexico,
Iceland, Lithuania, Poland, Slovenia and Spain, while rates Influenza vaccination rates refer to the number of
have dropped at least three percentage points for measles people aged 65 and over who have received an annual
coverage in Estonia, Lithuania, Poland, Canada, Chile, influenza vaccination, divided by the total number of
Iceland, the Netherlands, the Slovak Republic and Slovenia. people over 65. In some countries, the data are for
people over 60. The main limitation in terms of data
Figure 6.39 shows trends of vaccination from 2008 to 2018 by
comparability arises from the use of different data
country and vaccine type. Countries listed in green boxes
sources, whether survey or programme, which are
increased vaccination rates over the time period while
susceptible to different types of errors and biases. For
countries in red boxes had declining rates. Roughly one-
example, data from population surveys may reflect
third of countries had declining levels for each vaccine.
some variation due to recall errors and irregularity of
Eroding public confidence in the safety and efficacy of administration.
vaccination, despite the lack of scientific evidence to
support this, may play a role in declining coverage in some
countries. In North America, only 72% of the population
agreed that vaccines are safe; this number was only 59% in
western Europe. In France, one in three people disagree that
References
vaccines are safe (Gallup, 2019[3]). [1] CDC (2019), Measles Cases and Outbreaks.
Influenza is a common infectious disease responsible for [2] ECDC (2019), Monthly measles and rubella monitoring report -
3-5 million severe cases worldwide, along with up to 650 000 April 2019,.
deaths, including 72 000 in the WHO Europe Region (WHO, [3] Gallup (2019), Wellcome Global Monitor – First Wave Findings.
2019[4]). The WHO recommends that 75% of elderly people
[4] WHO (2019), Seasonal influenza.
be vaccinated against seasonal influenza.
Figure 6.40 shows vaccination rates among adults over 65 for
2007 and 2017. Over this period, the average vaccination rate

Vaccinations
Figure 6.38. Percentage of children at 1 year of age vaccinated for diphtheria, tetanus and pertussis (DTP), measles and
hepatitis B, 2018 (or nearest year)
Diptheria, tetanus and pertussis Measles Hepatitis B

% vaccinated
100
95
90
85
80
75
70
65
60
55
50
1. DTP data are estimated. 2. Measles data are estimated.

Figure 6.39. Trends in vaccination coverage for DTP, measles and hepatitis B, 2008-18 (or nearest year)
DTP Measles Hepatitis B
Austria Latvia
Australia Latvia Belgium Luxembourg
Canada New Zealand Denmark New Zealand
Denmark Norway Germany Norway Canada New Zealand
Ireland Portugal Ireland Portugal France Sweden
Israel Switzerland Italy Switzerland Korea Turkey
Korea United Kingdom Korea United Kingdom Netherlands
Czech Republic Netherlands Canada Lithuania Czech Republic Poland
Estonia Poland Chile Netherlands Germany Slovak Republic
France Slovak Republic Estonia Poland Israel Slovenia
Germany Slovenia Greece Slovak Republic Lithuania Spain
Iceland Spain Iceland Slovenia Mexico United States
Lithuania United States
Mexico
Note: Countries above the dashed line have increased and those below have decreased vaccination coverage by at least two percentage points over the
last decade.
Figure 6.40. Percentage of population aged 65 and over vaccinated for influenza, 2007 and 2017
2007 2017
% vaccinated
100
83
90
80
65
70
61
60
73
60
50
64
50
61
59
58
56
49
40
52
48
50
45
42
41
30
20
38
35
34
13
20
27
7
7
10
5
13
12
1. 2017 data are estimated.


145
Given the importance of incorporating people’s voices into countries are under increasing pressure to address patient
the development of health systems and improving quality of needs, but measures of patient-reported experiences and
care, national efforts to develop and monitor patient- health outcomes are still limited across countries. The
reported measures have been intensified in recent years (see OECD’s PaRIS initiative aims to collect key people-reported
Chapter 2). In many countries, specific organisations have outcomes and experiences to improve the performance of
been established or existing institutions have been health care providers and to drive changes in health
identified and made responsible for measuring and systems, based on people’s voices (OECD, 2018[3]) (see
reporting patient experiences. These organisations develop https://www.oecd.org/health/paris.htm).
survey instruments for regular collection of patient
experience data and standardise procedures for analysis
and reporting. Definition and comparability
Countries use patient-reported data differently to drive
quality improvements in health systems. To promote To monitor general patient experiences in the health
quality of health care through increased provider system, the OECD recommends collecting data on
accountability and transparency, many countries report patient experiences with any doctor in ambulatory
patient experience data in periodic national health system settings. An increasing number of countries have been
reports and/or on public websites, showing differences collecting patient experience data based on this
across providers, regions and over time. Canada, the Czech recommendation through nationally representative
Republic, Denmark, France and the United Kingdom use population surveys, while Japan and Portugal collect
patient experience measures to inform health care them through nationally representative service user
regulators for inspection, regulation and/or accreditation. surveys. About half of the countries presented,
Patient-reported measures are also used in some Canadian including Poland, however, collect data on patient
jurisdictions, Denmark, the Netherlands and the United experiences with a regular doctor or regular practice,
Kingdom to provide specific feedback for providers to not data on patient experiences with any doctor in
support quality improvement (Fujisawa and Klazinga, ambulatory care. National data refer to years up to
2017[1]; Desomer et al., 2018[2]). Germany plans to use 2018.
patient surveys as part of external quality assurance in the In 11 countries, the Commonwealth Fund's
hospital sector. International Health Policy Surveys 2010 and 2016
Across OECD countries, the majority of patients reported were used as a data source, even though there are
that they spent enough time with a doctor during limitations relating to the small sample size and low
consultation (Figure 6.41), and that a doctor provided easy- response rates. Data from this survey refer to patient
to-understand explanations (Figure 6.42) and involved them experiences with a GP rather than any doctor,
in care and treatment decisions (Figure 6.43). For all three including both GPs and specialists.
aspects of patient experience, Belgium and Luxembourg Patient experience indicators are not age-standardised
score highly at above 95% of patients with positive to the 2010 OECD population because high-quality
experiences; Poland has lower rates, but patient experiences health care needs to be provided to all patients
have improved significantly over the past decade. Patient regardless of age, and patient experiences are not
experiences also improved in Estonia in recent years. consistently associated positively with age across
Japan has a low rate for patients’ perception of the time countries.
spent with a doctor, and this is likely to be associated with a
high number of consultations per doctor (see indicator
“Consultations with doctors” in Chapter 9). However, in
Korea, which has by far the highest number of consultations References
per doctor in OECD countries, a higher proportion of patients
[2] Desomer, A. et al. (2018), Use of patient-reported outcome and
report that their doctors spent enough time during
experience measures in patient care and policy – Short report,
consultation. http://www.kce.fgov.be.
Patients’ income level is associated not only with access to [1] Fujisawa, R. and N. Klazinga (2017), “Measuring patient
care (see indicator “Unmet needs for health care” in experiences (PREMS): Progress made by the OECD and its
Chapter 5) but also with their experiences with health care. member countries between 2006 and 2016”, OECD Health
On average across 11 OECD countries, patients with above- Working Papers, No. 102, OECD Publishing, Paris, https://
average income report a better health care experience than dx.doi.org/10.1787/893a07d2-en.
patients with below-average income. Patient experiences [3] OECD (2018), Patient-Reported Indicators Surveys (PaRIS) - OECD,
also vary by health condition (see indicator “Care for people http://www.oecd.org/health/paris.htm.
with mental health disorders”).
In order to ensure delivery of people-centred health care
across population groups, health care professionals in OECD

Figure 6.41. Doctor spending enough time with patient during consultation, 2010 and 2017 (or nearest year)
2017 2010
%
100
90
80
70
60
50
40
30
20
97.5
97.3
96.1
95.5
93.3
91.6
89.7
87.9
87.5
87.4
87.4
85.8
84.9
83.7
81.5
80.8
80.6
79.9
78.8
73.7
70.0
42.1
10
0
Note: H line shows 95% confidence intervals. 1. National sources. 2. Data refer to patient experiences with regular doctor or regular practice.
Source: Commonwealth Fund International Health Policy Survey 2016 and other national sources.
Figure 6.42. Doctor providing easy-to-understand explanations, 2010 and 2017 (or nearest year)
2017 2010
%
100
90
80
70
60
50
40
30
20
97.7
97.5
97.5
96.3
96.3
96.2
94.2
93.5
93.1
91.2
90.5
89.8
89.2
89.1
88.5
86.5
84.3
83.7
83.4
82.9
79.0
10
0
Figure 6.43. Doctor involving patient in decisions about care and treatment, 2010 and 2017 (or nearest year)
2017 2010
%
100
90
80
70
60
50
40
30
20
95.6
95.2
92.4
91.9
90.9
88.9
87.9
87.8
87.2
86.9
85.2
84.8
83.6
82.4
81.7
81.2
80.9
80.1
78.8
78.0
61.5
10
0

147
7. HEALTH EXPENDITURE
Health expenditure per capita
Health expenditure in relation to GDP
Prices in the health sector
Health expenditure by financing scheme
Public funding of health spending
Health expenditure by type of service
Health expenditure by provider
Capital expenditure in the health sector
Projections of health expenditure
international law.
149
The level of health spending in a country, covering both strong annual decreases in growth halted after 2013, even if
individual needs and population health as a whole, and how growth in health spending has been close to zero overall
this changes over time is dependent on a wide range of since 2013 (-9.4% in the time period 2008‑13 vs. 0.2% in the
demographic, social and economic factors, as well as the time period 2013‑18), and real per capita spending in 2018
financing and organisational arrangements of the health remained almost a third below the 2009 level. A similar if
system. less dramatic picture can also be seen in Iceland (-3.0% vs.
In 2018, overall spending on health care in the United States 4.0%). In other European countries, such as Germany and
was estimated to be the equivalent of more than 10 000 Norway, health spending remained relatively stable over the
dollars for each US resident. This amount of expenditure ten-year period, with annual growth of between 2.0-2.5%.
(when adjusted for different purchasing power in countries) Overall, health spending growth has picked up in the
was higher than all other OECD countries by a considerable majority of European countries in most recent years.
margin. Switzerland, the next highest spender in the OECD, Outside of Europe, Korea and Chile have continued to report
spent less than 70% of this amount, while the overall annual health spending increases above 5% in real terms
average of all OECD countries was less than 40% of the US since 2008. A provisional estimate for 2018 suggests further
figure (USD 3 994) (Figure 7.1). Many high-income OECD strong spending growth of 9.0% in Korea. In the United
countries, such as Germany, France, Canada and Japan States, health spending is estimated to have grown by 1.4%
spend only around a half or less of the US per capita in real terms in 2018, which along with similar growth in
spending on health, while the United Kingdom and Italy 2017 shows health spending in the United States growing
were around the OECD average. Lowest per capita spenders slower than the overall economy.
on health in the OECD were Mexico and Turkey with health
expenditure at around a quarter of the OECD average, and
levels similar to the key emerging economies such as the
Russian Federation, South Africa and Brazil. Latest available Definition and comparability
figures show that China spent around 20% of the OECD per
capita spending level, while both India and Indonesia spent Expenditure on health gives a measure of the final
less than 10%. consumption of health goods and services (i.e. current
Figure 7.1 also shows the split of health spending based on health expenditure). This includes spending by all
the type of health care coverage, either organised through types of financing arrangements (e.g. government-
government health schemes or some kind of compulsory based programmes, social insurance or out-of-pocket
insurance, or through a voluntary arrangement such as spending) on medical services and goods, population
private health insurance or direct payments by households health and prevention programmes, as well as
(see also indicator “Health expenditure by financing administration of the health system. The split of
schemes”). Across OECD countries, 76% of all health spending combines government and compulsory
spending is financed by government schemes or financing schemes, the latter including private
compulsory insurance (with a cross-country range of 51% to insurance of a mandatory nature (for example in
85%). In the United States, since the introduction of the Switzerland and the Netherlands). Due to data
Affordable Care Act in 2014, this share stands at 85%, limitations, voluntary private insurance in the United
reflecting the existence of an individual mandate to States is included with employer-based private
purchase health insurance. Federal and state programmes insurance, which is currently mandated under the
such as Medicaid and Medicare continue to play an Affordable Care Act.
important role in purchasing health care. To compare spending levels between countries, per
In 2017, OECD per capita spending on health care grew by an capita health expenditures are converted to a common
average of 2.0% – a marked slowdown from the 3.3% growth currency (US dollar) and adjusted to take account of
observed in 2015 and 2016, and significantly below the the different purchasing power of the national
growth rates experienced before the onset of the global currencies, in order to compare spending levels, Actual
financial and economic crisis. Preliminary estimates for Individual Consumption (AIC) PPPs are used as the
2018 point to growth having strengthened in 2018. On most available and reliable conversion rates. For the
average, since 2013, annual per capita health spending calculation of growth rates in real terms, AIC deflators
growth across the OECD has been 2.4% compared with 1.0% are used for all countries, where available.
in the five years up to 2013, in the period following the crisis Note that data for 2018 are based on provisional figures
(Figure 7.2). provided by the country or estimated by the OECD
In a number of European countries, there have been Secretariat.
significant turnarounds in health spending. In Greece, the

Figure 7.1. Health expenditure per capita, 2018 (or nearest year)
Government/Compulsory Voluntary/Out-of-pocket
USD PPP
10586
10000
7317
8000
6187
5986
5447
5395
5299
5288
6000
5005
5070
4974
4965
4944
4915
4766
4349
4228
4070
3994
3923
3428
3323
3192
4000
3058
2861
2859
2780
2416
2290
2238
2231
2182
2056
2047
1749
1514
1285
1282
1227
1138
2000
1072
960
688
301
209
0
Note: Expenditure excludes investments, unless otherwise stated.

1. Australia expenditure estimates exclude all expenditure for residential aged care facilities in welfare (social) services. 2. Includes investments.
Source: OECD Health Statistics 2019, WHO Global Health Expenditure Database.
Figure 7.2. Annual growth in health expenditure per capita (real terms), 2008 to 2018 (or nearest year)
2008-13 2013-18
%
10
7.3
8
6.7
6.2
5.2
5.2
5.4
6
5.2
4.3
4.0
3.9
4.1
3.0
2.8
2.1 2.9
4
2.8
2.8
2.7
2.5
2.5
2.3
3.0
2.4
2.6
2.1
2.1
1.9
1.9
2.1
1.9
1.9
1.7
1.8
2.1
1.7
1.6
2.0
1.6
1.6
1.8
1.5
1.4
1.4
1.5
1.2
1.1
1.6
1.0
0.9
1.0
1.0
0.8
2
0.8
0.8
1.1
1.0
1.1
1.0
0.7
0.8
0.6
0.2
0.5
0.5
0.1
0
0.0
-2
-0.4
-0.5
-0.8
-0.9
-1.4
-1.9
-4
-3.0
-6
-8
-9.4
-10


151
The ratio of spending on health care goods and services as overall economic growth in the US economy outpaced the
compared to total spending in the economy can vary over growth in health spending (Figure 7.5). Korea, due to its
time due to differences in the growth of health spending rapidly increasing wealth and ongoing government policy to
compared to overall economic growth. During the 1990s and increase health coverage for the population, has seen
early 2000s, health spending in OECD countries was substantial increases in the share of economic resources
generally growing at a faster pace than the rest of the allocated to health. In 2003, health spending in Korea
economy, leading to an almost continual rise in the health accounted for only 4.6% of GDP compared with 2018 when
expenditure to GDP ratio. After a period of volatility during the ratio was estimated to have reached 8.1%. Chile has also
the economic crisis, the average share has remained seen its health spending to GDP ratio increase from 7.3% to
relatively stable in recent years, as growth in health 9.0% over the same time, due to an expansion in the
spending across the OECD has broadly matched overall coverage of health care for the population.
economic growth. In Europe, France has seen the health spending to GDP ratio
On average, OECD countries are estimated to have spent fluctuate – increasing during the financial crisis to reach a
8.8% of GDP on health care in 2018, a figure more or less peak of 11.6% in 2014 – before a gradual decline to 11.2% by
unchanged since 2013 (Figure 7.3). The United States spent 2018. Health spending in France continued to outpace
by far the most on health care, equivalent to 16.9% of its GDP economic growth until 2016, but then stagnated due to a
– well above Switzerland, the next highest spending number of measures to contain costs including for example
country, at 12.2% (Figure 7.3). After the United States and price negotiations for pharmaceuticals. The Netherlands
Switzerland, a group of high-income countries, including has seen the proportion of GDP relating to health decrease
Germany, France, Sweden and Japan, all spent close to 11% from a high of 10.6% in 2014 to an estimated 9.9% in 2018,
of their GDP on health care. A large group of OECD countries relating to reforms in health and long-term care insurance
spanning Europe, but also Australia, New Zealand, Chile and aimed at limiting spending growth within predefined levels.
Korea, fit within a band of health spending of between 8-10%
of GDP. Many of the Central and Eastern European OECD
countries, such as Lithuania and Poland, as well as key
partner countries, allocated between 6-8% of their GDP to Definition and comparability
health care. Finally, a few OECD countries spent less than 6%
See indicator “Health expenditure per capita” for a
of their GDP on health care, including Mexico, Latvia,
definition of current expenditure on health.
Luxembourg, and Turkey at 4.2%. Turkey’s health spending
as a share of GDP sits between that of China and India. Gross Domestic Product (GDP) is the sum of final
consumption, gross capital formation (investment)
Looking in more detail at trends over the last decade, the
and net exports. Final consumption includes goods
average share of GDP related to health care jumped sharply
and services used by households or the community to
in 2009 as overall economic conditions rapidly deteriorated
satisfy their individual needs. It includes final
in many countries, but health spending growth was
consumption expenditure of households, general
generally maintained (Figure 7.4). Subsequently, growth in
government and non-profit institutions serving
health spending also significantly declined – on average,
households.
growth fell to around zero between 2009 and 2011 – as a
range of different policy measures to rein in public spending In countries such as Ireland and Luxembourg, where a
on health kicked in. Since 2011, the average rate of health significant proportion of GDP refers to repatriated
spending growth has tended to closely track growth in the profits and thus not available for national
overall economy, largely maintaining the increased ratio of consumption, Gross National Income (GNI) may be a
health spending to GDP at its present level of around 8.8%. more meaningful measure than GDP. However, for
consistency, GDP is maintained as the denominator for
On a country-by-country basis there have been differing
all countries.
patterns in the health-to-GDP ratio in recent years. In the
United States, after a number of years (2009-14) when the Note that data for 2018 are based on provisional figures
ratio of health spending to GDP remained stable at around provided by the country or preliminary estimates
16.4%, this rapidly increased to 17.1% with the onset of a made by the OECD Secretariat.
number of coverage changes, before falling to 16.9% in 2018

Figure 7.3. Health expenditure as a share of GDP, 2018 (or nearest year)
Government/Compulsory Voluntary/Out-of-pocket
% GDP
20
16.9
18
16
12.2
14
11.2
11.2
11.0
10.9
10.7
10.5
10.4
10.3
10.2
12
9.9
9.8
9.3
9.3
9.2
9.1
9.1
8.9
8.9
8.8
8.8
10
8.3
8.1
7.9
8.1
7.8
7.5
7.5
7.5
7.2
7.0
6.8
6.7
6.6
8
6.4
6.3
5.9
5.5
5.4
5.3
5.0
6
4.2
3.6
3.1
4
2
0
Note: Expenditure excludes investments, unless otherwise stated.

1. Australia expenditure estimates exclude all expenditure for residential aged care facilities in welfare (social) services. 2. Includes investments.
Source: OECD Health Statistics 2019, WHO Global Health Expenditure Database.
Figure 7.4. Annual growth in health expenditure and GDP Figure 7.5. Health expenditure as a share of GDP, selected
per capita, OECD average, 2003-18 OECD countries, 2003-18
Chile France
Health GDP
Korea Netherlands
% OECD36 United States
6 % GDP
18
4 16
14
2
12
0 10
8
-2
6
-4 4
2
-6
0

153
Variations in per capita health spending can be the result of labour-intensive, therefore tends to be greater than the
differences in prices for health care goods and services, and economy as a whole, with high-income countries having
in the quantity of care that individuals are using (“volume”). even higher prices for health care compared to lower-
Breaking down health spending into these two components income countries.
gives policymakers a better understanding of what is driving By removing the price differences for health goods and
the differences, and therefore guides them to what services between countries, we can get an idea of volume of
responses can be put in place to increase value for money. health services being consumed (Figure 7.7). The overall
Depending on what explains high spending, the options can effect is to reduce the differences between countries with
differ. relatively higher prices compared to those with lower prices.
Comparing spending across countries requires data to be For example, taking the relatively high health prices in the
expressed in a common currency. The choice of the currency United States into account means that they are still the
conversion measure, however, can significantly influence highest consumers of health services but the gap with the
the results and interpretation. Whilst market exchange OECD average decreases. It also shows that the difference in
rates are commonly used, they are not ideal for sectors such volume of health care consumed in the United States
as health care. First, exchange rates are determined by the compared to countries with lower prices, such as Australia
supply and demand for currencies, which can be influenced and France, is getting smaller. The very low prices in the
by speculation and interest rates, among other factors. Turkish health sector means that on average the population
Second, for predominantly non-traded sectors, such as still consumes around 54% of the OECD average in term of
health care, exchange rates are unlikely to reflect the health care, but spends only 30% of the average.
relative purchasing power of currencies in their national
markets (Eurostat/OECD, 2012[1]).
Purchasing power parities (PPPs), on the other hand, are Definition and comparability
conversion rates that show the ratio of the prices in national
currencies for the same basket of goods and services. When Purchasing power parities (PPPs) are conversion rates
PPPs are used, the results are valued at a uniform price level that show the ratio of the prices in national currencies
and reflect only differences in volumes of goods and services of the same basket of goods and services in different
consumed. Traditionally, health care expenditures have countries. Thus, they can be used as both currency
been compared using broad economy-wide PPPs (see converter and price deflators. When PPPs are used to
indicator “Health expenditure per capita”). This gives an convert expenditure to a common unit, the results are
indication of the level of spending on health adjusted to take valued at a uniform price level and should reflect only
account of differences in the overall price levels between differences in volumes of goods and services
countries. To assess differences solely in health volumes consumed.
requires the use of health-specific PPPs. Health and hospital To assess differences in health volumes requires
PPPs have been developed and can be used to calculate health-specific PPPs. Eurostat and the OECD calculate
health price level indices (PLI), a ratio of PPPs to exchange PPPs for GDP and some 50 product groups, including
rates, to indicate the number of units of a common currency health, on a regular and timely basis. In recent years, a
needed to purchase the same volume of health care. number of countries have worked towards output-
Figure 7.6 shows a comparison of prices for a basket of based measures of prices of health care goods and
health goods and services compared with the price level in services. The output-based methodology has then
the United States. This shows that prices in the health sector been used to produce both health and hospitals PPPs,
based on the same set of goods and services are estimated to which are now incorporated into the overall
be about 10% more in Sweden, 20% more in Norway and up calculation of GDP PPPs. Such PPPs can be used to
to 39% higher in Switzerland. Prices across all OECD calculate health price level indices (PLI) to compare
countries are on average around 28% lower than in the price levels and volumes across countries. These
United States. Health care prices in France and Germany are indices are calculated as ratios of health PPPs to
around a third cheaper than in the United States and half exchange rates, and indicate the number of units of a
that of their neighbour, Switzerland. The lowest prices for common currency needed to purchase the same
health care are in Turkey at 17% of the US level and less than volume.
a quarter of the OECD average.
In general, there is a high correlation between prices in a
country and its level of wealth. Prices of durable goods (e.g.,
cars) vary less than the prices of services (e.g., education and References
health). In different countries durable goods are frequently [2] Eurostat (2001), Handbook on Price and Volume Measures in
traded, which tends to equalise their price levels, while National Accounts, European Union, Luxembourg.
services are often purchased locally, with higher wages in
[1] OECD/Eurostat (2012), Eurostat-OECD Methodological Manual on
advanced countries leading to higher service prices. The Purchasing Power Parities (2012 Edition), OECD Publishing,
variation in prices in the health sector, which is relatively Paris, https://dx.doi.org/10.1787/9789264189232-en.

Figure 7.6. Comparative price levels for health, 2017, US=100
Index (US=100)
160
139138
140
120
120 111110
106
102100
100 92 90
88 86
83 82 82
80 76 75 72
72 72 71
68 66
59 57
60 55 54
48 47
42
40 34 32
31 30 29 28
18 17
20
Source: OECD estimates (unpublished).

Figure 7.7. Indices of per capita spending and volume of health care, 2017, US=100
Volume (Health PPP) Expenditure (AIC PPP)
Index (US=100)
100
80
60
40
20
Note: AIC refers to actual individual consumption.

Source: OECD estimates (unpublished).

155
A variety of financing arrangements, broadly classified Whereas this share is above 30% in Latvia (42%), Mexico
according to their compulsory or voluntary nature, provide (41%), Greece (35%), Korea (34%) and Chile (34%) it is below
coverage against the cost of health care by purchasing 10% in France. Out-of-pocket spending on health care was
health care services. Government financing schemes, greater than 30% in India, Russia and China.
organised at a national or regional level or for specific With the aim to move towards universal health coverage, a
population groups, automatically entitle individuals to care number of OECD countries have increased spending by
based on residency, and form the principle mechanism by government or compulsory insurance schemes in recent
which health care expenses are covered in a number of decades. As a result, there have been some significant
OECD countries. The main alternative is for residents to be decreases in the share of health care costs payable by
enrolled in a compulsory health insurance scheme (through individuals and voluntary insurance schemes in some
public or private entities) which then covers the bulk of their countries. Yet, while the proportion of health spending
health care use. Despite near universal health care coverage covered by those two schemes across the OECD has slightly
in many OECD countries, direct expenditure by households decreased from around 28% in 2003 to 26% in 2017, there is
(out-of-pocket spending) in the form of standalone notable variability within countries.
payments or as part of some co-payment arrangement
Among those countries where voluntary health insurance
remain an important element of health financing but the
plays a more important role, this share has been growing in
extent can vary considerably. Finally, among the other types
Korea and Australia in recent years while it remained more
of discretionary health care financing, voluntary health
or less flat in Slovenia and Canada (Figure 7.9). The share of
insurance, in its various forms, can play an important
expenditure covered by out-of-pocket payments rose
funding role in some countries.
substantially between 2009 and 2017 in several European
Taken together, government schemes and compulsory countries, such as Greece (5%), Spain (5%) and Portugal (3%),
health insurance form the principal financing arrangement though this proportion has stabilised in recent years
in all OECD countries (Figure 7.8). On average, around three- (Figure 7.10). This is the result of policies introduced in a
quarters of all health care spending across the OECD is number of countries to balance public budgets following the
currently covered through these types of mandatory global financial and economic crisis, such as introducing or
financing schemes. In Norway, Denmark, Sweden and the increasing co-payments for primary care and hospitals,
United Kingdom, central, regional or local government raising reimbursement thresholds or reducing benefits for
schemes account for around 80% or more of all health pharmaceuticals and dental care, or removing public
spending, with out-of-pocket payments making up most of coverage for particular groups.
the remainder. Compulsory health insurance schemes are
the dominant source of health care financing in Germany,
Japan, France, Luxembourg and the Netherlands, typically
covering about three-quarters of all health spending. While
Germany and Japan rely on a system of social health The financing of health care can be analysed from the
insurance, France supplements the public health insurance point of view of financing schemes (financing
coverage (“assurance maladie”) with a system of different arrangements through which health services are paid
private health insurance arrangements (e.g. “mutuelles”), for and obtained by people, e.g. social health
which have become compulsory under certain employment insurance), financing agents (organisations managing
conditions in 2016. the financing schemes, e.g. social insurance agencies,
In the United States, federal and state programmes, such as and types of revenues of financing schemes (e.g. social
Medicaid, make up around a quarter of all US health care insurance contributions). Here “financing” is used in
spending. Another 22% is covered by social health insurance the sense of financing schemes as defined in the
schemes (e.g. Medicare). Most private health insurance, System of Health Accounts (OECD, Eurostat and WHO,
which, since the introduction of the Affordable Care Act 2011) and includes government schemes, compulsory
(ACA) in 2014, is considered compulsory due to the current health insurance as well as voluntary health insurance
existence of an individual mandate for individuals to buy and private funds such as households’ out-of-pocket
health insurance or pay a penalty, covers more than a third payments, NGOs and private corporations. Out-of-
of total health spending. pocket payments are expenditures borne directly by
Out-of-pocket payments generally constitute the next patients. They include cost-sharing and, in certain
important source of funding. On average private households countries, estimations of informal payments to health
directly financed more than a fifth of all health spending in care providers.
2017, but with substantial variation across the OECD.

Figure 7.8. Health expenditure by type of financing, 2017 (or nearest year)
Government schemes Compulsory health insurance Voluntary health insurance Out-of-pocket Other
%
100
6 9 5 5 6 2 7 10 6 3 10 8 9 2 10
13 16
22 21 22 19 21 24 27 22
26 30 27
80 36
43 43 3
57 2
62 66 68 65 58
69 69 49 18
60 82 79 74 68 73 69 59 61 58 48 39 36 28
85 78 75 79 84 84 78 75 78 68 64 42 33
1
69 56 56 44 6
58 37 28
40 1 2 65
1 4 6 7 37
14
4 1 6 2 49 1 5 11 7
9 2 4 52 3 10 36
20 3 5 5
5 10 13 14 13 42 40 41
1 2 3 2 1 7 6 17 20 22 24 19 23 21 23 27 32 28 22 29 35 34 34 27
11 15 16 11 19 16 14 18 24 18 8
14 13 13 11 14 15 9 16 12 12 15 16
4 2 1 2 1 1 3 2 1 1 2 3 5 3 1 2 1 2 2 1 2 2 2 3 1 3 1 1 6 2 2 1 8
0
1. All spending by private health insurance companies in the United States is reported under compulsory health insurance. 2. Health payment schemes
unable to be disaggregated into voluntary health insurance, NPISH and enterprise financing are reported under other. 3. Voluntary payment schemes
unable to be disaggregated are reported under voluntary health insurance.
Figure 7.9. Voluntary health insurance expenditure as a Figure 7.10. Out-of-pocket health expenditure as a
proportion of total, selected countries, 2003-17 proportion of total, selected countries, 2003-17
Australia Slovenia Portugal Greece

Switzerland Canada Mexico Spain
Korea Czech Republic
% %
16 60
14
50
12
40
10
8 30
6
20
4
10
2
0 0


157
While health care goods and services are purchased through Around 20% or more of public spending was linked to health
different financing schemes (see indicator “Health care spending in Japan, the United States, New Zealand,
expenditure by financing scheme”), these in turn need to Ireland and Germany. On the other hand, Greece and
mobilise revenues to fund the spending, often relying on a Hungary allocated around 10% of government spending to
number of different sources. Analysing the financial flows health care, a level similar to that in Russia and Brazil.
from sources through to the schemes gives a more Many countries have a system of compulsory health
comprehensive understanding of how health services are insurance – either social health insurance or through private
ultimately funded and the overall burden on different coverage. There is more diversity in the composition of
sectors of the economy. revenues for these type of schemes (Figure 7.13). The
Funding of government schemes comes mainly from importance of government transfers as a source of revenue
general revenues, primarily through taxation, which are can differ significantly. On average, around three-quarters
then allocated through a budgetary process across the of financing comes from social contributions (or premiums)
various levels of government. However, governments might – primarily split between employees and employers - but
also contribute towards other schemes, such as social around a quarter still comes from government transfers,
health insurance, by covering the contributions of particular either on behalf of certain groups (e.g. the poor or
population groups or providing general budget support to unemployed) or as general support. In Hungary,
the insurance fund. Individuals can purchase private health governmental transfers funded 68% of the health spending
insurance, which means paying regular premiums into a of the social health insurance. In Poland, Slovenia and
pool, which then pays their medical needs. A proportion of Estonia the share was less than 5%, with social insurance
the premium may be paid by their employer or subsidised by contributions being the main funding source.
government. Individuals also finance care directly, using
household income to pay for services in their entirety, or as
part of a cost-sharing arrangement. Other health financing
schemes (e.g. non-profit or enterprise schemes) can receive Definition and comparability
donations, or income from investments or other commercial
operations. Finally, funds can be received from international Health financing schemes raise revenues to pay for
sources through bilateral agreements between foreign health care for the population they are covering. In
governments or development partners, though this is general, financing schemes can receive transfers from
limited in most OECD countries. the government, social insurance contributions,
voluntary or compulsory prepayments (e.g. insurance
Government transfers and social contributions paid by
premiums), other domestic revenues and revenues
employers, employees and others constitute public
from abroad (e.g. as part of development aid).
revenues. Private sources comprise the premiums for
voluntary and compulsory insurance policies, as well as any Revenues of a financing scheme are rarely equal to
other funds from households or corporations. On average, expenses in any given year leading to a surplus or
public sources fund around 71% of health care spending deficit of funds. In practice, most countries use the
across OECD countries (Figure 7.11). Where government composition of revenues per scheme to apply on a pro-
financing schemes are the principal mechanism, such as in rata basis to the scheme’s expenditure thus providing
Denmark, public funding is the major source for health care a picture of how spending was financed in the
expenditure (84%). In other countries, governments do not accounting period.
directly pay for the majority of health services but provide Total government expenditure is as defined in the
transfers and subsidies to other schemes (Mueller and System of National Accounts. Public spending on
Morgan, 2017[1]). In Japan, only about 9% of spending on health from the System of Health Accounts is equal to
health was directly from government schemes, but transfers the sum of FS.1 Transfers from government (domestic),
and social insurance contributions means that a large FS.2 Transfers from government (foreign) and FS.3
proportion of expenditure is still publicly funded (84% of the Social insurance contributions. In the absence of
total). information from the revenue side, the sum of HF.1.1
Governments are responsible for funding a range of public Government financing schemes and HF1.2.1 Social
services, and health care is competing with other sectors health insurance is taken as a proxy.
such as education, defence and housing. The level of public
funding of health is determined by factors such as the type
of health system in place, the demographic composition of
the population, and government policy. Budget priorities References
can also shift from year to year due to political decision-
[1] Mueller, M. and D. Morgan (2017), “New insights into health
making and economic effects. Public funding of health financing: First results of the international data collection
spending (via government transfers and social insurance under the System of Health Accounts 2011 framework”,
contributions) accounted for an average of 15% of total Health Policy, Vol. 121/7, pp. 764-769, http://dx.doi.org/10.1016/
government expenditure across the OECD (Figure 7.12). j.healthpol.2017.04.008.

Figure 7.11. Health expenditure from public sources as share of total, 2017 (or nearest year)
%
100 85 85 84 84 84
82 82 82 80 79 79 78 78 77
77 77 75 74 74 73 73 73
80 72 71 71 69 69 69 68
66 66 64
61 58 57 57 57
54 51 50 50
60 45 43
40 30 26
20
0
1. Public is calculated using spending by government schemes and social health insurance.
2. Public is calculated using spending by government schemes, social health insurance and compulsory private insurance.
Figure 7.12. Health expenditure from public sources as a share of total government expenditure, 2017 (or nearest year)
%
25 23
23 20 20 20
19 19 19 19
20 18 18
17 17 17 16 16
15 15 15 15 15 15
14 13 13 13 13 13 13
15 12 12
11 11 11 11 10 10 10
10 10 9 9
10
5
5 3
1. Government expenditure includes expenditure by government schemes and social health insurance.
2. Government expenditure includes expenditure by government schemes, social health insurance, and compulsory private insurance.
Figure 7.13. Financing sources of compulsory health insurance, 2017 (or nearest year)
Transfers from government Social insurance contributions Compulsory prepayment Others
%
100 10 3 4 2 23 13 18 16 19
80 40 28 30 3 38
43 54
68 18 57 70
60
81 96 96 97 83 79 100
40 38 70 83 81
60 57 59 26 70 62
20 5 31 21
9 1 3 1 1 17 2 3 1 9
0
Note: Numbers in brackets indicate the contribution of compulsory health insurance to total expenditure. "Other" includes voluntary prepayments and
other domestic revenues.

159
Factors such as how care is organised and prioritised across system. Reducing wages in public hospitals, postponing
providers, input costs and population needs all affect the staff replacement and delaying investment in hospital
level of spending across different services. Inpatient and infrastructure were among the most frequent measures
outpatient services comprise the greatest share – typically taken in OECD countries to balance health budgets. While
accounting for around 60% of all health spending across outpatient care and long-term care continued to grow
OECD countries (Figure 7.14). Medical goods (mostly annually during the period 2009-13, spending on inpatient
pharmaceuticals) take up a further 20%, followed by a care and administration stalled in many countries, and
growing share on long-term care, which in 2017 averaged decreased for pharmaceuticals and prevention services.
around 14% of health spending. Administration and overall These cuts have since been reversed, and prevention was
governance of the health system, together with preventive the fastest growing area between 2013-17 at 3.2% on
care covered the remainder. average, annually. The rate of growth for outpatient care has
The structure of spending across the various types of care more than doubled (2.8% vs 1.1%), and inpatient care grew
can vary considerably by country. About 42% of health by 2.4%. Spending on pharmaceuticals and administration
spending in Greece can be attributed to inpatient (curative increased more modestly at 1.6% and 2.0% per year,
and rehabilitative) care services. This is by far the highest respectively. Finally, spending on long-term care has
share and some 14 percentage points above the OECD continued to grow at a consistent rate since 2003.
average. At the other end of the scale, many of the Nordic
countries, but also Canada and the Netherlands, saw
inpatient services account for a quarter or less of all
spending. Outpatient care, covering generalist and specialist
consultations, was particularly high in Portugal and Israel The System of Health Accounts (OECD, Eurostat and
relative to the OECD average of 32%. Greece and Belgium WHO, 2017[1]) defines the boundaries of the health
spent the lowest proportion on outpatient services. care system from a functional perspective, with health
Spending on medical goods comprises the third largest care functions referring to the different types of health
category. Prices of goods generally tend to be less variable care services and goods. Current health expenditure
across countries than services (see indicator on Prices in the comprises personal health care (curative care,
health sector). This means that spending on rehabilitative care, long-term care, ancillary services
pharmaceuticals and medical devices often accounts for a and medical goods) and collective services (prevention
higher share of health spending in lower income countries. and public health services as well as administration –
As such, medical goods accounted for more than a third of referring to governance and administration of the
all health spending in the Slovak Republic. By contrast, in overall health system rather than at the health
Denmark, Norway, the Netherlands and Sweden, the share provider level). Curative, rehabilitative and long-term
was much lower, at between 10 and 12%. care can also be classified by mode of provision
Where formal arrangements are in place for the care of the (inpatient, day care, outpatient and home care).
elderly and the dependent population such as in Norway, A key health service that has been notably missing in
Sweden and the Netherlands, a quarter or more of all health the SHA framework is primary care. Efforts have been
spending can relate to long-term care services. In countries made in recent years to develop a methodology using
with a more informal long-term care sector such as in many the SHA framework to develop a proxy indicator for
Southern, Central and Eastern European countries,
primary care spending (Mueller and Morgan, 2018[2]).
spending on long-term care is much lower – around 5% or
Comparability of primary care figures is mainly
less in Greece, Portugal, Hungary and Latvia.
affected by the extent to which countries are able to
A vital component of any health system that stretches distinguish between generalist and specialist services
across the different types of services described above is and the methods used to implement such a split.
primary care. As a proxy for this complex concept, primary
For the calculation of growth rates in real terms, AIC
care is here defined to include a variety of different services
deflators are used.
such as general outpatient care, preventive services, dental
care services and home-based curative services when
provided by ambulatory care providers. Using this proxy
measure, primary care accounts for around 13% of all health
spending across the OECD, ranging from around 10% in References
Switzerland, the Slovak Republic, the Netherlands and
[2] Mueller, M. and D. Morgan (2018), “Deriving preliminary
Austria to 18% in Australia and Estonia (Figure 7.15).
estimates of primary care spending under the SHA 2011
Growth in health expenditure resumed across all areas framework”; http://www.oecd.org/health/health-systems/
following the general slowdown after the economic crisis Preliminary-Estimates-of-Primary-Care-Spending-under-
(Figure 7.16). During the years of the economic downturn, SHA-2011-Framework.pdf.
some governments introduced policies to protect [1] OECD/Eurostat/WHO (2017), A System of Health Accounts
expenditure for primary care and front-line services while 2011: Revised edition, OECD Publishing, Paris, https://doi.org/
looking to make cost savings elsewhere in the health 10.1787/9789264270985-en.

Figure 7.14. Health expenditure by type of service, 2017 (or nearest year)
Inpatient care* Outpatient care** Long-term care Medical goods Collective services
%
100 4 5 5 5 4 5 6 7 4 6 6 11 5 6 6 5 5 5 4 8 4 8 6 8 7 4 7 5 6 6 8 11 8
19 15 21 23 31 22 20 14 17 14 15 23 20 10 14 29 19 16 20 14 11 23 20 12 16 19
80 3 8 6 30 35 25 31 31 20 12
6 2 9 11 20 15 19 27 19 10 14 19 8 15 19 14 21 28 12 19 26 23 18
60 1 4 5 15 26
49 46 43 32 22 37 31 26 31 28 34 33 32 29 26
40 37 32 32 35 32 31 29 27 34 32 29 32 29 34 25 27 32 29
20 42
26 27 26 34 26 32 36 31 34 28 29 25 29 28 28 25 31 28 29 30 32 25 26 33 29 26 28 22 30 27 22 24
0
Note: Countries are ranked by curative-rehabilitative care as a share of current expenditure on health.
* Refers to curative-rehabilitative care in inpatient and day care settings. ** Includes home care and ancillary services.
Figure 7.15. Spending on primary care as a share of current health expenditure, 2017 (or nearest year)
%
20
18 18 17 17 16 16 15 14 14 14 14 13
15 13 12 12 12 12 11 11 11 11 10 10 9
10

Figure 7.16. Annual growth in health expenditure for selected services (real terms), OECD average, 2009-13 and 2013-17
2009-13 2013-17
Annual growth in real terms (%)
4
2.8 3.0 3.1 3.2
3 2.4
2.0
2 1.6
1.1
1 0.1 0.2
0
-1
-2 -1.5
-3 -2.1
-4
Inpatient care Outpatient care Long-term care Pharmaceuticals Prevention Administration


161
How and where health care is delivered can have a services provided to outpatients. In Germany and Greece,
significant impact on spending for different goods and hospitals are generally mono-functional with the vast
services. Health care can be provided in many different majority (93%) of spending on inpatient care services, and
organisational settings, ranging from hospitals and medical very little outpatient and day care spending. On the other
practices to pharmacies and even private households caring hand, outpatient care accounts for over 40% of hospital
for family members. Analysing health spending by provider expenditure in Denmark, Sweden, Estonia, Finland and
can be particularly useful when considered alongside the Portugal. In those countries, specialists are typically
functional breakdown of health expenditure, giving a fuller receiving outpatients in hospital outpatient departments.
picture of the organisation of health systems (see indicator Many countries have shifted some medical services from
“Health expenditure by type of service”). inpatient to day care settings in recent years (see indicator
Activities delivered in hospitals account for the largest on “Ambulatory surgery” in Chapter 9). The main motivation
proportion of health care expenditure in almost all OECD behind this is the generation of efficiency gains and a
countries, even though each country organises their system reduction of waiting times. Moreover, for some
to provide funding and care in different ways. On average, interventions day care procedures are now the most
hospitals receive 38% of health system funding, but receive appropriate treatment method. Hence, in a number of
more than half of all financial resources in Turkey countries day care now accounts for more than 10% of all
(Figure 7.17). Estonia, Korea and Italy also have significant hospital expenditure. Furthermore, the provision of long-
hospital sectors, where spending accounts for around 45%. term care in hospital makes up a sizeable share of hospital
Only Germany and Mexico spend less than 30% of the total expenditure in some countries (e.g. Korea, Japan and Israel).
on hospitals.
After hospitals, the largest provider category are ambulatory
providers. This category covers a wide range of facilities and
depending on the country-specific organisation of health Definition and comparability
service delivery, most spending relates either to medical
practices including offices of GPs and specialists (e.g. The universe of health care providers is defined in the
Austria, France and Germany) or ambulatory health care System of Health Accounts (OECD, Eurostat and WHO,
centres (e.g. Finland, Ireland and Sweden). Across OECD 2017) and encompasses primary providers, i.e.
countries, care delivered by ambulatory providers accounts organisations and actors that deliver health care goods
for around a quarter of all health spending. This share and services as their primary activity, as well as
stands above 30% in Israel, Belgium, the United States, secondary providers for which health care provision is
Luxembourg, Mexico and Germany, but is less than 20% in only one among a number of activities.
Turkey, Greece, the Netherlands and the Slovak Republic. The main categories of primary providers are hospitals
Around two-thirds of all spending on ambulatory providers (acute and psychiatric), residential long-term care
relate to GP and specialist practices together with facilities, ambulatory providers (practices of GPs and
ambulatory health care centres, and roughly one-fifth to specialists, dental practices, ambulatory health care
dental practices. centres, providers of home health care services),
Other main provider categories include retailers (mainly providers of ancillary services (e.g. ambulance
pharmacies selling prescription and over-the-counter services, laboratories), retailers (e.g. pharmacies), and
medicines) – accounting for 18% of all health spending – and providers of preventive care (e.g. public health
residential long-term care facilities (mainly providing institutes).
inpatient care to long-term dependent people), to which 9% Secondary providers include residential care
of the total health spending bill can be attributed. institutions whose main activities might be the
There is a large variation in the range of activities that may provision of accommodation but provide nursing
be performed by the same category of provider across supervision as secondary activity, supermarkets that
countries, depending on the structure and organisation of sell over-the-counter medicines, or facilities that
the health system. This variation is most pronounced in provide health care services to a restricted group of the
hospitals (Figure 7.18). Although inpatient curative and population such as prison health services. Secondary
rehabilitative care defines most of the hospital expenditure providers also include providers of health care system
in almost all OECD countries, hospitals can also be administration and financing (e.g. government
important providers of outpatient care in many countries, agencies, health insurance agencies) and households
for example through accident and emergency departments, as providers of home health care.
specialist outpatient units, or laboratory and imaging

Figure 7.17. Health expenditure by provider, 2017 (or nearest year)
Hospitals LTC facilities* Ambulatory providers Retailers Other

%
100
8 67 10 5 7 9 6 11 8 5
13
6 11 5 8 9 11 9 12 5 5 10 12 8 7 10
13 17 10 12 13 12
13 14 4 16
10 1014 15
18 11 9 12 11
80 26 10 21 19 16 19 22 11 22 18 17 14
31 17 22 31 16 14 30 12 30 20 19
29 27
29 27 24 19 35
27
28 23 26 23
24
28 20 29 54 30 33
60 13 28 23 23 22 23 26 22
26 31 30 27
18 20 31
4 2 6 12 12 16 23 29
9 8 16 18 18 27 25
2 2 5 7 11 14 16 31
40 1 3 9 9 13 19
1 2 5 8 11
1 3 9
53 49
46 46 45 44 43 43 42 42 41
20 41 41 40 39 39 39 39 38 38 38 37 37 37
35 35 34 34 34 34 33 33 32
30 29 28
Note: Countries ranked by hospitals as a share of current expenditure on health. * Refers to long-term care facilities.
Figure 7.18. Hospital expenditure by type of service, 2017 (or nearest year)
Inpatient Day care Outpatient care* Long-term care Other

%
100
5 6 1 3 1 7 1 4 1 4 1 3 3 4 1
3 4 5 1 4 10
13 1
2 2 15 15 1 11
1 15 19 11 9 21
1 14 15 16
1 3 7 24 27 23 32 19 24 30 17
80 3 23 34 43
8 11 22 43 36
8
9 22 23 43 43 46
4 6
4 13 10 17 18
1 8
11 13 24
60 2 5
5 10
6 5
93 93 15
86 83 82
40 81 79
73 72 72 71 69
66 65 64 63
61 61 61 60 59 59 57 57
56 53 53
51 49 48
47
20 39
Note: Countries ranked by inpatient curative-rehabilitative care as a share of hospital expenditure. * Includes ancillary services.

163
The health and long-term care sectors remain highly Capital spending fluctuates more than current spending
dependent on labour inputs, but capital is also a key factor in from year to year, particularly in small economies, as capital
the production of health services. How much a country projects on construction (i.e. building of hospitals and other
invests in new health facilities, the latest diagnostic and health care facilities) and investment programmes on new
therapeutic equipment and information and equipment (e.g. medical and ICT equipment) are
communications technology (ICT) can have an important implemented. Decisions on capital spending also tend to be
impact on the capacity of a health system to meet the health more affected by economic cycles, with spending on health
needs of the population and thus contribute to better system infrastructure and equipment often a prime target
outcomes. For example, a low level of MRI and CT scanners for reduction or postponement during downturns.
(see indicator “Medical technologies” in Chapter 5) can have Figure 7.20 shows an index of capital spending in real terms
consequences on the ability to detect diseases at an early over a ten-year period for a selection of European and North
stage. However, the level of capital expenditure tends to American countries. While France maintained a constant
fluctuate more from year to year than current spending on level of capital investment over the period, both the United
health services, as investment decisions can be much more Kingdom and, in particular, Greece reported a sharp drop in
dependent on economic circumstances and political or capital spending in the wake of the global financial and
business choices as well as reflecting future needs and past economic crisis, and expenditure remains at levels well
levels of investment. In making such decisions, policy- below that of 2007. Both the United States and Canada have
makers and providers need to weigh up not only the short- current capital spending similar to the levels (in real terms)
term costs, but also the potential benefits in the short, before the crisis. There was a marked increase in capital
medium and longer-term. As with any industry, a lack of expenditure in Canada in 2010/11 as a counter-cyclical
investment spending in the present can lead to an measure, which was even more pronounced in Mexico from
accumulation of problems and bigger costs in the future as 2008-12, as the public health insurance (Seguro Popular) was
current equipment and facilities deteriorate. significantly expanded.
For the most recent year available, the average capital
expenditure in OECD countries was equivalent to around
5.6% of current spending on health (that is, on medical care, Definition and comparability
pharmaceuticals, etc.) and around 0.5% of GDP compared to
8.8% of GDP for current spending on health (see indicator Gross fixed capital formation in the health sector is
“Health expenditure as a share of GDP”) (Figure 7.19). As is measured by the total value of the fixed assets that
the case with current spending, there are significant health providers have acquired during the accounting
differences in the levels of investment expenditure between period (less the value of the disposals of assets) and
countries and over time, especially as a result of the that are used repeatedly or continuously for more than
economic crisis. one year in the production of health services. The
breakdown by assets includes infrastructure (e.g.
In relation to their current spending, Luxembourg and Japan
hospitals, clinics, etc.), machinery and equipment
were the highest spenders in 2017 with the equivalent of
(including diagnostic and surgical machinery,
more than 10% going on new construction, equipment and
ambulances, and ICT equipment), as well as software
technology in the health and social sector, although in
and databases.
relation to its GDP, Luxembourg is closer to the average. A
number of European countries – including Germany, Gross fixed capital formation is reported by many
Belgium, and the Netherlands – were also relatively high countries under the System of Health Accounts. It is
capital spenders, corresponding to around 9% of current also reported under the National Accounts broken
spending on health. Both Japan and Germany spent more down by industrial sector according to the
than 1% of GDP on capital investment in the health sector in International Standard Industrial Classification (ISIC)
2017. The United States and the United Kingdom spent less Rev. 4 using Section Q: Human health and social work
than the average compared to current spending at 3.5% and activities or Division 86: Human health activities. The
3.2%, although because of the very high expenditure on former is normally broader than the SHA boundary
health services, this translated into a relatively high share of while the latter is narrower.
GDP in the case of the United States. Turkey, by contrast,
allocated only 0.3% of GDP to capital spending in 2017 but
this appears relatively high compared to its low current
spending on health.

Figure 7.19. Capital expenditure on health as a share of current health expenditure, 2017 (or nearest year)
% of current spending Share of GDP

% %
12 1.2
10 1.0
8 0.8
6 0.6
10.4
9.6
10.6
9.2
8.8
8.6
8.2
7.4
4 0.4
7.8
7.5
7.2
6.6
6.2
6.0
5.7
5.6
5.6
5.3
5.1
5.1
5.1
5.0
4.8
4.3
4.3
4.1
2 0.2
3.5
3.3
3.2
3.7
2.9
2.7
2.7
1.3
3.4
2.3
2.8
1.8
0 0.0
1. Refers to gross fixed capital formation in ISIC Q: Human health and social work activities (ISIC Rev. 4).
Source: OECD Health Statistics 2019, OECD National Accounts.
Figure 7.20. Trends in capital expenditure (constant prices), selected countries, 2007-17
France Greece Canada Mexico
OECD13 United Kingdom OECD13 United States
Index Index
250 250
200 200
150 150
100 100
50 50
0 0
Source: OECD Health Statistics 2019, OECD National Accounts.


165
Health expenditure has outpaced economic growth across 2030, compared to 8.8% in 2015 (Figure 7.23). The only
OECD countries over most of the past half century. This countries for which a slight decrease in this ratio is expected
additional spending has contributed to improvements in are Latvia, Hungary and Lithuania, largely due to projected
health outcomes and been an important source of economic decreases in population size over the coming decades. Most
growth and jobs. Nevertheless, financial sustainability is countries are expected to experience moderate increases in
becoming an increasing concern, as most countries draw health expenditure as a share of GDP, with only the United
their funding largely from public sources (OECD, 2015[1]). States seeing growth of more than three percentage points.
Projections of health expenditure growth can give countries
a perspective regarding how quickly, and by how much,
health expenditure could rise compared to general
economic growth, or with respect to a country’s population
(Lorenzoni et al., 2019[2]). The underlying model for projecting health
Over the long run, health expenditure has largely outpaced expenditure in the future includes several country-
GDP growth across all OECD countries, even taking into specific determinants. It is based on age-specific
account the volatility following the financial crisis of health expenditure curves for total health expenditure
2007-08 (Figure 7.21). Over the period 2000-15, annual health (in real terms), which are projected in the future by
spending growth across the OECD was 3.0%, compared to using population changes, mortality rates, expected
GDP growth of 2.3%. By comparison, for the period costs associated with dying, and the share of survivors
2015-2030, health expenditure per capita is projected to and non-survivors in any given year. These are further
grow at an average annual rate of 2.7% across the OECD adjusted for GDP growth, productivity and wages
under a base scenario (with GDP growth averaging 2.1%). growth, time effects, individual and collective shares
Average growth is projected to be as low as 2.2% with greater of expenditure and technological change. This
cost control, but as high as 3.1% in a cost pressure scenario. modelling is applied to both total and public current
These scenarios reflect diverging assumptions such as health expenditure (excluding capital expenditure),
countries’ economic growth, productivity and healthy and a range of scenarios are constructed based on
ageing. However, across OECD countries health expenditure parameters gathered from the literature, regression-
is projected to outpace GDP growth in the next 15 years in all based sensitivity analysis, and assumptions in line
scenarios. with specific theories in the literature (i.e. time-to-
Looking at country-specific projections, health spending per death, healthy ageing). A detailed breakdown of the
capita in 2015-30 is projected to grow more than 4% per year theoretical framework and the methodological
in the Slovak Republic, Turkey and Korea, while in Belgium, assumptions underlying the projections presented in
Germany, Italy, Lithuania, Japan and Portugal projected this column are available in the References section.
growth is less than 2% per year (Figure 7.22). In 20 out of 36
OECD countries, growth is projected to be within
±1 percentage points growth compared to 2000-15. In the six
countries – Iceland, Hungary, Mexico, Israel, Portugal and References
Turkey – where per capita growth is projected to be more
[2] Lorenzoni, L. et al. (2019), “Health Spending Projections to
than one percentage point higher than that observed for
2030: New results based on a revised OECD methodology”,
2000-2015, most experienced a slowdown in health OECD Health Working Papers, No. 110, OECD Publishing, Paris,
spending growth in the aftermath of the global economic https://doi.org/10.1787/5667f23d-en.
and financial crisis. In contrast, in Lithuania, Korea, Chile,
[3] Marino, A. et al. (2017), “Future trends in health care
Latvia and Estonia, growth rates are projected to be over two
expenditure: A modelling framework for cross-country
percentage points lower than historical rates. These forecasts”, OECD Health Working Papers, No. 95, OECD
countries also reported some of the highest growth rates in Publishing, Paris, https://doi.org/10.1787/247995bb-en.
health spending per capita from 2000 to 2015.
[1] OECD (2015), Fiscal Sustainability of Health Systems: Bridging
Across the OECD, under the base scenario, health Health and Finance Perspectives, OECD Publishing, Paris,
expenditure as a share of GDP is projected to rise to 10.2% by https://doi.org/10.1787/9789264233386-en.

Figure 7.21. Health expenditure per capita vs GDP growth trends, observed and projected, 2000‑30
Base Full cost control Cost pressure GDP

Growth
8%
6%
4%
2%
0%
-2%
-4%
-6%
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 2022 2024 2026 2028 2030
Source: OECD Health Division projections, 2019.

Figure 7.22. Average per capita health expenditure growth, 2000-15 and 2015-30
2000-15 2015-30
Growth
8%
7%
6%
5%
4%
3%
2%
1%
0%

Figure 7.23. Health expenditure as a share of GDP, projection to 2030
2015 2030
% GDP
20%
14.5%
20.2%
13.3%
13.1%
13.0%
13.0%
12.3%
12.2%
12.1%
12.0%
12.0%
11.7%
11.6%
11.4%
11.3%
11.3%
10.4%
10.2%
9.9%
9.9%
9.7%
9.7%
15%
9.5%
9.1%
8.9%
8.8%
8.3%
8.1%
8.0%
7.5%
7.4%
7.0%
7.0%
6.7%
6.7%
6.2%
5.5%
4.6%
10%
5%
0%


167
8. HEALTH WORKFORCE
Health and social care workforce
Doctors (overall number)
Doctors (by age, sex and category)
Remuneration of doctors (general practitioners and specialists)
Nurses
Remuneration of nurses
Medical graduates
Nursing graduates
International migration of doctors and nurses
international law.
169
8. HEALTH WORKFORCE
In OECD countries, health and social systems employ more physician providers (such as nurse practitioners,
workers now than at any other time in history. In 2017, pharmacists and community health workers), or
about one in every ten jobs was found in health or social care introducing more multi-professional teams and treatment
(Figure 8.1), which amounts to a nearly two percentage- structures, can increase the productivity of the health
point increase since 2000. In Nordic countries and the workforce, as well as improving continuity and quality of
Netherlands, more than 15% of all jobs are in health and care for patients.
social work. From 2000 to 2017 the share of health and social New health technologies are a further factor driving rapid
care workers remained steady or increased in all countries change in the health and social care sector, and their
except the Slovak Republic (where it decreased in the 2000s development and impact can be hard to predict.
and has remained stable since 2010). In some countries, Technological shifts are expected in information technology
notably Japan, Ireland and Luxembourg, the share of health and big data, automation and artificial intelligence; these
and social care workers increased considerably. may generate demand for new specialities or skills for
The health and social care sector is critical for the effective health and social care workers, while reducing the
functioning of OECD societies and economies, and as a importance of other professional roles (OECD, 2019[3]).
result the sector is not directly aligned with general
workforce trends. Specifically, in OECD countries from 2000
to 2017, employment in the health and social sector
increased on average by 42% (with a median increase of Definition and comparability
38%), outpacing even the growth in the service sector and
Health and social work is one of the economic
trends in total employment, while employment in
activities defined according to the major divisions of
agriculture and industry declined sharply across the same
the International Standard Industrial Classification of
period (Figure 8.2). At the same time, the health and social
All Economic Activities (ISIC). Health and social work is
care sector also tends to be more robust to cyclical
a sub-component of the Services sector, and is defined
employment fluctuations. For example, while total
as a composite of human health activities, residential
employment declined in the United States and other OECD
care activities (including long-term care), and social
countries during the economic recessions of the early 1990s
work activities without accommodation. The
and, in particular, 2008-09, employment in the health and
employment data are taken from the OECD National
social care sector continued to grow steadily throughout.
Accounts database for the 36 OECD member countries,
Looking forward, employment in the health and social care except for Turkey where the source is the OECD
sector is likely to continue to increase. Investment in health Annual Labour Force Statistics database.
systems, including in workforce development, can promote
economic growth by securing a healthy population, as well
as along other pathways such as innovation and health
security (UN High-Level Commission on Health
Employment and Economic Growth, 2016[1]). The References
distribution of health and social care workers’ skills and [2] OECD (2019), Who Cares? Attracting and Retaining Care Workers
roles, however, is expected to change, driven in large part by for the Elderly, OECD Publishing, Paris, https://doi.org/
ageing populations. With more older people, the pattern of 10.1787/92c0ef68-en.
demand for health and social services will shift towards [3] OECD (2019), “Engaging and transforming the health
greater demand for long-term care and related social workforce”, in Health in the 21st Century: Putting Data to Work
services, which are particularly labour-intensive (OECD, for Stronger Health Systems, OECD Publishing, Paris.
2019[2]). In response to, or in anticipation of, this [1] UN High-Level Commission on Health Employment and
demographic shift, many countries have begun to introduce Economic Growth (2016), Working for Health and Growth:
new care delivery models that integrate health and social Investing in the Health Workforce, World Health Organization,
services. Policies such as expanding the roles of non- Geneva, http://www.who.int/hrh/com-heeg/reports.

8. HEALTH WORKFORCE
Figure 8.1. Employment in health and social work as a share of total employment, 2000 and 2017 (or nearest year)
% 2000 2017
25
20.9
20
17.5
17.3
15.6
15.4
14.1
13.6
15
13.4
13.3
13.3
13.1
12.4
12.3
11.9
10.9
10.8
10.5
10.4
10.4
10.1
10.3
10
8.2
7.8
7.2
7.2
6.8
6.6
6.5
6.4
6.0
5.4
5.4
4.2
5
6.0
5.8
5.5
3.0
0
Source: OECD National Accounts; OECD Annual Labour Force Statistics for Turkey.
Figure 8.2. Employment growth by sector, OECD average1, 2000-17 (or nearest year)
Mean Median
Change in employment since 2000
50%
42%
40% 38%
30% 28%
24%
20%
15%
12%
10%
0%
-4%
-10%
-10%
-20%
-23%
-25%
-30%
Total Agriculture Industry Services Health and social work²
1. Average of 30 OECD countries (excluding Chile, Iceland, Korea, New Zealand, Switzerland and Turkey).
2. Health and social work is classified as a sub-component of the services sector.
Source: OECD National Accounts.

171
8. HEALTH WORKFORCE
Across OECD countries in 2017 the number of doctors ranged towards retirement have prompted many OECD countries to
from 2.5 or less per 1 000 population in Turkey, Korea, increase the number of students in medical and nursing
Poland, Mexico, Japan and Chile, to five or more in Portugal, education programmes (OECD, 2016[2]). While some
Austria, and Greece. However, numbers in Portugal and countries, such as Australia, have already started to see the
Greece are over-estimated as they include all doctors benefits of earlier increases in medical education places, the
licensed to practise. On average, there were 3.5 doctors per long duration of doctors’ training means that it takes a
1 000 population (Figure 8.3). In Indonesia, India and South decade or more to feel the impact of increasing intake into
Africa there were significantly fewer doctors per 1 000 medical education.
population – less than one – while in China the number of In most OECD countries, there are also concerns about
doctors increased rapidly from 1.25 per 1 000 population in shortages of general practitioners (see the indicator on
2000 to 2 per 1 000 population in 2017. “Doctors by age, sex and category”) and an undersupply of
Targeted education and training policies, as well as greater doctors in rural and remote regions (see the indicator on
retention rates and in some countries immigration of “Geographic distribution of doctors” in Chapter 5). These
doctors, have meant that both the absolute and per capita issues have been driven or exacerbated by the ageing of
numbers of doctors have increased in almost all OECD general practitioners and of the population in general.
countries since 2000. The only exception is Israel, where a
25% increase in the absolute number of doctors was still not
enough to keep pace with total population growth of about
40% between 2000 and 2017. Overall, in most OECD countries
the number of doctors increased steadily between 2000 and The data for most countries refer to practising doctors,
2017, and did not appear vulnerable to external shocks. defined as the number of doctors providing care
However, the 2008-09 recession had a profound impact in directly to patients. In many countries, the numbers
Greece, where the number of doctors increased until 2008 include interns and residents (doctors in training). The
before stagnating from 2012. numbers are based on head counts. The
In some countries there were particularly rapid expansions Slovak Republic and Turkey also include doctors who
in the number of doctors between 2000 and 2017 (Figure 8.4). are active in the health sector even though they may
This was the case in Korea, Mexico and the United Kingdom, not provide direct care to patients, adding another
where despite outpacing average per capita growth in 5‑10% of doctors. Chile, Greece and Portugal report the
doctors, there were still fewer doctors per 1 000 than the number of physicians entitled to practice, resulting in
OECD average in 2017. In other countries, such as an even larger over-estimation of the number of
Australia,Denmark and Austria, increases both outpaced practising doctors. Belgium sets a minimum threshold
OECD average growth, and left these countries with more of activities for general practitioners to be considered
doctors per capita than the OECD average. In Australia, to be practising (500 consultations per year), thereby
where the number of doctors per capita went from below the resulting in an under-estimation compared with other
OECD average in 2000, to above it in 2017, this increase was countries that do not set such minimum thresholds.
driven by a significant rise in the number of graduates from Data for India may be over-estimated as they are based
domestic medical education programmes (see indicator on on medical registers that are not updated to account
“Medical graduates”). for migration, retirement or death; nor do they take
At the other end of the spectrum, the number of doctors per into account doctors registered in multiple states.
capita grew much more slowly or remained stable since 2000
in Belgium, France, Poland, and the Slovak Republic. In these
four countries, the number of domestic students admitted to
medical schools has increased in recent years. This should References
contribute towards replacing those doctors who will be
[1] OECD (2019), Recent Trends in International Migration of Doctors,
retiring in the coming years, as long as new doctors end up
Nurses and Medical Students, OECD Publishing, Paris, https://
working in their country of training (OECD, 2019[1]).
dx.doi.org/10.1787/5571ef48-en.
Concerns about shortages of health professionals are not
[2] OECD (2016), “Education and training for doctors and nurses:
new in OECD countries, but these concerns have grown in What’s happening with numerus clausus policies?”, in
many countries, especially as the “baby-boom” generation Health Workforce Policies in OECD Countries: Right Jobs, Right
of doctors and nurses starts to retire. Over the past decade, Skills, Right Places, OECD Publishing, Paris, https://dx.doi.org/
concerns about the ageing medical workforce moving 10.1787/9789264239517-6-en.

8. HEALTH WORKFORCE
Figure 8.3. Practising doctors per 1 000 population, 2000 and 2017 (or nearest year)
2000 2017
7
6.1
6
5.2
5.0
4.7
4.6
5
4.3
4.3
4.1
4.0
4.0
4.0
3.9
3.9
3.7
3.7
3.6
4
3.5
3.5
3.4
3.3
3.3
3.2
3.2
3.2
3.1
3.1
3.1
3.0
3.0
2.8
2.7
2.6
3
2.5
2.4
2.4
2.4
2.3
3.1
2.1
2.0
1.9
1.8
2
0.8
0.8
1
0.3
0
1. Data refer to all doctors licensed to practice, resulting in a large over-estimation of the number of practising doctors (e.g. of around 30% in Portugal).
2. Data include not only doctors providing direct care to patients but also those working in the health sector as managers, educators, researchers, etc.
(adding another 5-10% of doctors).
Figure 8.4. Evolution in the number of doctors, selected countries, 2000-17 (or nearest year)
Countries above OECD average in doctors per capita in 2017 Countries below OECD average in doctors per capita in 2017
Australia Austria Japan Korea
Denmark Germany Mexico United Kingdom
Greece OECD32 United States OECD32
Index (2000=100) Index (2000=100)
200 200
180 180
160 160
140 140
120 120
100 100
80 80


173
8. HEALTH WORKFORCE
In 2017, more than one third of all doctors in OECD countries practitioners/family doctors as a percentage of all doctors
were over 55 years of age, up from one-fifth in 2000 ranged from around half in Chile, Canada and Portugal, to
(Figure 8.5). The share of doctors over 55 increased in all just 5% in Greece and Korea (Figure 8.7). The numbers of
countries between 2000 and 2017%. generalists remains difficult to compare, however, due to
While some countries saw only a small increase, such as variation between countries in the ways doctors are
Norway (+2 percentage points), Australia (+3 percentage categorised. For example, in the United States, general
points), and the United Kingdom (+4 percentage points), internal medicine doctors often play a role similar to that of
others saw a dramatic ageing of their medical workforce. In general practitioners/family doctors in other countries, yet
Italy, the share of older doctors increased by 36%, with 55% they are categorised as specialists. In other countries, such
of all doctors aged 55 or over by 2017. In France the doctor as Japan, general practitioners/family doctors are very
population is ageing almost as rapidly, with a 30% increase uncommon, and the majority of physician consultations are
in older doctors between 2000 and 2017; other countries with specialists.
such as Israel, Spain and Austria are not far behind In many countries, general practitioners/family doctors play
(Figure 8.5). a key role in guaranteeing good access to health care,
Ageing of the medical workforce is a concern, as doctors managing chronic conditions and keeping people out of
aged 55 and over are generally expected to retire in the hospital (see indicator on “Avoidable hospital admissions”
following decade and need to be replaced in order to prevent in Chapter 6). Accordingly, many countries have taken steps
a decline in overall physician numbers. Many doctors do to increase the number of training places in general
keep working beyond age 65, and several OECD countries medicine in response to concerns about shortages of general
have reformed their pension systems and increased the practitioners. However, in most OECD countries, specialists
retirement age to take into account the longer average life earn more than general practitioners, which provides
expectancy (OECD, 2016[1]). While few studies have financial incentives for doctors to specialize (see indicator
examined the impact of these pension reforms specifically on the “Remuneration of doctors”).
on doctors, it is possible that such steps will prolong the
working lives of doctors, which could have a significant
impact on future replacement needs.
In 2017 almost half of all doctors in OECD countries were Definition and comparability
female, at between one-third and two-thirds of all doctors in
The definition of doctors is provided under the
most OECD countries. In some countries, the gender balance
previous indicator. In some countries, the data are
was skewed more dramatically: in Japan and Korea only
based on all doctors licensed to practice, not only those
one-fifth of doctors were women in 2017, while in Latvia and
practising (Chile, Greece and Portugal; and also Israel
Estonia three quarters of doctors were female (Figure 8.6). In
and New Zealand for doctors by age and gender). Not
most OECD countries the share of female doctors increased
all countries are able to report all their physicians in
between 2000 and 2017, while in countries such as
the two broad categories of specialists and generalists.
Lithuania, Estonia and Latvia – which traditionally have far
This may be due to the fact that specialty-specific data
more female than male doctors – the ratio of male-to-female
are not available for doctors in training or for those
doctors remained stable. The most significant increases in
working in private practice. A distinction is made in
the share of female doctors were reported for the
the generalists category between general
Netherlands (+19 percentage points) and Spain
practitioners/family doctors and non-specialist
(+18 percentage points). In countries where the number of
doctors working in hospital or in other settings. In
female doctors has increased, this is probably driven by
Switzerland, general internal medicine doctors and
rising female labour force participation and higher numbers
other generalists are included under general
of young women enrolling in medical school, but may also
practitioners.
be affected by the retirement of older and more commonly
male generations of doctors.
Up to and including the 2015 issue of Health at a Glance, the
category ‘generalist’ did not distinguish between general
practitioners/family doctors and non-specialised physicians References
who work in hospitals and other settings. It is now possible [1] OECD (2016), Health Workforce Policies in OECD Countries: Right
to distinguish between these two categories of phyisicans, Jobs, Right Skills, Right Places, OECD Health Policy Studies,
and as of 2017, general practitioners/family doctors OECD Publishing, Paris, https://dx.doi.org/
represented 23% of all physicians. The share of general 10.1787/9789264239517-en.

8. HEALTH WORKFORCE
Figure 8.5. Share of doctors aged 55 and older, 2000 and 2017 (or nearest year)
2000 2017
%
60 55 50 48
46 45 45 45 43
50 43 43
39 37 37 37
36 36 34 34 34
40 33 33
30 30 29 28 28
27 26 26 26 25
30 22
19 18
15
20
10
0

Figure 8.6. Share of female doctors, 2000 and 2017 (or nearest year)
2000 2017
%
90
74 74
80 69
63
70 58 58 57 56 55 55 55 54
60 51 49 48 48 48 47
47 45 44 44 44 43
43 42 42 42 42 41 41
50 39 37 36 36
40
23 21
30
20
10
0

Figure 8.7. Share of different categories of doctors, 2017 (or nearest year)
General practitioners Other generalists ¹ Specialists Other doctors (not further defined)
%
100 4 1 7 3 4 4 1
14 15 11
24 30 17
80 44 36 39
49 52 49 55 55
58 62 49 68 70 56 73
64
65 77 77 77 70 73
74 80 78 77
60 60 53 79 88 82
5 65
60 54 82
40 12 31 44 42
11 16
9 21
51 48 46 8
20 37 37 33 32 30 30 2 3 3 4 2 7 16 21 21
29 27 27 27 25 24 23 23 21 21 8 8
20 20 19 19 18 17 17 16 16 15 13 12 26
9 9 6
0
1. Includes non-specialist doctors working in hospital and recent medical graduates who have not yet started post-graduate specialty training.
2. In Portugal, only about 30% of doctors employed by the public sector work as GPs in primary care, the other 70% work in hospitals.

175
8. HEALTH WORKFORCE
The remuneration level and structure for the different

categories of doctors affects the (relative) financial Definition and comparability
attractiveness of these specialities. In many countries,
governments can determine or influence the level and The remuneration of doctors refers to average gross
structure of physician remuneration by regulating their fees annual income, including social security contributions
or by setting salaries when doctors are employed in the and income taxes payable by the employee. It should
public sector. As for any other category of workers, normally exclude practice expenses for self-employed
differences in remuneration levels of doctors across doctors (in Belgium, practice expenses are included).
countries can be a push or pull factor when it comes to OECD data on physician remuneration makes the
physician migration (OECD, 2019[1]). distinction between salaried and self-employed
physicians. In some countries this distinction is
Across OECD countries, the remuneration of doctors (both
blurred, since some salaried physicians are allowed to
general practitioners and specialists) is substantially higher
have a private practice and some self-employed
than the average wages (Figure 8.8). In most countries,
doctors receive part of their remuneration through
general practitioners earn two to four times more than the
salaries. The OECD data also distinguish between
average wage in each country, while specialists earn two to
general practitioners and all other medical specialists
six times more.
combined, although especially the latter may be a
In most countries, specialists earned more than general rather inhomogeneous group.
practitioners (Figure 8.8). In Australia, Belgium, and
A number of data limitations contribute to an under-
Luxembourg self-employed specialists earned at least twice
estimation of remuneration levels in some countries:
as much as self-employed general practitioners. In Germany
1) payments for overtime work, bonuses, other
the difference between specialists and general practitioners
supplementary income or social security contributions
is much smaller, at only 20%. Among salaried physicians,
are excluded in some countries (in Austria for GPs,
specialists in Israel and the United Kingdom earned twice as
Ireland for salaried specialists, and Italy); 2) incomes
much as general practitioners in 2017. In Poland, however,
from private practices for salaried doctors are not
salaried specialists earned 40% less than salaried general
included in some countries (e.g. Czech Republic,
practitioners.
Hungary, Iceland, Ireland and Slovenia); 3) informal
The remuneration of physicians has generally increased payments, which may be common in certain countries
since 2010, but at different rates across countries and (e.g. Greece and Hungary), are not included; 4) data
between general practitioners and specialists (Figure 8.9). relate only to public sector employees, who tend to
Both generalists and specialists in Hungary and Estonia earn less than those working in the private sector in
have obtained substantial pay raises in recent years. To Chile, Denmark, Greece, Hungary, Iceland, Ireland,
reduce shortages and emigration of doctors, the Hungarian Norway, the Slovak Republic and the United Kingdom;
government has substantially increased their remuneration and 5) physicians in training are included in Australia.
since 2010, with the income of general practitioners
The income of doctors is compared to the average
increasing by about 80% between 2010 and 2017 and that of
wage of full-time employees in all sectors in the
specialists nearly doubling. These pay raises have started to
country. The average wage of workers in the economy
have a measurable impact on the intention of Hungarian
is from the OECD Employment Database.
doctors to leave the country: between 2017 and 2018, the
number of doctors asking for foreign work certificates
decreased by over 10%.
In several countries, the remuneration of specialists has
risen faster than those of generalists since 2010, thereby References
increasing the remuneration gap. However, in Austria and [1] OECD (2019), Recent Trends in International Migration of Doctors,
Belgium, the gap has narrowed slightly, as the income of Nurses and Medical Students, OECD Publishing, Paris, https://
general practitioners grew a little more than that of doi.org/10.1787/5571ef48-en.
specialists (Figure 8.9).

8. HEALTH WORKFORCE
Figure 8.8. Remuneration of doctors, ratio to average wage, 2017 (or nearest year)
Salaried Self-employed Salaried Self-employed
General practitioners (GPs) Specialists
1.9 Australia ¹ 3.8
2.8 Austria 4.2
2.5 Belgium ²
3.1 Canada 4.9 5.9
2.9 Chile 5.1
n.a. Czech Republic 2.4
n.a. Denmark 2.6
1.6 2.2
2.4 Estonia
1.8 Finland 2.6
France
2.2
2.9 4.9
4.4 Germany 3.5 5.4
n.a. Greece 2.4
2.0 Hungary 2.5
2.0 Iceland 2.2
2.8 Ireland 3.5
1.9 Israel 3.8
2.4 4.1
n.a. Italy 2.5
1.0 Latvia 1.6
1.2 Lithuania 1.7
Luxembourg 4.2
2.8 2.5 Mexico 3.3 5.9
2.3 Netherlands 3.3
2.4 3.6
n.a. New Zealand 3.0
n.a. Norway 1.8
2.2 Poland 1.4
2.7 Portugal 2.6
n.a. Slovak Republic 2.4
2.1 Slovenia 2.1
2.1 Spain 2.4
n.a. Sweden 2.3
1.7 United Kingdom 3.3
3.1
6 4 2 0 0 2 4 6
Ratio to average wage in each country Ratio to average wage in each country
1. Physicians in training included (resulting in an under-estimation). 2. Practice expenses included (resulting in an over-estimation).
Source: OECD Health Statistics 2019 and OECD Employment Database 2019.
Figure 8.9. Growth in remuneration of GPs and specialists, 2010-17 (or nearest year)
GPs Specialists
Average annual growth rate (%, in nominal terms)

12
10.2
10
8.7
8
6.8
6.4
6 5.3
4.5
4.0 3.9 3.9
4 3.3
2.8 3.0 3.0
2.6
1.9 2.2
1.7 1.5 1.6
2 1.0
-0.9
-2 -1.3
1. The growth rate is for self employed GPs and specialists.


177
8. HEALTH WORKFORCE
Nurses
There were just under nine nurses per 1 000 population in doctors for a range of patients, including those with minor
OECD countries in 2017, ranging from about two per 1 000 in illnesses and those needing routine follow-ups. These
Turkey to more than 17 per 1 000 in Norway and evaluations find a high patient satisfaction rate, while the
Switzerland. Between 2000 and 2017 the number of nurses impact on cost is either cost-reducing or cost-neutral. The
per capita grew in almost all OECD countries, and the implementation of new advanced practice nursing roles can
average rose from 7.4 per 1 000 population in 2000 to 8.8 per require changes to legislation or regulation (Maier, Aiken
1 000 population in 2017. In the Slovak Republic, Israel, the and Busse, 2017[1]).
United Kingdom and Ireland, however, the number of
nurses per capita fell over that period (Figure 8.10).
The decreases in Israel and Ireland are due to the rapid
growth of the population, with the increase in the number of Definition and comparability
nurses not keeping up. In Ireland, the growth in the number
of nurses outpaced population growth until 2008, when it The number of nurses includes those employed in
peaked at 13.6 per 1 000 population, but has since fallen public and private settings providing services directly
behind population increases. In the Slovak Republic, the to patients (“practising”) and in some cases also those
number of nurses declined both in absolute and per capita working as managers, educators or researchers. The
numbers, mainly during the 2000s, while in the United numbers are based on head counts.
Kingdom the number of nurses per capita increased rapidly In countries where different nurses can hold different
between 2000 and 2006 and then declined until 2017. levels of qualification or role, the data include both
No clear pattern emerges from the rate of increase of nurses: “professional nurses” who have a higher level of
significant increases were seen in both countries which education and perform more complex or skilled tasks,
already have high numbers of nurses per capita, such as and “associate professional nurses” who have a lower
Switzerland, as well as countries with lower numbers of level of education but are nonetheless recognised and
nurses, such as France, Slovenia and Korea. In most registered as nurses. Health care assistants (or nursing
countries, growth in the number of both doctors and nurses aides) who are not recognised as nurses are excluded.
has been driven by growing numbers of domestic nursing The number of nurses in Denmark and Austria is lower
and medical school graduates, although in some countries than reported in previous editions because “caring
immigration of foreign-trained doctors and nurses also personnel” (nursing aides) were formerly included for
played an important role (see indicator on “International these two countries. Midwives are excluded, except in
migration of doctors and nurses”). some countries where they are included at least in part
because they are considered as specialist nurses, or for
Nurses outnumber physicians in most OECD countries, and
other categorisation reasons (Australia, Ireland and
on average there are three nurses to every doctor. The ratio
Spain).
of nurses to doctors ranges from about one nurse per doctor
in Chile, Turkey and Greece, to more than four nurses per Austria and Greece report only nurses working in
doctor in Japan, Ireland, Finland and the United States hospitals, resulting in an under-estimation.
(Figure 8.11).
In response to shortages of doctors, and to ensure proper
access to care, some countries have developed more
advanced roles for nurses, including “nurse practitioner” References
roles. Evaluations of nurse practitioners from the United [1] Maier, C., L. Aiken and R. Busse (2017), “Nurses in advanced
States, Canada and the United Kingdom show that advanced roles in primary care: Policy levers for implementation”,
practice nurses can improve access to services and reduce OECD Health Working Papers, No. 98, OECD Publishing, Paris,
waiting times, while delivering the same quality of care as https://dx.doi.org/10.1787/a8756593-en.

8. HEALTH WORKFORCE
Nurses
Figure 8.10. Practising nurses per 1 000 population, 2000 and 2017 (or nearest year)
2000 2017
20
17.7
17.2
18
14.5
14.3
16
12.9
14
11.7
11.7
11.7
11.3
11.0
10.9
10.9
10.5
10.2
12
10.0
10.0
9.9
12.2
8.8
8.5
10
8.1
7.7
6.9
6.9
6.7
6.5
8
6.2
5.8
5.7
5.1
7.8
4.6
6
3.3
3.2
2.9
2.7
2.7
5.7
4
2.1
5.1
1.5
1.5
1.3
1.3
1.2
2
1. Data include not only nurses providing direct care to patients, but also those working in the health sector as managers, educators, researchers, etc. 2.
Austria and Greece report only nurses employed in hospital. 3. Data in Chile refer to all nurses who are licensed to practice.
Figure 8.11. Ratio of nurses to doctors, 2017 (or nearest year)
Ratio
5
4.7
4.5
4.4
4.3
4.0
3.9
3.8
3.8
3.7
4
3.7
3.6
3.2
3.2
3.1
3.1
3.0
3.0
2.9
2.8
3
2.7
2.6
2.5
2.5
2.2
2.1
2.1
2.0
2.0
1.8
2
1.7
1.7
1.6
1.6
1.5
1.5
1.4
1.3
1.3
1.2
1.1
1.1
1.1
1.0
0.8
1
0.6
1. For countries that have not provided data for practising nurses and/or practising doctors, the numbers relate to the "professionally active" concept for
both nurses and doctors (except Chile, where numbers include all nurses and doctors licensed to practise). 2. For Austria and Greece, the data refer to
nurses and doctors employed in hospitals. 3. The ratio for Portugal is underestimated because the numerator refers to professionally active nurses while
the denominator includes all doctors licensed to practise.

179
8. HEALTH WORKFORCE
On average across OECD countries, the remuneration of

hospital nurses was slightly above the average wage of all Definition and comparability
workers in 2017. In most countries, their remuneration was
in the range of being about 10% lower than the average wage The remuneration of nurses refers to average gross
to 20% higher. However, in some countries like Lithuania annual income, including social security contributions
and Latvia, nurses earn much less than the average wage of and income taxes payable by the employee. It should
all workers, while in other countries like Chile, Mexico, normally include all extra formal payments, such as
Israel and Luxembourg, they earn much more (Figure 8.12). . bonuses and payments for night shifts and overtime.
In most countries, the data relate specifically to nurses
Converting the remuneration of hospital nurses to a
working in hospitals, although in Canada the data also
common currency (here US dollars) and adjusting for
cover nurses working in other settings. In some federal
purchasing power parity (PPP) reveals a sizeable variation in
states, such as Australia, Canada and the United
the income of hospital nurses across countries. In 2017,
States, the level and structure of nurse remuneration is
nurses in Luxembourg had remuneration levels six times
determined at the sub-national level, which may
higher than those working in Latvia and Lithuania
contribute to variations across jurisdictions.
(Figure 8.13). In general, nurses working in Central and
Eastern European countries have the lowest levels of Data refer only to registered (“professional”) nurses in
remuneration, explaining at least partly that many of them Canada, Chile, Ireland and the United States, resulting
migrate to other EU countries (OECD, 2019[1]). in an over-estimation compared to other countries
where lower-level (“associate professional”) nurses are
The remuneration of nurses in the United States is higher
also included. Data for New Zealand include all nurses
than in most other OECD countries, explaining why the
employed by publicly funded district health boards,
United States is able to attract several thousands of nurses
registered and otherwise, and includes health
from other countries every year.
assistants who have a different and significantly lower
In most countries, the remuneration of nurses has increased salary structure than registered nurses.
since 2010, albeit at different rates (Figure 8.14). In some
The data relate to nurses working full time, with the
countries, like the Czech Republic and the Slovak Republic,
exception of Belgium, where the data provided also
nurses have obtained substantial pay raises in recent years.
include part-time nurses (resulting in an under-
In the Czech Republic, nurses benefitted from a pay increase
estimation). The data for some countries do not
following protests of hospital workers in 2011 (although
include additional income such as overtime payments
their pay rise was lower than that given to doctors),
and bonuses (e.g. Italy and Slovenia). Informal
accompanied by improvements in other areas of their
payments, which in some countries represent a
working conditions (OECD, 2016[2]). The remuneration of
significant part of total income, are not reported.
nurses in the Slovak Republic increased by about 40%
between 2010 and 2017, and in 2018 the Slovak government The income of nurses is compared to the average wage
also announced a further increase of at least 10% in the of full-time employees in all sectors in the country.
salaries of nurses and other non-medical health The source for the average wage of workers in the
professionals. economy is the OECD Employment Database.
In other countries, like Portugal and Spain, the
remuneration of nurses fell after the 2008-09 economic crisis
due to remuneration cuts in the public sector and have only
recovered slowly in recent years. . This was also the case in References
Greece where the salaries of nurses decreased by about 25%
[1] OECD (2019), Recent Trends in International Migration of Doctors,
between 2009 and 2015. Nurses and Medical Students, OECD Publishing, Paris, https://
dx.doi.org/10.1787/5571ef48-en.
[2] OECD (2016), Health Workforce Policies in OECD Countries: Right
Jobs, Right Skills, Right Places, OECD Health Policy Studies, OECD
Publishing, Paris, https://dx.doi.org/10.1787/9789264239517-en.

8. HEALTH WORKFORCE
Figure 8.12. Remuneration of hospital nurses, ratio to Figure 8.13. Remuneration of hospital nurses, USD PPP,
average wage, 2017 (or nearest year) 2017 (or nearest year)
Chile¹ 1.8 Luxembourg 108.9

Mexico 1.8 United States¹ 75.8
Israel 1.5 Netherlands 69.4
Luxembourg 1.5 Iceland 68.0
Spain 1.3 Australia 67.7
United States¹ 1.3 Ireland¹ 64.2
Australia 1.2 Switzerland 62.9
New Zealand 1.2 Israel 60.9
Greece 1.2 Belgium 59.5
Netherlands 1.2 Denmark 58.9
Czech Republic 1.2 Canada¹ 57.0
Germany 1.1 Spain 56.3
OECD32 1.1 Chile¹ 55.3
Belgium 1.1 Norway 54.7
Canada¹ 1.1 New Zealand 53.9
Poland 1.1 Germany 53.6
Ireland¹ 1.1 United Kingdom 50.8
Japan 1.1 OECD33 49.0
Denmark 1.1 Turkey 46.3
Italy 1.1 Japan 45.2
Portugal 1.1 Italy 44.0
Estonia 1.0 Finland 43.1
Hungary France 42.4
1.0 Slovenia 40.3
Norway 1.0 Greece 33.9
United Kingdom 1.0 Czech Republic 32.9
Slovak Republic 1.0 Mexico 31.9
Slovenia 1.0 Portugal 30.9
Iceland 1.0 Poland 29.7
France 0.9 Estonia 28.8
Finland 0.9 Slovak Republic 27.5
Switzerland 0.9 Hungary 25.8
Latvia 0.8 Lithuania 17.6
Lithuania 0.7 Latvia 17.4
0 0.5 1 1.5 2 0 25 50 75 100 125
Ratio to average wage in each country USD PPP, thousands
1. Data refer to registered ("professional") nurses in the United States, 1. Data refer to registered ("professional") nurses in the United States,
Canada, Ireland and Chile (resulting in an over-estimation). Canada, Ireland and Chile (resulting in an over-estimation).
Figure 8.14. Trends in the remuneration of hospital nurses in nominal terms, selected OECD countries, 2010-17
Australia Norway Czech Republic Portugal
United Kingdom United States Slovak Republic Spain¹
Index (2010 = 100) Index (2010 = 100)
150 150
140 140
130 130
120 120
110 110
100 100
90 90
80 80
2010 2012 2014 2016 2010 2012 2014 2016
1. Index for Spain, 2011 = 100.


181
8. HEALTH WORKFORCE
Medical graduates
On average across OECD countries in 2017, there were 13 The growth of the number of doctors in the majority of the
new medical graduates per 100 000 population (up from 12 in OECD countries since 2000 has been fueled predominantly
2015). This ranges from about seven in countries such as by a rise in the number of domestic medical graduates. In
Japan and Israel to more than 20 in Ireland and Denmark most cases, this rise reflects goal-oriented policy decisions
(Figure 8.15). taken a few years earlier to raise the number of students
In Israel, the low number of domestic medical graduates is admitted to medical schools. This was in response to
compensated by the high number (about 60%) of foreign- concerns about current or possible future shortages of
trained doctors. Increasingly however, foreign-trained doctors. In some countries like Poland, as well as other
doctors consist of Israeli-born people returning after central, and eastern European countries, the strong increase
completing studies abroad. In contrast, Japan does not in recent years also reflects the growing number of
currently rely on foreign-trained doctors. However, Japan international medical students and graduates. Polish
recently took action to increase the number of students medical schools, for example, offer medical studies in
admitted to medical schools (the numerus clausus), but this is English, and 25% of all medical students are foreigners
not yet reflected in the number of new medical graduates (OECD, 2019[1]).
due to lags. In Ireland, the high number of medical graduates In reply to the OECD Health System Characteristics Survey
reflects the large share of international medical students. In 2016, none of the responding OECD countries other than
the academic year 2017/18, this share made up half of all Italy and Spain reported that they had reduced admission
medical students, with the majority coming from outside rates for medical schools and most countries declared
the OECD area. However, after obtaining their first medical increases (OECD, 2016[2]). Hence, the number of new
degree, international medical students often leave Ireland medical graduates can be expected to continue to increase
due to difficulties in securing an internship – the last stage in in most countries in the coming years.
medical education prior to postgraduate training. At the
same time, Ireland compensates for its shortage of doctors
by importing doctors trained in other countries (OECD, Definition and comparability
2019[1]).
In all OECD countries except Greece, the number of new Medical graduates are defined as students who have
medical graduates per capita has risen since 2000. However graduated from medical schools in a given year. The
increases have not been steady, with numbers falling to less data for Australia, Austria and the Czech Republic
than 90% of levels in 2000 (mostly during the 2000s) in include foreign graduates, but other countries may
Belgium, the Slovak Republic and Switzerland (countries exclude them.
close to the OECD average), as well as in Turkey, France, and
Israel, with numbers considerably below the OECD average
(OECD, 2019[1]).
In Latvia, Slovenia, Portugal and Australia, where annual References
numbers of new medical graduates per capita are above the [1] OECD (2019), Recent Trends in International Migration of Doctors,
OECD average, the number increased up to fourfold between Nurses and Medical Students, OECD Publishing, Paris, https://
2007 and 2017. Twofold increases are common, and are dx.doi.org/10.1787/5571ef48-en.
found in countries with high, medium, and low numbers of [2] OECD (2016), OECD Health System Characteristics Survey 2016,
new medical graduates per capita (Figure 8.16). In total, the http://www.oecd.org/els/health-systems/characteristics.htm.
number of medical graduates across OECD countries
increased from less than 100 000 in 2006 to nearly 120 000 in
2017.

8. HEALTH WORKFORCE
Medical graduates
Figure 8.15. Medical graduates, 2017 (or nearest year)

30
24.9
25
21.5
19.3
20
17.5
17.4
17.1
16.9
16.1
16.0
15.5
14.8
14.6
14.5
14.4
14.4
13.5
13.3
13.1
15
12.9
12.0
12.0
11.5
11.5
11.2
11.1
11.0
10.6
10.2
9.5
9.1
8.7
10
7.8
7.7
7.6
6.9
6.8
5

Figure 8.16. Evolution in the number of medical graduates, selected OECD countries, 2000‑17 (or nearest year)
Countries above OECD average in graduates per capita in 2017 Countries below OECD average in graduates per capita in 2017
Australia Ireland Canada France
Italy Netherlands Japan Poland
Spain United States
Index (2000=100) Index (2000=100)
300 300
250 250
200 200
150 150
100 100
50 50


183
8. HEALTH WORKFORCE
Nursing graduates
On average across OECD countries in 2017, there were graduates in 2017 was one-third higher than in 2000, which
around 44 new nurse graduates per 100 000 population, with should contribute to increasing the supply of nurses.
a range from around 14 in the Czech Republic and Mexico to However, as many as one in five recently graduated nurses
about 100 in Switzerland and Korea (Figure 8.17). This wide work outside the health sector. This has led to the
range may be explained by differences in the current implementation of a series of measures in recent years to
number and age structure of the nursing workforce, in the improve the working conditions of nurses to increase
capacity of nursing schools to take on more students, and in retention rates, including pay raises.
the future employment prospects of nurses. In Italy, the number of nurse graduates increased fairly
Since 2000, the number of nursing graduates has increased rapidly in the 2000s but has levelled off and even decreased
in most OECD countries, with the exception of Luxembourg, slightly in recent years. While the number of students
Japan, the Czech Republic, Lithuania and Ireland. Of these admitted to nursing education programmes has remained
countries, only Japan has maintained a number above the more or less stable during this decade, there has been a
OECD average. In Finland, Hungary and Belgium, the sharp drop in the number of applicants (with the number cut
number of nursing graduates has recently returned to by half), signalling reduced student interest in the
numbers above the level in 2000 and is now well above the profession.
OECD average, after experiencing intermittent declines.
Despite a more than tenfold increase in the annual number
of nursing graduates since 2000 in Poland, Turkey and
Mexico, the numbers in these countries remain well below Definition and comparability
the OECD average. At least 50% increases between 2000 and
Nursing graduates refer to students who have obtained
2017 are common and are seen across countries with high,
a recognised qualification required to become a
medium and low numbers of nurse graduates per capita
licensed or registered nurse. They include graduates
(Figure 8.18). In total, the number of nurse graduates across
from both higher-level and lower-level nursing
OECD countries increased from about 450 000 in 2006 to
programmes. They exclude graduates from Masters or
more than 550 000 in 2017.
PhD degrees in nursing to avoid double-counting
The increase in the number of nursing graduates in most nurses acquiring further qualifications.
casesreflects deliberate policy decisions taken a few years
The data for the United Kingdom are based on the
earlier to increase the number of students admitted to
number of new nurses receiving an authorisation to
nursing schools, in response to concerns about current or
practise.
possible future shortages (OECD, 2016[1]). In reply to the
OECD Health System Characteristics Survey 2016, none of
the responding OECD countries reported that they had
reduced admission rates for nursing schools and many
declared increases (OECD, 2016[2]). Hence, the number of References
nursing graduates can be expected to continue to increase in [1] OECD (2016), Health Workforce Policies in OECD Countries: Right
most countries in the coming years. Jobs, Right Skills, Right Places, OECD Health Policy Studies, OECD
In Norway, the number of students admitted to and Publishing, Paris, https://dx.doi.org/10.1787/9789264239517-en.
graduating from nursing education programmes has grown [2] OECD (2016), OECD Health System Characteristics Survey 2016,
particularly since 2010, and the number of new nursing http://www.oecd.org/els/health-systems/characteristics.htm.

8. HEALTH WORKFORCE
Nursing graduates
Figure 8.17. Nursing graduates, 2017 (or nearest year)

120
100.9
99.9
100
84.5
79.8
75.4
73.7
80
69.5
61.9
61.7
56.9
54.5
52.9
52.5
60
51.5
45.4
44.0
43.6
40.8
39.2
35.5
34.5
40
31.0
29.4
28.9
28.9
27.5
24.5
24.2
21.7
21.1
20.2
20.0
18.1
16.9
15.5
14.6
14.1
20
1. In the United Kingdom, the numbers refer to new nurses receiving an authorisation to practise, which may result in an over-estimation if these
include foreign-trained nurses. 2. In Mexico, the data include professional nursing graduates only.
Figure 8.18. Evolution in the number of nursing graduates, selected OECD countries, 2000‑17
Countries above OECD average in graduates per capita in 2017 Countries below OECD average in graduates per capita in 2017
Germany Japan France Italy ¹
Norway Switzerland Portugal Spain
Index (2000=100) Index (2000=100)
250 250
200 200
150 150
100 100
50 50
0 0
1. Index for Italy, 2002 = 100.


185
8. HEALTH WORKFORCE
The number and share of foreign-trained doctors – and in 2016 and 2017 (Figure 8.22). In Israel, the share of foreign-
some countries foreign-trained nurses – working in OECD trained nurses has decreased over time, but has stagnated at
countries has continued to rise over the past decade (OECD, around 9% since 2015. In France, while the share of foreign-
2019[1]). In 2017, more than one in six doctors working in trained nurses is relatively low, the number has nearly
OECD countries had obtained at least their first medical doubled over the past decade. In Italy, the number of
degree in another country (Figure 8.19), up from one in seven foreign-trained nurses increased sharply between 2007 and
a decade earlier. For nurses, on average, one in 17 had 2015 (driven mainly by the arrival of nurses trained in
obtained a nursing degree in another country in 2017 Romania following its accession to the EU in 2007), but the
(Figure 8.20). These developments occurred in parallel with a number and share have started to decrease in recent years.
significant increase in the numbers of domestically trained
medical and nursing graduates in nearly all OECD countries
(see also indicators on “Medical graduates” and “Nursing
graduates”), which is indicative of substantial demand for Definition and comparability
these professionals.
The data relate to foreign-trained doctors and nurses
In 2017, the share of foreign-trained doctors ranged from working in OECD countries measured in terms of total
less than 3% in Turkey, Lithuania, Italy, the Netherlands and stocks. The OECD health database also includes data
Poland, to around 40% in Norway, Ireland and New Zealand, on the annual flows for most of the countries shown
and to nearly 60% in Israel. In most OECD countries, the here, as well as by country of origin. The data sources
share of foreign-trained nurses is below 5%, but Australia, in most countries are professional registries or other
Switzerland and New Zealand have proportions of around or administrative sources.
above 20%. However, in some cases, foreign-trained doctors
The main comparability limitation relates to
and nurses consists of people born in the country who
differences in the activity status of doctors and nurses.
studied abroad but have returned. In a number of countries
Some registries are regularly updated, making it
(including Israel, Norway, Sweden and the United States),
possible to distinguish doctors and nurses who are still
this share is large and growing. These foreign-trained but
actively working in health systems, while other
native-born doctors and nurses frequently paid the full cost
sources include all doctors and nurses licensed to
of their studies abroad. In 2017 in Israel, for example, around
practice, regardless of whether they are still active.
40% of foreign-trained doctors and nurses are native-born.
The latter will tend to over-estimate not only the
The share of foreign-trained doctors in various OECD number of foreign-trained doctors and nurses, but also
countries evolved between 2000 and 2017 (Figure 8.21). The the total number of doctors and nurses (including
share remained relatively stable in the United States, with those trained domestically), making the impact on the
the number of foreign and domestically trained doctors share unclear.
increasing at a similar rate. However, among the medical
The data source in some countries includes interns
graduates with a foreign degree who obtained certification
and residents, while these physicians in training are
to practise in the United States in 2017, one-third were
not included in other countries. Because foreign-
American citizens, up from 17% in 2007 (OECD, 2019[1]). In
trained doctors are often over-represented in the
Europe, the share of foreign-trained doctors increased
categories of interns and residents, this may result in
rapidly in Norway and Sweden. However, in Norway more
an under-estimation of the share of foreign-trained
than one half of foreign-trained doctors are Norwegian-
doctors in countries where they are not included (such
born, returning after studying abroad. In Sweden, the
as Austria, France and Switzerland).
number of foreign-trained but native-born doctors
quadrupled since 2006, accounting for nearly one-fifth of The data for Germany (on foreign-trained doctors) and
foreign-trained doctors in 2015. In France and Germany, the for some regions in Spain are based on nationality (or
number and share of foreign-trained doctors has also place of birth in the case of Spain), not on the place of
increased steadily over the past decade (with the share training.
doubling from 5-6% of all doctors in 2007 to 11-12% in 2017).
Conversely, in the United Kingdom, the share of foreign-
trained doctors decreased slightly, as the number of
domestically-trained doctors increased more rapidly. References
The share of foreign-trained nurses has increased steadily [1] OECD (2019), Recent Trends in International Migration of Doctors,
over the past decade in Australia, Canada and New Zealand, Nurses and Medical Students, OECD Publishing, Paris, https://
although in New Zealand, a slight decline occurred between dx.doi.org/10.1787/5571ef48-en.

8. HEALTH WORKFORCE
Figure 8.19. Share of foreign-trained doctors, 2017 (or Figure 8.20. Share of foreign-trained nurses, 2017 (or
nearest year) nearest year)
Israel 57.8 New Zealand 26.0

New Zealand 42.4 Switzerland 25.9
Ireland 42.3 Australia 18.4
Norway 39.7 United Kingdom 15.0
Sweden 34.8 Israel 9.2
Switzerland 34.1 Norway
Australia 8.7
32.1 Canada
United Kingdom 28.7 8.1
United States 25.0 Germany 7.9
Canada 24.6 United States 6.0
Chile 21.3 OECD27 5.9
Finland 19.9 Italy 5.0
OECD29 17.7 Belgium 3.5
Slovenia 17.3 Latvia 3.2
Belgium 12.3 Sweden 3.0
Germany ¹ 11.9 France 2.9
France 11.2 Greece 2.5
Spain ¹ 9.4 Spain ¹ 2.1
Denmark 9.2 Chile 2.1
Hungary 8.0 Portugal 1.8
Czech Republic 7.1 Denmark 1.8
Latvia 6.0 Finland 1.8
Austria 5.8 Hungary 1.5
Estonia 3.5 Netherlands 0.5
Slovak Republic 3.0
Netherlands Slovenia 0.4
2.2
Poland 1.9 Lithuania 0.4
Italy 0.8 Turkey 0.3
Lithuania 0.4 Estonia 0.1
Turkey 0.2 Poland 0.1
0 10 20 30 40 50 60 0 5 10 15 20 25 30
% %
1. In Germany and some regions in Spain data based on nationality (or 1. Data for some regions in Spain based on nationality or place of birth, not
place of birth in the case of Spain), not on the place of training. on the place of training.
Figure 8.21. Evolution in the share of foreign-trained Figure 8.22. Evolution in the share of foreign-trained
doctors, selected OECD countries, 2000‑17 nurses, selected OECD countries, 2000‑17
France Germany Australia Canada

Norway Switzerland Israel Italy
% United Kingdom United States % New Zealand Switzerland
40 30
35
25
30
20
25
20 15
15
10
10
5
5
0 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

187
9. HEALTH CARE ACTIVITIES
Consultations with doctors
Medical technologies
Hospital beds and discharge rates
Average length of stay in hospitals
Hip and knee replacement
Caesarean sections
Ambulatory surgery
international law.
189
Consultations with doctors are, for many people, the most Turkey (Figure 9.2). Numbers were lowest in Sweden and
frequent contact with health services, and often provide an Norway, where consultations with doctors in both primary
entry point for subsequent medical treatment. care and hospital settings tend to be focused towards
Consultations can take place in doctors’ clinics, hospital patients with more severe and complex cases.
outpatient departments or, in some cases, patients’ own The number and type of doctor consultations can vary
homes. Increasingly, consultations occur online or by video among different socio-economic groups. Wealthier
call, to improve access for remote populations, or for individuals are more likely to see a doctor than individuals
consultations after regular hours. in the lowest income quintile, for a comparable level of need
In 2017, the number of doctor consultations per person (see indicator on “Use of primary care services” in
ranged from less than 3 in Mexico and Sweden, to almost 17 Chapter 5). Income inequalities in accessing doctors are
in Korea (Figure 9.1). The OECD average was 6.8 much more marked for specialists than for general
consultations per person per year, with most countries practitioner consultations (OECD, 2019 [2]).
reporting between four and ten. Among key partners,
consultation rates were also less than 3 in Colombia, Costa
Rica, South Africa and Brazil.
Cultural factors play a role in explaining some of the
variations across countries, but incentive structures also Consultations with doctors refer to the number of
matter. Provider payment methods and the levels of co- contacts with physicians, including generalists and
payments are particularly relevant. For example, in Korea specialists. There are variations across countries in the
and Japan, health providers are paid through fee-for-service, physicians counted (e.g. physicians on parental or sick
thus creating incentives for overprovision of services, while leave) and in the coverage of these consultations,
countries with mostly salaried doctors tend to have below- notably in outpatient departments of hospitals. Data
average rates (e.g. Mexico, Finland and Sweden). However, come mainly from administrative sources, although in
in Switzerland and the United States, doctors are paid some countries (Ireland, Italy, Netherlands, New
mainly by fee-for-service but consultation rates are below Zealand, Spain and Switzerland) the data come from
average. In these countries, patient co-payments can be health interview surveys. Estimates from
high, which may result in patients not consulting a doctor administrative sources tend to be higher than those
because of the cost of care (see indicators in Chapter 5 on from surveys because of problems with recall and non-
access). response rates.
Recent reforms to expand the role of nurses across many In Hungary, figures include consultations for
OECD countries can also partially explain low rates of diagnostic exams such as CT and MRI scans (resulting
consultations with doctors. This may involve nurses
in an over-estimation). Figures for the Netherlands
working as generalists to support GPs, focusing on health
exclude contacts for maternal and child care. Data for
promotion, or as single-disease specialists. In many cases,
Portugal exclude visits to private practitioners
nurses also have the authority to prescribe pharmaceuticals
(resulting in an under estimation). In Germany, data
and order medical tests and exams. In Canada, Finland,
include only the number of cases of physicians’
Ireland, New Zealand, Sweden, the United Kingdom and the
treatment according to reimbursement regulations of
United States, nurses are authorised to work at high levels of
the social health insurance scheme. This may lead to
advanced practice in primary care – in all these countries
both underestimation (a case only counts the first
doctor consultation rates are below the OECD average
contact over a three-month period, even if the patient
(Maier, Aiken and Busse, 2017[1]).
consults a doctor more often) and overestimation
The average number of doctor consultations per person (contacts that are not face-to-face, such as laboratory
across OECD countries has remained relatively stable since testing, are counted). Telephone contacts are included
2000 (between 6.5 and 6.8). However, some countries have
in a few countries (e.g. Spain). In Turkey, the most
seen large increases over time (Germany, Korea, Lithuania
consultations with doctors occur in outpatient
and Turkey), while in a few countries, numbers have fallen.
departments in hospitals.
This was the case in Japan and Spain, although
consultations remain above the OECD average in both
countries.
Information on the number of doctor consultations per
person can be used to estimate the annual numbers of References
consultations per doctor. This indicator should not be taken [1] Maier, C., L. Aiken and R. Busse (2017), “Nurses in advanced
as a measure of doctors’ productivity, since consultations roles in primary care: Policy levers for implementation”,
vary in length and effectiveness; and because it excludes OECD Health Working Papers, No. 98, OECD Publishing, Paris,
services doctors deliver for hospital inpatients, as well as https://dx.doi.org/10.1787/a8756593-en.
time spent on research and administration. Keeping these [2] OECD (2019), Health for Everyone? Social Inequalities in Health and
comparability issues in mind, the estimated number of Health Systems, OECD Publishing, Paris, https://doi.org/
consultations per doctor is highest in Korea, Japan and 10.1787/3c8385d0-en.

Figure 9.1. Number of doctor consultations per person, 2000 and 2017 (or nearest year)
2000 2017
Annual consultations per person
18 16.6
16
14
12 12.6 10.9 10.9

9.9 9.7
9.5
10 8.9
8.3 8.0
7.7 7.6
8 7.0 6.8 6.8 6.8
6.6
6.1 5.9 5.8
7.3
6 6.5 4.5 4.4 4.3 4.3
6.1 5.9 5.7 4.1 4.0
3.6
4 2.8 2.8 2.5
3.8 2.1 1.9
2 2.8

Figure 9.2. Estimated number of consultations per doctor, 2017 (or nearest year)
Annual consultations per doctor

8000
7080
7000
6000
5191
4765
5000
4000
3403
3278
3197
3186
2568
3000
2401
2330
2317
2271
2181
2128
2095
2085
2007
1976
1944
1910
1903
1883
1744
1701
1624
1619
1568
2000
1310
1254
1164
1153
1075
1001
1000
966
909
711
680
1000
1. In Chile and Portugal, data for the denominator include all doctors licensed to practice.

191
Technology plays an important role in the health system, of countries since, some medical societies have identified
allowing physicians to better diagnose and treat patients. cases when an MRI or CT exam is not necessary. For
However, new technologies can also drive up costs, and are example, the Royal College of Physicians in the United
commonly acknowledged to be one of the main causes Kingdom recommends, based on evidence from the
behind increases in health spending (Lorenzoni et al National Institute for Health and Care Excellence (NICE),
2019[1]). This section presents data on the availability and that patients with low back pain or suspected migraine do
use of two diagnostic imaging technologies: computed not routinely need an imaging test (Choosing Wisely UK,
tomography (CT) scanners and magnetic resonance imaging 2018[3]).
(MRI) units. CT and MRI exams help physicians diagnose a
range of conditions.
The availability of CT scanners and MRI units has increased
rapidly in most OECD countries over the past two decades. Definition and comparability
Japan has by far the highest number of MRI units and CT
scanners per capita, followed by the United States for MRI The data in most countries cover MRI units and CT
units and by Australia for CT scanners (Figure 9.3). Austria, scanners installed both in hospitals and the
Germany, Greece, Iceland, Italy, Korea and Switzerland also ambulatory sector, but coverage is more limited in
have significantly more MRI and CT scanners per capita some countries. MRI units and CT scanners outside
than the OECD average. The number of MRI units and CT hospitals are not included in Belgium, Portugal,
scanners per population is the lowest in Mexico, Hungary, Sweden and Switzerland (for MRI units). For the United
Israel and the United Kingdom. It is also comparatively low Kingdom, the data only include equipment in the
in Colombia, Costa Rica and the Russian Federation. public sector. For Australia and Hungary, the number
of MRI units and CT scanners includes only those
There is no general guideline or international benchmark
eligible for public reimbursement.
regarding the ideal number of CT scanners or MRI units per
million population. However, too few units may lead to Similarly, MRI and CT exams performed outside
access problems in terms of geographic proximity or waiting hospitals are not included in Austria, Portugal,
times. If there are too many, this may result in overuse of Switzerland and the United Kingdom. In Australia, the
these costly diagnostic procedures, with little if any benefits data only include exams for private patients (in or out
for patients. of hospitals); while in Korea and the Netherlands they
only include publicly financed exams.
Data on the use of these diagnostic scanners are available
for most OECD countries. The number of MRI examinations
per capita is highest in Germany, the United States, Japan
and France, all of which have more than 100 MRI exams per
1 000 population (Figure 9.4). In France, the (absolute) References
number of MRI exams more than doubled between 2007 and [3] Choosing Wisely UK (2018), “Clinical Recommendations:
2017. The number of CT exams per capita is highest in the Royal College of Physicians”, http://
United States, followed by Japan and Iceland (Figure 9.5). www.choosingwisely.co.uk/.
There are large variations in the use of CT scanners and MRI
[2] INAMI/RIVIZ (2019), “Medical Practice Variations”, https://
units not only across but also within countries – for www.healthybelgium.be/en/medical-practice-variations.
example, in Belgium, recent analysis shows a 50% variation
[1] Lorenzoni, L. et al. (2019), “Health Spending Projections to
in the use of diagnostic exams of the spine across provinces
2030: New results based on a revised OECD methodology”,
in 2017, and this variation is even larger across smaller areas
OECD Health Working Papers, No. 110, OECD Publishing, Paris,
(INAMI/RIVIZ, 2019[2]), . https://doi.org/10.1787/5667f23d-en.
Clinical guidelines exist in several OECD countries to [4] OECD (2014), Geographic Variations in Health Care: What Do We
promote more rational use of MRI and CT exams. Through Know and What Can Be Done to Improve Health System
the Choosing Wisely campaign, which began in the United Performance?, OECD Health Policy Studies, OECD Publishing,
States in 2012 and has been emulated in a growing number Paris, http://dx.doi.org/10.1787/9789264216594-en.

Figure 9.3. CT scanners and MRI units, 2017 (or nearest year)
CT Scanners MRI Units

Per million population
70 112 65
60 55
50 44 43
38 40 39 39 38
35 35 35 34
40
29 29 27 29 27 27
30 20
23 23 25 24 24 23 23
19 19 18 18 17 17 17 17
15 17 15 16 14 14 14 17 16 15 15 15 15
20 14 14 12 12 14 1313 13
8
12 10 8 12 9 10 12 11 10 9 7 9 8
7 5 6
10 5 5
2 3 10
0
1. Only equipment eligible for public reimbursement. 2. Equipment outside hospital not included. For Switzerland, this only applies for MRI units.
Figure 9.4. MRI exams, 2007 and 2017 (or nearest year)
2007 2017
160 143
140 114 112 111
120 94 91 88 87
100 81
74 71 67 64 63
80 62 62 61 55 53 52 51 51 50 45 44 44 43
60 38 36 36
25
40
20
0
1. Exams outside hospital not included. 2. Exams on public patients not included. 3. Exams privately funded not included.
Figure 9.5. CT exams, 2007 and 2017 (or nearest year)
2007 2017
300 256
231
250 214 211 207 205 201
190 189
173 172 169
200 154 153 150 150 149 148 145
126 123
150 115 110 104 102 100 97 94 92 90
71
100
44
50
0
1. Exams outside hospital not included. 2. Exams on public patients not included. 3. Exams privately funded not included.

193
The number of hospital beds provides an indication of the and Canada in 2017. In Ireland, this represents a ten
resources available for delivering services to inpatients. The percentage point increase since 2000 (from 85% to 95%).
influence of the supply of hospital beds on admission rates Occupancy rates were comparatively low in Greece, the
has been widely documented, confirming that a greater United States, the Netherlands and Hungary (around 65% or
supply generally leads to higher admission numbers less). Around half of OECD countries have bed occupancy
(Roemer’s Law that a “built bed is a filled bed”). Therefore rates of 70-80%, and the OECD average is 75%.
policymakers are recognising that simply increasing the
number of hospital beds will not solve problems of
overcrowding or delays in hospitals.
Across OECD countries, there were on average 4.7 hospital Definition and comparability
beds per 1 000 people in 2017. In Japan and Korea, rates were
much higher (13.1 and 12.3 beds per 1 000 people Hospital beds include all beds that are regularly
respectively). Two-thirds of OECD countries reported maintained and staffed and are immediately available
between 3 and 8 hospital beds per 1 000 population, with for use. They include beds in general hospitals, mental
rates lowest in Mexico, Chile and Sweden. health and substance abuse hospitals, and other
specialty hospitals. Beds in residential long-term care
Since 2000, the number of beds per capita has decreased in
facilities are excluded. In the United Kingdom, data are
nearly all OECD countries. The largest reduction occurred in
restricted to public hospitals. Data for Sweden exclude
Finland, with a fall of more than 50% (from 7.5 beds per 1 000
private beds that are privately financed. Beds for use
population in 2000 to 3.3 in 2017), mainly affecting long-term
by patients recovering from day surgery but released
care beds and psychiatric care beds. Several other countries
the same day may be included in countries where they
reduced capacity by 2 beds or more per 1 000 population
cannot be distinguished from inpatient beds (e.g.
(Estonia, France, Latvia, Lithuania and the Slovak Republic).
Austria, Luxembourg and the Netherlands). Cots for
Part of the decrease can be attributed to advances in medical
healthy infants are included for a few countries (e.g.
technology, allowing more surgery to be performed on a
Canada, the Netherlands and Poland).
same-day basis, or as part of a broader policy strategy to
reduce the number of hospital admissions. On the other Discharge is defined as the release of a patient who has
hand, the number of beds has strongly increased in Korea stayed at least one night in hospital. It includes deaths
(+164%), with a significant number of these dedicated to in hospital following inpatient care. Same-day
long-term care. discharges are usually excluded, with the exceptions
of Chile, Japan, Norway and the United States which
Hospital discharge rates measure the number of patients
include some same-day discharges. Healthy babies
who leave a hospital after staying at least one night.
born in hospitals are excluded from hospital discharge
Improving timely discharge of patients can help the flow of
rates in several countries (Australia, Austria, Canada,
patients through a hospital, allowing hospitals to reduce the
Chile, Estonia, Finland, France, Greece, Ireland,
number of beds. Both premature and delayed discharges not
Lithuania, Luxembourg, Mexico, the Netherlands and
only worsen health outcomes, but also increase costs:
Norway). These comprise around 3-10% of all
premature discharges can lead to costly readmissions;
discharges. Data for some countries do not cover all
delayed discharges use up limited hospital resources.
hospitals. For instance, data for Mexico, New Zealand
On average across OECD countries, there were 154 hospital and the United Kingdom are restricted to public or
discharges per 1 000 population in 2017. Hospital discharge publicly funded hospitals. Data for Ireland cover public
rates were highest in Germany, Austria and Lithuania (over acute and psychiatric (public and private) hospitals.
200 per 1 000 population) and lowest in Mexico, Canada, Data for Canada, the Netherlands and the United
Chile and the Netherlands (less than 100). The number of States include only acute care/short-stay hospitals.
discharges fell in the majority of OECD countries, with some
The occupancy rate for curative (acute) care beds is
of the largest reductions observed in countries where there
calculated as the number of hospital bed-days related
were also large decreases in the number of beds (e.g. Italy,
to curative care divided by the number of available
Finland, Estonia, Sweden and Latvia). On the other hand,
curative care beds (multiplied by 365).
hospital discharge rates doubled in Korea, Turkey and
China.
High occupancy rates of curative (acute) care beds can be
symptomatic of a health system under pressure, and may
lead to bed shortages and higher rates of infection. Overly References
low occupancy rates may reflect underutilised resources. [1] NICE (2018), “Bed occupancy”, https://www.nice.org.uk/
The National Institute of Health and Care Excellence (NICE) guidance/ng94/evidence/39.bed-occupancy-pdf-172397464704.
in the United Kingdom recommend that health care [2] OECD (2014), Geographic Variations in Health Care: What Do We
providers should plan capacity to minimise the risks Know and What Can Be Done to Improve Health System
associated with occupancy rates exceeding 90% (NICE, Performance?, OECD Health Policy Studies, OECD Publishing,
2018[1]). The occupancy rate was over 90% in Ireland, Israel Paris, https://dx.doi.org/10.1787/9789264216594-en.

Figure 9.6. Hospital beds, 2000 and 2017 (or nearest year)
2000 2017
16
14 12.3
12
13.1
10
8
6 8.1 8.0 4.3
7.4 7.0 6.6 6.6 6.6
4 6.0 5.8 5.7 5.6 2.8
4.7 4.7 4.7 4.5 4.5
2 4.2 3.8
3.6 3.4 3.3 3.3 3.2 3.1 3.0
1.0 0.5
3.0 3.0 2.8 2.7 2.6 2.5 2.5 2.3 2.3 2.2 2.1 1.7 1.4 1.1
0

Figure 9.7. Hospital discharge rates, 2000 and 2017 (or nearest year)
2000 2017
300 255
222
250 195
249 182 181 176 173 171 171
200 170
225 141
198 128 125
150 194 184
182 110
96
165 164 162 162
154 154 146 146 145
100 136 131 131 47
117 116 115 33
50 89 84
73
55
0
1. Data exclude discharges of healthy babies born in hospital (3-10% of all discharges).
2. Data include discharges for curative (acute) care only.
Figure 9.8. Occupancy rate of curative (acute) care beds, 2000 and 2017 (or nearest year)
2000 2017
%
100 94.9 93.3 91.6
90 84.3
81.8
79.1 78.9
75.6 75.2
80 74.0
82.0 70.7 70.4
80.7 79.8 68.0 66.8
70 75.5 75.3 73.8
64.0
61.6
73.2
71.1 70.1 69.5 67.8
60 65.5 65.4
50


195
The average length of stay in hospitals is often regarded as France, Austria and Sweden are among the countries that
an indicator of efficiency in health service delivery. All else have moved to DRG payment structures, and in doing so
being equal, a shorter stay will reduce the cost per discharge have experienced a decrease in the average length of stay.
and will shift care from inpatient to less expensive settings. Results from a recent OECD study highlight the significance
Longer stays can be a sign of poor care coordination, of a number of hospital characteristics on the average length
resulting in some patients waiting unnecessarily in hospital of stay in hospitals. Specifically, hospitals with many beds
until rehabilitation or long-term care can be arranged. At the (higher than 200) are associated with a longer length of stay,
same time, some patients may be discharged too early, while a bed occupancy rate of 70% or more is associated with
when staying in hospital longer could have improved their a shorter length of stay (Lorenzoni and Marino, 2017[1]).
health outcomes or reduced chances of re-admission.
In 2017, the average length of stay in hospitals was slightly
less than 8 days across OECD countries (Figure 9.9). Mexico
and Turkey had the shortest stays, with patients staying for Definition and comparability
about 4 days on average in hospitals. Korea and Japan had
the longest stays, averaging over 16 days per patient. Since Average length of stay refers to the average number of
2000, the average length of stay has decreased in most days patients spend in hospital. It is generally
countries; the most significant declines occurred in Japan, measured by dividing the total number of days stayed
Finland, Switzerland, the United Kingdom, Israel and the by all inpatients during a year by the number of
Netherlands. The only country with a large increase was admissions or discharges. Day cases are excluded.
Korea (from around 15 days in 2002 to 18.5 in 2017) – but this Data cover all inpatient cases (including not only
reflects in part an increase in the role of ‘long-term care’ curative/acute care cases) for most countries, with the
hospitals whose function is similar to nursing homes or exceptions of Canada, Japan and the Netherlands,
long-term care facilities. where data refer to average length of stay for curative/
Focusing on specific diseases or conditions can remove acute care or in acute care hospitals only (resulting in
some of the effect of different case mix and severity. Across an under estimation).
OECD countries, the average length of stay for a normal Healthy babies born in hospitals are excluded from
delivery was 2.9 days in 2017 (Figure 9.10). It reached over hospital discharge rates in several countries (e.g.
4 days in Hungary, the Slovak Republic and the Czech Australia, Austria, Canada, Chile, Estonia, Finland,
Republic, and was less than 2 in Mexico, the United France, Greece, Ireland, Lithuania, Luxembourg,
Kingdom, Canada, Iceland and the Netherlands. Length of Mexico and Norway), resulting in a slight over-
stay for normal deliveries has decreased since 2000 in most estimation of the length of stay (e.g. the inclusion of
countries, most notably in those with long stays such as the healthy newborns would reduce the average length of
Slovak Republic and Czech Republic. stay by 0.5 days in Canada). These comprise around 3-
For acute myocardial infarction (AMI), the average length of 10% of all discharges.
stay ranged from 11 days or over in Chile and Korea to about Data for normal delivery refer to ICD-10 code O80, and
4 or under in Norway, Denmark and Sweden (Figure 9.11). for AMI to ICD-10 codes I21-I22.
The OECD average stood at 6.6 days, three days shorter than
in 2000. The average length of stay for AMI decreased in all
countries except Chile (where it increased by more than
3 days).
References
Apart from disparities in the average length of stay due to
case mix, other factors including payment structures can [1] Lorenzoni, L. and A. Marino (2017), “Understanding variations
explain cross-country variations. In particular, the in hospital length of stay and cost: Results of a pilot project”,
OECD Health Working Papers, No. 94, OECD Publishing, Paris,
introduction of prospective payment systems that
https://dx.doi.org/10.1787/ae3a5ce9-en.
encourage providers to reduce the cost of episodes in care,
such as diagnosis-related groups (DRG), has been credited [2] OECD (2017). Tackling Wasteful Spending in Health, OECD
for the reduction in the average length of stay in hospitals. Publishing, Paris, http://dx.doi.org/10.1787/9789264266414-en.

Figure 9.9. Average length of stay in hospital, 2000 and 2017 (or nearest year)
2000 2017
Days
25
20 18.5
15
16.2
9.6
10 7.8 7.4
11.0 6.5
9.9 9.3 9.3 9.1 8.9 8.9 6.0
8.4 8.3 8.2 8.1
5 7.7 7.6 7.5 7.3 7.3 7.3 7.3 7.1 7.0 7.0 6.9 6.8
6.5 6.1 6.1 6.1 6.0 5.7 5.6 5.4
5.0
4.1 3.7
0
1. Data refer to average length of stay for curative (acute) care (resulting in an under-estimation). In Japan, the average length of stay for all inpatient care
was 28 days in 2017 (down from 39 days in 2000).
Figure 9.10. Average length of stay for normal delivery, Figure 9.11. Average length of stay for acute myocardial
2017 (or nearest year) infarction, 2017 (or nearest year)
Hungary 4.9 Chile 12.0
Slovak Republic 4.7 Korea 11.2
Czech Republic 4.1 Germany 9.9
Luxembourg 4.0 Lithuania 9.8
France 3.9 Estonia 9.1
Poland 3.8 Hungary 8.1
Slovenia 3.7 Italy 7.9
Austria 3.6 Portugal 7.7
Lithuania 3.6 Austria 7.5
Italy 3.4 Mexico 7.1
Latvia 3.2 Spain 7.1
Switzerland 3.2
Luxembourg 6.9
Belgium 3.1
Slovenia 6.8
Belgium 6.7
Norway 3.1 Ireland 6.6
Germany 3.0 Latvia 6.6
Greece 3.0 Switzerland 6.6
Israel 3.0 OECD35 6.6
Finland 2.9 Poland 6.4
OECD33 2.9 United Kingdom 6.3
Chile 2.7 Greece 6.0
Australia 2.6 Czech Republic 5.6
Ireland 2.4 New Zealand 5.5
Korea 2.4 Finland 5.4
Spain 2.4 France 5.4
Denmark 2.3 United States 5.4
Sweden 2.3 Israel 5.3
Turkey 2.3 Australia 5.2
New Zealand 2.1 Canada 5.2
United States 2.0
Slovak Republic 5.1
Netherlands 4.9
Netherlands 1.9 Turkey 4.9
Iceland 1.7 Iceland 4.7
Canada 1.5 Sweden 4.1
United Kingdom 1.4 Denmark 3.7
Mexico 1.2 Norway 3.4
0 1 2 3 4 5 6 0 2 4 6 8 10 12 14
Days Days

197
Hip and knee replacements are some of the most frequently obesity rates in OECD countries. For example, in the United
performed and effective surgeries worldwide. The main States, the prevalence of knee osteoarthritis has more than
indication for hip and knee replacement (joint replacement doubled since the mid-20th century (Wallace et al., 2017[4]).
surgery) is osteoarthritis, which leads to reduced function Most OECD countries show increasing trends of varying
and quality of life. degrees, but Ireland and Luxembourg show slower growth
Osteoarthritis is a degenerative form of arthritis than the average, these are also the only OECD countries to
characterised by the wearing down of cartilage that show a decrease in hip replacements rates from 2007.
cushions and smooths the movement of joints – most
commonly for the hip and knee. It causes pain, swelling and
stiffness resulting in a loss of mobility and function. Definition and comparability
Osteoarthritis is one of the ten most disabling diseases in
developed countries. Worldwide, estimates show that 10% Hip replacement is a surgical procedure in which the
of men and 18% of women aged over 60 years have hip joint is replaced by a prosthetic implant. It is
symptomatic osteoarthritis, including moderate and severe generally conducted to relieve arthritis pain or treat
forms (WHO, 2014[1]). severe physical joint damage following hip fracture.
Age is the strongest predictor of the development and Knee replacement is a surgical procedure to replace
progression of osteoarthritis. It is more common in women, the weight-bearing surfaces of the knee joint in order
increasing after the age of 50 especially in the hand and to relieve the pain and disability of osteoarthritis. It
knee. Other risk factors include obesity, physical inactivity, may also be performed for other knee diseases such as
smoking, excessive alcohol consumption and injuries. rheumatoid arthritis.
While joint replacement surgery is mainly carried out Classification systems and registration practices vary
among people aged 60 and over, it can also be performed on across countries, which may affect the comparability
people at younger ages. of the data. While most countries include both total
In 2017, Germany, Austria, Switzerland, Finland, and partial hip replacement, some countries only
Luxembourg and Belgium were among the countries with include total replacement. In Ireland, Mexico, New
the highest rates for hip and knee replacement (Figure 9.12 Zealand and the United Kingdom, the data only
and Figure 9.13). The OECD averages are 182 per 100 000 include activities in publicly funded hospitals, thereby
population for hip replacement, and 135 per 100 000 for knee underestimating the number of total procedures
replacement. Mexico, Portugal, Israel, Ireland and Korea presented here (for example, approximately 15% of all
have low hip and knee replacement rates. Differences in hospital activity in Ireland is undertaken in private
population structure may explain part of this variation hospitals). Data for Portugal relate only to public
across countries, and age standardisation reduces it to some hospitals on the mainland. Data for Spain only partly
extent. Nevertheless, large differences persist and the include activities in private hospitals.
country ranking does not change significantly after age
standardisation (McPherson, Gon and Scott, 2013[2]).
National averages can mask important variation in hip and
knee replacement rates within countries. In Australia, References
Canada, Germany, France and Italy, the rate of knee
[2] McPherson, K., G. Gon and M. Scott (2013), “International
replacement is more than twice as high in some regions
Variations in a Selected Number of Surgical Procedures”,
than others, even after age-standardisation (OECD, 2014[3]). OECD Health Working Papers, No. 61, OECD Publishing, Paris,
Alongside the number of operations, the quality of hip and https://dx.doi.org/10.1787/5k49h4p5g9mw-en.
knee surgery (see indicator on “Hip and knee surgery” in
[3] OECD (2014), Geographic Variations in Health Care: What Do We
Chapter 6) and waiting times (see indicator on “Waiting
times for elective surgery” in Chapter 5) are also critical for Performance?, OECD Health Policy Studies, OECD Publishing,
patients. Paris, https://dx.doi.org/10.1787/9789264216594-en.
Since 2000, the number of hip and knee replacements has [4] Wallace, I. et al. (2017), “Knee osteoarthritis has doubled in
increased rapidly in most OECD countries (Figure 9.14 and prevalence since the mid-20th century”, Proceedings of the
Figure 9.15). On average, hip replacement rates increased by National Academy of Sciences, Vol. 114/35, pp. 9332-9336, http://
30% between 2007 and 2017 and knee replacement rates by dx.doi.org/10.1073/pnas.1703856114.
40%. This aligns with the rising incidence and prevalence of [1] WHO (2014), “Chronic Rheumatic Conditions”, Fact Sheet,
osteoarthritis, caused by ageing populations and growing http://www.who.int/chp/topics/rheumatic/en/.

Figure 9.12. Hip replacement surgery, 2017 (or nearest year) Figure 9.13. Knee replacement surgery, 2017 (or nearest
year)
Germany 309
Austria 227
Switzerland 307
Austria 286 Luxembourg 226
Belgium 274 Finland 224
Finland 271 Germany 223
Norway 252 Australia 213
France 248 Belgium 210
Denmark 248 Canada 191
Sweden 240 France 175
Netherlands 238 Denmark 163
Iceland 224 Netherlands 159
Slovenia 200 United Kingdom 145
Australia 195 Korea 136
Luxembourg 194 OECD31 135
Lithuania 194 Czech Republic 132
Czech Republic 189 Sweden 132
Italy 183
Lithuania 130
OECD32 182
United Kingdom 181 Spain 130
Poland 160 Slovenia 128
Canada 159 Norway 126
New Zealand 158 Italy 124
Latvia 157 New Zealand 111
Estonia 156 Slovak Republic 106
Hungary 139 Latvia 103
Slovak Republic 136 Hungary 85
Ireland 130 Estonia 82
Spain 116 Israel 66
Portugal 91 Poland 64
Israel 67 Portugal 62
Korea 56 Ireland 49
Chile 46 Chile 19
Mexico 9
Mexico 4
0 50 100 150 200 250 300 350 0 50 100 150 200 250
Per 100 000 population Per 100 000 population
Figure 9.14. Hip replacement surgery trends in selected Figure 9.15. Knee replacement surgery trends in selected
OECD countries, 2007-17 OECD countries, 2007-17
Canada Germany Italy Belgium France Hungary
Sweden OECD30 Slovenia OECD29
Per 100 000 population Per 100 000 population
350 250
300 200
250 150
200 100
150 50
100 0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

199
Caesarean sections
Caesarean sections can be a lifesaving and necessary Australia. Preference for a caesarean section in young
procedure. Nonetheless, caesarean delivery continues to women can also be linked to psychological reasons,
result in increased maternal mortality, maternal and infant including fear of uncontrollable pain and fear of physical
morbidity, and increased complications for subsequent damage (Stoll et al., 2017[2]).
deliveries. This raises concerns over the growing rates of Public reporting, provider feedback, the development of
caesarean sections performed across OECD countries since clearer clinical guidelines, and adjustments to financial
2000, in particular among women at low risk of a incentives have been used to try to reduce the inappropriate
complicated birth who have their first baby by caesarean use of caesarean sections. In Australia, where caesarean
section for non-medical reasons. The World Health section rates are high relative to most OECD countries, a
Organization concludes that caesarean sections are number of states have developed clinical guidelines and
effective in saving maternal and infant lives, but that required reporting of hospital caesarean section rates,
caesarean section rates higher than 10% are not associated including investigation of performance against the
with reductions in maternal and newborn mortality rates at guidelines. These measures have discouraged variations in
the population level. Nevertheless, caesarean sections practice and contributed to slowing down the rise in
should be provided based on need, rather than striving to caesarean sections. Other countries have reduced the gap in
achieve a specific rate. hospital payment rates between a caesarean section and a
In 2017, caesarean section rates remain lowest in Nordic normal delivery, with the aim of discouraging the
countries (Iceland, Finland, Sweden and Norway), Israel and inappropriate use of caesareans (OECD, 2014[3]).
the Netherlands, with rates ranging from 15% to 17% of all
live births (Figure 9.16). They were highest in Korea, Chile,
Mexico and Turkey, with rates ranging from 45% to 53% of all
births. Across OECD countries, 28% of live births were
performed as caesarean sections. The caesarean section rate is the number of caesarean
Caesarean rates have increased since 2000 in most OECD deliveries performed per 100 live births.
countries, with the average rising from 20% in 2000 to 28% in In Ireland, Mexico, New Zealand and the United
2017, although the rate of growth has slowed over the past Kingdom, the data only include activities in publicly
five years (Figure 9.17). Growth rates have been particularly funded hospitals (though for Ireland all maternity
rapid in the Slovak Republic and Czech Republic, Slovenia units are located in publicly funded hospitals and for
and Austria, which have historically had relatively low rates. New Zealand the number of privately funded births is
There have also been large increases over the past decade in negligible). This may lead to an underestimation of
Chile, Korea, Mexico and Turkey – countries that already had caesarean section rates in these countries, since there
high caesarean rates. In Italy, caesarean rates have come is some evidence that private hospitals tend to
down significantly in recent years, although they remain perform more caesarean sections than public
among the highest in Europe. hospitals.
Variations in caesarean section rates across countries have
been attributed to a number of factors, including financial
incentives, malpractice liability concerns, differences in the
availability and training of midwives and nurses, and the
References
proportion of women who access private maternity care. For
example, there is evidence that private hospitals tend to [3] OECD (2014), Geographic Variations in Health Care: What Do We
perform more caesarean sections than public hospitals. In
Performance?, OECD Health Policy Studies, OECD Publishing,
Switzerland, caesarean sections were found to be
Paris, https://dx.doi.org/10.1787/9789264216594-en.
substantially higher in private clinics (41%) than in public
hospitals (30.5%) (OFSP, 2013[1]). [1] OFSP – Office fédéral de la santé publique (2013),
Accouchements par césariennes en Suisse [Births by caesareans
Furthermore, divergences exist for preferences among in Switzerland], Bern.
women for a caesarean section for a healthy birth across
[2] Stoll, K. et al. (2017), “International Childbirth Attitudes- Prior
countries, which can be linked to the institutional
to Pregnancy (ICAPP) Study Team - Preference for cesarean
arrangements of the maternal health system and cultural section in young nulligravid women in eight OECD countries
attitudes towards labour and birth. For example, in Iceland, and implications for reproductive health education”,
the rate of preference for a caesarean section in the context Reproductive Health, Vol. 14/1, http://dx.doi.org/10.1186/
of a healthy birth was 9.2% of women, compared to 16% in s12978-017-0354-x.

Caesarean sections
Figure 9.16. Caesarean section rates, 2017 (or nearest year)
Per 100 live births

60
53.1
48.7
50 47.7
45.2
39.3
40 37.3
33.8 33.7
32.5 32.0 31.9
31.4
30.2 29.7 29.7
29.3
30 28.1 27.7 27.4
26.3
24.4 23.8
22.3 21.4
21.0 20.4
19.7 19.4 19.4
20 16.6 16.5 16.2 16.2 16.0
14.8
10

Figure 9.17. Caesarean section trends in selected OECD countries, 2000‑17
Germany Italy Estonia Finland

Korea Poland France United Kingdom
OECD31 OECD31
Per 100 live births Per 100 live births
45 45
40 40
35 35
30 30
25 25
20 20
15 15
10 10


201
Ambulatory surgery
In the past few decades, the number of surgical procedures average across OECD countries. Day surgery rates are
carried out on a same-day basis has markedly increased in relatively high in Iceland, Finland and Sweden (75% of cases
OECD countries. Advances in medical technologies – in or higher) but remain less than 10% of cases in 10 OECD
particular the diffusion of less invasive surgical countries. In Slovenia, Hungary, the Czech Republic and
interventions – and better anaesthetics have made this Austria, practically no tonsillectomies are undertaken as
development possible. These innovations have improved day cases. These large differences in the share of same-day
patient safety and health outcomes. Further, by shortening surgery may reflect variations in the perceived risks of
the treatment episode, same-day surgery can save postoperative complications, or simply clinical traditions of
important resources without any adverse effects on quality keeping children for at least one night in hospital after the
of care. It also frees up capacity within hospitals to focus on operation.
more complex cases or to reduce waiting lists. However, the Financial incentives can also affect the extent to which
impact of the rise in same-day surgeries on overall health minor surgery is conducted on a same-day basis. In
spending may not be straightforward since the reduction in Denmark and France, diagnostic-related group (DRG)
unit costs (compared to inpatient surgery), may be offset by systems have been adjusted to incentivise same-day
overall growth in the volume of procedures performed. Any surgery. In the United Kingdom, a financial incentive of
additional cost related to post-acute care and community approximately GBP 300 per case is awarded for selected
health services following the interventions also need to be surgical procedures if the patient was managed on a day-
considered. case basis (OECD, 2017[1]).
Cataract surgeries and tonsillectomies (the removal of
tonsils – glands at the back of the throat – mainly performed
on children) provide good examples of high-volume
surgeries that are now mainly carried out on a same-day Definition and comparability
basis in many OECD countries.
Cataract surgery consists of removing the lens of the
Day surgery accounts for 90% or more of all cataract
eye because of the presence of cataracts partially or
surgeries in the majority of OECD countries (Figure 9.18). In
completely clouding the lens, and replacing it with an
several countries, nearly all cataract surgeries are
artificial lens. It is mainly performed on elderly people.
performed as day cases. However, the use of day surgery is
Tonsillectomy consists of removing the tonsils –
low in Poland, Lithuania, Turkey and Hungary, with less
glands at the back of the throat. It is mainly performed
than 60% of surgeries performed as day cases). While this
on children.
may be explained partly by limitations in the data coverage
of outpatient activities in hospital or outside hospital, it may The data for several countries do not include
also reflect higher reimbursement for inpatient stays or outpatient cases in hospital or outside hospital (i.e.
constraints on the development of day surgery. patients who are not formally admitted and
discharged), leading to some under-estimation. In
The number of cataract surgeries performed on a same-day
Ireland, Mexico, New Zealand and the United
basis has grown significantly since 2007 in many countries,
Kingdom, the data only include cataract surgeries
including Austria, France, Hungary, Ireland, Poland,
carried out in public or publicly funded hospitals,
Portugal and Slovenia (Figure 9.18). In Austria, the share of
excluding any procedures performed in private
cataract surgeries performed as day cases increased from
hospitals (in Ireland, it is estimated that approximately
only 10% in 2007 to almost 85% in 2017.
15% of all hospital activity is undertaken in private
Tonsillectomies are one of the most frequent surgical hospitals). Data for Portugal relate only to public
procedures performed on children, usually those suffering hospitals on the mainland. Data for Spain only partly
from repeated or chronic infections of the tonsils, breathing include activities in private hospitals.
problems or obstructive sleep apnoea due to large tonsils.
Although the operation is performed under general
anaesthesia, it is now carried out predominantly as same-
day surgery in 10 of 29 OECD countries with comparable
data, with children returning home the same day References
(Figure 9.19). However, the proportion of day cases is not as [1] OECD (2017), Tackling Wasteful Spending in Health, OECD
high as for cataract surgery, at 34% of tonsillectomies, on Publishing, Paris, http://dx.doi.org/10.1787/9789264266414-en.

Ambulatory surgery
Figure 9.18. Share of cataract surgery carried out as ambulatory cases, 2007 and 2017 (or nearest year)
% 2007 2017
99.8 99.8 99.6 99.0 98.9 98.8 98.8 98.7 98.1
97.9 97.5 97.0 97.0 96.7
95.8 95.6 95.6 94.9 94.7
100 93.6 93.6 93.3 93.2
91.0 89.9
88.7
84.5 82.8
80
58.1
60 53.3
63.3
46.4
40.4
40
20

Figure 9.19. Share of tonsillectomy carried out as ambulatory cases, 2007 and 2017 (or nearest year)
% 2007 2017
97.7
100
85.9
80 75.3
70.9
68.4
72.7 61.0
57.4
55.6 54.4
60
39.2
48.5
40 34.1 33.0
41.5 29.9
18.3
20 12.8
22.3 10.1
7.7 7.2
4.3 3.9 3.0
0.5 0.0 0.0 0.0
7.7
0


203
10. PHARMACEUTICAL SECTOR
Pharmaceutical expenditure
Pharmacists and pharmacies
Pharmaceutical consumption
Generics and biosimilars
Research and development in the pharmaceutical sector
international law.
205
Pharmaceutical care is constantly evolving, with many of OECD countries. In Greece, where a policy to reduce
novel drugs entering the market. These offer alternatives to wasteful use of drugs was introduced, retail spending on
existing treatments, and in some cases, the prospect of pharmaceuticals has decreased substantially. Growth over
treating conditions previously considered incurable. the last decade has been positive in some countries, such as
However, the costs of new drugs can be very high, with Germany and Canada, partly due to new high cost
significant implications for health care budgets. In 2017, treatments – notably oncology treatments and hepatitis C
retail pharmaceuticals accounted for almost one-fifth of all drugs. Yet analysing retail pharmaceuticals only gives a
health care expenditure, and represented the third largest partial picture of spending: the costs of pharmaceuticals
spending component in OECD countries after inpatient and used for hospital inpatient care can also be high, accounting
outpatient care. on average for an additional 20% on top of retail spending.
Across OECD countries, funding from governments and Growth in spending on hospital pharmaceuticals has
compulsory insurance schemes played the largest role in generally been higher than that for retail medicines, with
purchasing pharmaceuticals (Figure 10.1). On average, these the highest rates in Korea and Iceland. Several countries,
schemes covered 58% of spending on retail including Denmark, Finland and Portugal, experienced
pharmaceuticals. Most of the remainder is financed from growth in hospital pharmaceutical expenditure at the same
household out-of-pocket payments; only 3% of spending is time as spending on retail drugs declined.
covered by voluntary insurance. In Germany and France,
government and compulsory schemes cover 80% or more of
pharmaceutical costs. By contrast, in Latvia, Poland and Definition and comparability
Lithuania, almost two-thirds of pharmaceutical spending
was through out-of-pocket payments. Pharmaceutical expenditure covers spending on
prescription medicines and self-medication, the latter
Spending for retail pharmaceuticals averaged USD 564 per
often referred to as over-the-counter products. Other
person across OECD countries in 2017, adjusted for
medical non-durable goods (such as first aid kits and
differences in purchasing power (Figure 10.2). Cross-country
hypodermic syringes) are also included. It further
differences are marked, with spending more than double
includes pharmacists’ remuneration when the latter is
the average in the United States, followed by Switzerland
separate from the price of medicines. Retail
and Japan. Per capita spending was lowest in Mexico and
pharmaceuticals are provided outside hospital care,
Denmark, at around half or less of the OECD average. Cross-
such as those dispensed through a pharmacy or
country differences in spending reflect differences in
bought from a supermarket. Hospital pharmaceuticals
distribution and dispensing patterns, the uptake of both
include drugs administered or dispensed during an
generic and novel medicines, as well as pricing and
episode of hospital care.
procurement policies.
Expenditure on retail pharmaceuticals includes
Most spending on retail pharmaceuticals is for prescription
wholesale and retail margins and value-added tax.
medicines (75%), with the remainder spent on over-the-
Total pharmaceutical spending refers in most
counter (OTC) medicines (19%) and medical non-durables
countries to “net” spending – i.e. adjusted for possible
(5%). The costs of OTC medicines are typically borne by
rebates payable by manufacturers, wholesalers or
patients, though occasionally public payers or mandatory
pharmacies. Pharmaceuticals consumed in hospitals
insurance schemes may contribute. Depending on country-
and other health care settings as part of an inpatient or
specific legislation, some OTC medicines can be sold outside
day-case treatment are excluded (available data
pharmacies, for example, in supermarkets, other retail
suggests that their inclusion would add another
stores or via the internet. Expenditure on OTC medicines in
10-20% to retail pharmaceutical spending).
Poland is almost equal to that on prescription medicines,
Comparability issues exist regarding the
and accounted for almost a third of the total in Spain, Latvia
administration and dispensing of pharmaceuticals for
and Australia.
outpatients in hospitals. In some countries, the costs
Growth in retail pharmaceutical spending has fluctuated are included under curative care; in others, under
over the past decade across OECD countries, declining in the pharmaceuticals.
years during and after the financial crisis, but increasing
again in recent years (see indicator on “Health expenditure
by type of service” in Chapter 7). This reflects the actions of
many governments in introducing cost-control measures
such as de-listing of products (excluding them from
References
reimbursement), cutting manufacturer prices and margins [1] Belloni, A., D. Morgan and V. Paris (2016), "Pharmaceutical
for pharmacists and wholesalers, and introducing or Expenditure And Policies: Past Trends And Future
increasing user charges for retail prescription drugs (Belloni Challenges", OECD Health Working Papers, No. 87, OECD
Publishing, Paris, https://doi.org/10.1787/5jm0q1f4cdq7-en.
et al., 2016[1]).
Figure 10.3 compares growth rates of pharmaceutical
spending in the retail sector and in hospitals for a selection

Figure 10.1. Expenditure on retail pharmaceuticals1 by type of financing, 2017 (or nearest year)
Government/compulsory schemes Voluntary health insurance schemes Out-of-pocket Other

%
100
1
16 13 22 27 27 29 29 31 5
7 31 30 34 38 42 23 33
80 42 39 44 41 44 45 45 46 46 47 47 47
1 51 57 63 64
1 1 1 26 59 66
60 3 4 1 88
1 3 6 31
40 84 80 78
73 72 71 71 68 68 68 66 62 1
58 58 58 56 55 55 55 54 54 53 53 53 51 50
20 43 42 37 36 36 35 34
12
0
Note: "Other" includes financing from non-profit-schemes, enterprises and the rest of the world.
1. Includes medical non-durables.
Figure 10.2. Expenditure on retail pharmaceuticals per capita, 2017 (or nearest year)
Prescribed medicines Over-the-counter medicines Medical non-durable Total

USD PPP
1400
1220
963
1200
838
823
806
1000
689
673
653
646
603
599
599
598
590
577
564
563
557
556
800
515
515
508
484
469
456
452
451
439
417
403
391
386
600
318
251
175
400
200
0

Figure 10.3. Annual average growth in retail and hospital pharmaceutical expenditure, in real terms, 2008-18 (or nearest year)
Retail pharmaceuticals Hospital pharmaceuticals

%
10 7.9
8
4.9 4.9 5.4
6 4.3 3.7 4.2
3.1
4 2.1 1.8
1.4 1.7 1.5
2 0.7 0.4 0.5
0
-2 -0.9
-4 -2.3 -1.8
-6 -5.0 -5.4 -4.3
-8
Canada Czech Denmark Finland Germany Greece Iceland Israel Korea Portugal Spain
Republic
Note: OECD estimates for Portugal exclude expenditure on other medical products from retail spending.

207
Pharmacists are trained health care professionals who The role of the community pharmacist has changed over
manage the distribution of medicines to consumers/ recent years. Although their main role is to dispense
patients and help ensure their safe and efficacious use. medications, pharmacists are increasingly providing direct
Between 2000 and 2017, the density of practising care to patients (e.g. flu vaccinations in Australia, Ireland
pharmacists increased by 33% on average in OECD and New Zealand; medicine adherence support in Australia,
countries, to 83 pharmacists per 100 000 inhabitants Japan, New Zealand and the United Kingdom), both in
(Figure 10.4). The number of pharmacists per capita is community pharmacies and as part of integrated health
highest in Japan (181 pharmacists per 100 000 people), and care provider teams.
lowest in the Netherlands (21 pharmacists).
The number of pharmacists per capita increased in all OECD
countries for which time series are available. Pharmacist Definition and comparability
density increased most rapidly in Japan, Portugal and
Slovenia. In Japan, increased numbers of pharmacists are Practising pharmacists are defined as the number of
largely attributable to the government’s efforts to more pharmacists who are licensed to practice and provide
clearly separate drug prescribing by doctors from drug direct services to clients/patients. They can be either
dispensing by pharmacists (the Bungyo system). salaried or self-employed, and work in community
pharmacies, hospitals and other settings. Assistant
Across the OECD, most pharmacists work in community
pharmacists and other employees of pharmacies are
retail pharmacies, but some also work in hospital, industry,
normally excluded.
research and academic settings. In Canada, for example, in
2016 more than three-quarters of practising pharmacists In Ireland, the figures include all pharmacists
worked in community pharmacies, while about 20% worked registered with the Pharmaceutical Society of Ireland,
in hospitals and other health care facilities (CIHI, 2017[1]). In possibly including some pharmacists who are not
Japan, around 57% of pharmacists worked in community actively working. Assistant pharmacists are included
pharmacies in 2016, while around 19% worked in hospitals in Iceland.
or clinics and the remaining 24% in other settings (Ministry Community pharmacies are premises which, in
of Health, Labour and Welfare, 2017[2]). accordance with the local legal provisions and
The number of community pharmacies per 100 000 people definitions, may operate as a facility for the provision
ranges from 7 in Denmark to 88 in Greece; with an average of of pharmacy services in community settings. The
29 across OECD countries (Figure 10.5). This variation can be number of community pharmacies reported are the
explained in part by differences in common distribution number of premises where medicines are dispensed
channels. Some countries rely more on hospital pharmacies under the supervision of a pharmacist.
to dispense medicines to outpatients; others still have
doctors dispensing medicines to their patients (e.g. in the
Netherlands). Denmark has fewer community pharmacies,
but these are often large, and include branch pharmacies References
and subsidiary pharmacy units attached to the main
[1] CIHI (2017), Pharmacists in 2016, Health Workforce, https://
pharmacy. The range of products and services provided by
www.cihi.ca/en/pharmacists (accessed on 19 July 2019).
pharmacies also varies between countries. In most
European countries, for example, pharmacies also sell [2] Ministry of Health, Labour and Welfare (2017), Summary of
Survey of Physicians, Dentists and Pharmacists, Health Statistics
cosmetics, food supplements, medical devices and
Office, Director-General for Statistics and Information
homeopathic products.
Policy, Ministry of Health, Labour and Welfare, Tokyo.

Figure 10.4. Practising pharmacists, 2000 and 2017 (or nearest year)
2000 2017
200
181
180
160
140 124
117 116 115
120 109 105 104
102 99
95 91
100 88 88 84 83
80 78 77 77 77 76
73 72 71 70 70 69 69
80 67 65
52 50 50
60
36
40 21
20
0
1. Data refer to all pharmacists licensed to practice. 2. Data include not only pharmacists providing direct services to patients, but also those working in
the health sector as researchers, for pharmaceutical companies, etc.
Figure 10.5. Community pharmacies, 2017 (or nearest year)

100
90 88
80
70
60
47
50 43
40
37 37 36 36
40 33 31 31 29 28
30 24 24 23 21 21
17 17 16 15 15
20 14 12
7
10
0
Source: Pharmaceutical Group of the European Union database 2017 or national sources.

209
Pharmaceutical consumption has been increasing for

decades, driven by a growing need for drugs to treat age- Definition and comparability
related and chronic diseases, and by changes in clinical
practice. This section examines consumption of four The defined daily dose (DDD) is the assumed average
categories of medicines: anti-hypertensives, cholesterol- maintenance dose per day for a drug used for its main
lowering agents, anti-diabetics, and anti-depressants. These indication in adults. DDDs are assigned to each active
medicines address illnesses for which the prevalence has ingredient in a given therapeutic class by international
increased markedly across OECD countries in recent expert consensus. For example, the DDD for oral
decades. aspirin is 3 grammes, which is the assumed
maintenance daily dose to treat pain in adults. DDDs
Consumption of anti-hypertensive drugs in OECD countries
do not necessarily reflect the average daily dose
increased by 70% on average between 2000 and 2017, nearly
actually used in a given country. They can be
quadrupling in Luxembourg and Estonia (Figure 10.6). It
aggregated within and across therapeutic classes of
remains highest in Germany and Hungary, which report
the Anatomic-Therapeutic Classification (ATC). For
almost five times the levels of consumption seen in Korea
more detail, see http://www.whocc.no/atcddd.
and Turkey. These variations probably reflect both
differences in the prevalence of hypertension and variations The volume of anti-hypertensive drugs consumption
in clinical practice. presented in Figure 10.6 refers to the sum of five ATC2
categories, which may all be prescribed for
Even greater growth was seen in the use of cholesterol-
hypertension (C02-anti-hypertensives, C03-diuretics,
lowering agents, with consumption in OECD countries
C07-beta blocking agents, C08-calcium channel
increasing by a factor of three between 2000 and 2017
blockers, C09-agents acting on the renin-angiotensin
(Figure 10.7). The United Kingdom, Denmark and Belgium
system). ATC codes for other classes are: C10 for
report the highest levels of consumption per capita in 2017,
cholesterol lowering drugs; A10 for antidiabetic drugs;
with a seven-fold variation in consumption levels across the
and N06A for anti-depressants.
OECD.
Data generally refer to outpatient consumption only,
The use of anti-diabetic drugs also grew dramatically,
except for Chile, the Czech Republic, Estonia, Finland,
almost doubling in OECD over the same period (Figure 10.8).
Iceland, Italy, Korea, Norway, the Slovak Republic and
This growth can be explained in part by the rising
Sweden, where data also include hospital
prevalence of diabetes, which is largely linked to the
consumption. The data for Canada relate to three
increasing prevalence of obesity (see indicator on
provinces only (British Columbia, Manitoba and
“Overweight and obesity” in Chapter 4), a major risk factor
Saskatchewan). The data for Luxembourg and Spain
for the development of type 2 diabetes. In 2017,
refer to outpatient consumption for prescribed drugs
consumption of anti-diabetic drugs was highest in Finland
covered by the national health system (public
and lowest in Latvia, with a two-fold variation.
insurance). Data for Luxembourg are underestimated
Consumption of anti-depressant drugs doubled in OECD due to incomplete consideration of products with
countries between 2000 and 2017 (Figure 10.9). This may multiple active ingredients.
reflect improved recognition of depression, availability of
therapies, evolving clinical guidelines and changes in
patient and provider attitudes (Mars et al., 2017[1]).
However, there was significant variation between countries,
with Iceland reporting the highest level of consumption in References
2018, at a rate ten times that of Latvia. [1] Mars, B. et al. (2017), “Influences on antidepressant
prescribing trends in the UK: 1995–2011”, Social Psychiatry
and Psychiatric Epidemiology, Vol. 52/2, pp. 193-200, http://
dx.doi.org/10.1007/s00127-016-1306-4.

Figure 10.6. Anti-hypertensive drug consumption, 2000 Figure 10.7. Cholesterol-lowering drug consumption, 2000
and 2017 (or nearest year) and 2017 (or nearest year)
2000 2017 2000 2017
Turkey 22
Korea 132 Chile
Turkey 37
141 Lithuania
Latvia 38
189 Estonia 58
Israel 203 Korea
Luxembourg 69
209 Latvia 78
Austria 220 Germany
Australia 87
222 Austria 87
Chile 232 Italy
Portugal 89
248 Iceland 93
Iceland 277 Slovak Republic
Norway 99
278 OECD28 103
Spain 295 Hungary
Netherlands 109
301 Luxembourg 110
Greece 304 Portugal
Belgium 110
314 Finland 113
OECD28 320 Israel
Estonia 115
331 Sweden 115
Canada 339 Greece
Lithuania 116
372 Spain 118
Italy 373 Canada
United Kingdom 121
378 Netherlands 130
Sweden 378 Czech Republic
Denmark 130
389 Slovenia 133
Slovak Republic 399 Australia
Slovenia 134
403 Norway 136
Finland 439 Belgium
Czech Republic 138
446 560 Denmark 148
Hungary United Kingdom
Germany 593 149
0 30 60 90 120 150 180
0 100 200 300 400 500 600
Defined daily dose, per 1 000 people per day
Defined daily dose, per 1 000 people per day
Note: Data refer to the sum of classes: C02-antihypertensives, C03- Note: Data refer to class C10-lipid modifying agents. Source: OECD Health
diuretics, C07-beta blocking agents, C08-calcium channel blockers, C09- Statistics 2019.
agents acting on the renin-angiotensin system. StatLink 2 https://doi.org/10.1787/888934018108
Figure 10.8. Anti-diabetic drug consumption, 2000 and Figure 10.9. Anti-depressant drug consumption, 2000 and
2017 (or nearest year) 2017 (or nearest year)
2000 2017 2000 2017
Latvia 46 Latvia 15
Austria 47 Korea 22
Chile 48 Hungary 29
Iceland 49 Estonia 29
Lithuania 50 Lithuania 32
Norway 56 Slovak Republic 39
Denmark 57 Italy 40
Australia 57 Chile 41
Estonia 63 Turkey 44
Italy 63 Netherlands 46
Sweden 63 Israel 49
Luxembourg 64 Luxembourg 54
Israel 64 Greece 55
Korea 67 Germany 57
OECD28 68 Norway 57
Portugal 68 Slovenia 60
Belgium 71 Czech Republic 60
Turkey 73 Austria 61
Hungary OECD29 63
74 Finland
Slovak Republic 76 70
Spain New Zealand 73
76 Denmark 76
Netherlands 77 Spain
Greece 81 77
Belgium 79
Slovenia 81 Sweden
Germany 97
84 Portugal 104
United Kingdom 85 United Kingdom 108
Canada 85 Australia 109
Czech Republic 90 Canada 110
Finland 92 Iceland 141
0 20 40 60 80 100 0 30 60 90 120 150
Defined daily dose, per 1 000 people per day Defined daily dose, per 1 000 people per day
Note: Data refer to class A10-drugs used in diabetes. Note: Data refer to class N06A-antidepressants.

211
All OECD countries view generic and biosimilar markets as

an opportunity to increase efficiency in pharmaceutical Definition and comparability
spending, but many do not fully exploit their potential. In
2017, generics accounted for more than three-quarters of A generic medicine is defined as a pharmaceutical
the volume of pharmaceuticals sold in the United Kingdom, product which has the same qualitative and
Chile, Germany and New Zealand, but less than one-quarter quantitative composition in active substances and the
in Luxembourg and Switzerland (Figure 10.10). Differences same pharmaceutical form as the reference product,
in market structures (notably the number of off-patent and whose bioequivalence with the reference product
medicines) and prescribing practices explain some cross- has been demonstrated. Generics may be either
country differences, but generic uptake also depends on branded (generics with a specific trade name) or
policies (OECD, 2018[1]; Socha-Dietrich, James and unbranded (identified using the international non-
Couffinhal, 2017[2]). In Austria, for example, generic proprietary name and the name of the company).
substitution by pharmacists is still not allowed. In Countries were requested to provide data for the whole
Luxembourg, generic substitution by pharmacists is set by of their respective markets. However, many countries
law but is limited to selected medicines. provided data covering only the community
Many countries have implemented incentives for pharmaceutical market or the reimbursed
physicians, pharmacists and patients to boost generic pharmaceutical market (see figure notes). The share of
markets. Over the last decade, France and Hungary, for generic market expressed in value can be the turnover
example, have introduced incentives for GPs to prescribe of pharmaceutical companies, the amount paid for
generics through pay-for-performance schemes. In pharmaceuticals by third-party payers, or the amount
Switzerland, pharmacists receive a fee for generic paid by all payers (third party and consumers). The
substitution; in France, pharmacies receive bonuses if their share of the generic market by volume can be
substitution rates are high. In many countries, third-party expressed in DDDs or as a number of packages/boxes
payers fund a fixed reimbursement amount for a given or standard units.
medicine, allowing the patient a choice between the A biosimilar medicinal product (a biosimilar) is a
originator and a generic, but with responsibility for any product granted regulatory approval by demonstrating
difference in price. In Greece, patients choosing originator sufficient similarity to the reference medicinal product
over generic drugs are also required to directly pay the (biological) in terms of quality characteristics,
difference. biological activity, safety and efficacy.
Biological medicines contain active substances from a Biosimilar market shares and changes in prices are
biological source, such as living cells or organisms. When measured for the ‘accessible market’, i.e. the market
such medicines no longer have monopoly protection, composed of originator products that are no longer
‘copies’ (“biosimilars”) of these products can be approved. protected and their biosimilars. Market share is
Biosimilars have increased price competition and improved computed as biosimilar treatment days as a share of
affordability. In 2017, biosimilars accounted for more than the total volume of biosimilar and referenced
70% of the volume of the ‘accessible market’ for product(s). Price change is measured as the difference
erythropoietin (used to treat anaemia) in Finland, Germany, between prices in 2017 and in the year before entry of
the Slovak Republic and Greece (Figure 10.11). In most the first biosimilar.
European countries, prices of erythropoietin fell between
30% and 80% after biosimilar entry. In Norway and
Denmark, known for their effective procurement policies,
data show zero or small biosimilar uptake and no price
reduction in 2017. In Denmark, the tender process had
References
already triggered competition between originator products, [1] OECD (2018), “Strategies to reduce wasteful spending:
leading to price reductions with which biosimilars could not Turning the lens to hospitals and pharmaceuticals”, in
compete. In Norway, the originator product won the Health at a Glance: Europe 2018: State of Health in the EU Cycle,
OECD Publishing, Paris, https://dx.doi.org/10.1787/
nationwide tender in 2017, with confidential rebates that
health_glance_eur-2018-5-en.
affected the list price. These examples highlight the
inherent problems of lack of price transparency. [3] QuintilesIMS (2017), The Impact of Biosimilar Competition in
Europe, QuintilesIMS Institute, Parsippany, http://
For tumour necrosis factor (TNF) inhibitors (used to treat www.quintilesims.com.
autoimmune and immune-mediated disorders), biosimilars
have over 90% of the accessible market in Denmark and [2] Socha-Dietrich, K., C. James and A. Couffinhal (2017),
“Reducing ineffective health care spending on
Norway, but less than 10% in Switzerland, Ireland and
pharmaceuticals”, in Tackling Wasteful Spending on Health,
Greece (Figure 10.11). Price reductions since biosimilar entry OECD Publishing, Paris, https://dx.doi.org/
are more modest than for erythropoietin, ranging from 4% in 10.1787/9789264266414-7-en.
Switzerland to 45% in Poland. For both biosimilars, actual
price reductions may be higher than what appears in
figures, which only report list prices.

Figure 10.10. Share of generics in the total pharmaceutical market, 2017 (or nearest year)
Value Volume
%
90
85 84 82
81 76 76
74
64 64 64 63
58
60 55 52
50 51 49
46 46
43 43
40 40
36 35 34 36 34
32 30
27 27 28 25 23 27 25
30 22 23
21
18 19 18 20 18 19 18
15 15 16 16
11
8 6
1. Reimbursed pharmaceutical market. 2. Community pharmacy market.

Figure 10.11. Biosimilar market share in treatment days for anti-TNF alfas and erythropoietin vs accessible market, 2017
(or nearest year), in European countries
Anti-TNF alfas Erythropoietins

Price change / year of biosimilar entry Price change / year of biosimilar entry
10% 10%
GRC DNK
0% 0%
BEL
CHE AUT ITA
-10% HUN -10% NOR
GBR GBR ITA
CZE DEU
NLD NOR
-20% EST -20%
FRA SWE
IRL PRT SWE
-30% BEL -30% IRL ESP
FIN FRA
SVK DNK CZE
-40% SVN -40% NLD AUT FIN
SVN HUN
POL CHE
-50% -50%
DEU GRC
-60% -60% SVK
POL
-70% -70%
-80% -80% PRT
-90% -90%
0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100%
Share of biosimilars in accessible market Share of biosimilars in accessible market
Source: IQVIA MIDAS MAT December 2017.


213
Pharmaceutical research and development (R&D) is funded ever-increasing base of effective drugs that has shifted
from a complex mix of private and public sources. efforts to drugs for more complex conditions. Rising R&D
Governments mainly support basic and early-stage research costs can be both a cause and a result of higher drug prices,
through direct budget allocations, research grants, publicly as the acceptance of higher prices by payers can make
owned research institutions and higher education increasingly expensive R&D and acquisitions of R&D
institutions. The pharmaceutical industry is active across all projects financially viable. Increasing R&D and acquisition
phases of R&D but makes the largest contribution to costs can, in turn, drive up prices.
translating and applying knowledge to develop products.
Clinical trials required to gain market approval are largely
funded by industry. However, industry also receives direct
R&D subsidies or tax credits in many countries. Definition and comparability
In 2016, governments of 31 OECD countries from which data
Business enterprise expenditure on R&D (BERD) covers
are available collectively budgeted about USD 53 billion for
R&D carried out by corporations, regardless of the
health-related R&D (a broader category than
origin of the funding, which can include government
pharmaceuticals). This figure understates total government
subsidies. BERD is recorded in the country where the
support because it excludes most tax incentives and funding
R&D activity took place, not the country providing
for higher education and publicly-owned corporations.
funding. National statistical agencies collect data
Meanwhile, the pharmaceutical industry spent
primarily through surveys and according to the
approximately USD 101 billion on R&D across OECD
Frascati Manual but there is some variation in national
countries.
practices. Pharmaceutical R&D refers to BERD by
Most pharmaceutical industry R&D expenditure comes from businesses classified in the pharmaceutical industry.
OECD countries but the share from non-OECD countries is Europe includes 21 EU member states that are also
increasing (EFPIA, 2018[1]). Growth has been particularly OECD countries, Iceland, Norway and Switzerland
rapid in China, where the industry spent USD 14 billion on (with no data available for Lithuania and Luxembourg).
R&D in 2016 (0.07% of GDP) – a more than 2.5-fold increase
Government budgets for R&D (GBARD) capture R&D
since 2010 (in real terms) (OECD, 2019[2]). Nearly two-thirds
performed directly by government and amounts paid
of the spending in OECD countries (Figure 10.12) occurs in
to other institutions for R&D. Health-related R&D
the United States, where the industry spent about
refers to GBARD aimed at protecting, promoting and
USD 65 billion (0.35% of GDP), and government budgets on
restoring human health, including all aspects of
health-related R&D were USD 36 billion (0.19% of GDP). The
medical and social care. It does not cover spending by
industry spent USD 20 billion (0.1% of GDP) and governments
public corporations or general university funding that
budgeted USD 11 billion (0.06% of GDP) in Europe; the figures
is subsequently allocated to health.
were USD 13 billion (0.25% of GDP) and USD 1.4 billion (0.03%
of GDP) respectively in Japan. As a share of GDP, industry The gross value added (GVA) of a sector equals gross
spending is highest in Switzerland (0.85%), Denmark (0.46%) output less intermediate consumption. It includes the
and Slovenia (0.45%), smaller countries with relatively large cost of wages, consumption of fixed capital and taxes
pharmaceutical sectors. on production. Because GVA does not include
intermediate consumption, it is less sensitive than
The pharmaceutical industry is highly R&D intensive. On
gross output to sector-specific reliance on raw
average across OECD countries, the industry spent nearly
materials. The OECD average in Figure 10.13 is an
12% of its gross value added on R&D. This is almost as high
unweighted mean of R&D intensity across 18 countries
as in the electronics and optical and air and spacecraft
with data available for air and spacecraft; and 29-33
industries, and considerably higher than across
countries for all other industries.
manufacturing as a whole (Figure 10.13).
Data in Figure 10.14 include approvals of new
Expenditure on R&D in the pharmaceutical industry in OECD
molecular entities (NMEs) and other new drug
countries grew by 14% in real terms between 2010 and 2016.
applications (NDAs) and new biologic license
The number of new drug approvals has also increased since
application (BLAs) and other BLAs.
2010, following a decline after the 1980s. In the United
States, for example, the annual number of approvals is now
back to a similar level to that seen in the 1980s (Figure 10.14).
However, given the increase in R&D expenditure, the
number of approvals per inflation-adjusted R&D spending References
has declined steadily. [1] EFPIA (2018), The Pharmaceutical Industry in Figures, https://
This pattern of decreasing productivity despite advances in www.efpia.eu/media/361960/efpia-pharmafigures2018_v07-
technology is driven by a complex combination of factors. hq.pdf.
These include growing requirements to obtain market [2] OECD (2019), Analytical Business Enterprise Research and
approval, which have increased clinical trial costs, and an Development (ANBERD) Database, http://oe.cd/anberd.

Figure 10.12. Business enterprise expenditure for pharmaceutical R&D (BERD) and government outlays for health-related
R&D (GBARD), 2016 (or nearest year)
Business R&D expenditure, pharma Direct government R&D budgets, health

Billion USD % of GDP
70 0.40
60 0.35
64.6
0.25
0.30
0.35
50
35.9
0.19
0.25
40
0.20
20.1
30
0.10
0.15
13.2
11.3
0.06
20
0.05
0.10
0.03
0.03
4.6
3.1
1.4
10 0.05
0 0.00
United States Europe Japan Other OECD United States Europe Japan Other OECD
Source: OECD Main Science and Technology Indicators and Research and Development Statistics databases.
Figure 10.13. R&D intensity by industry: business enterprise R&D expenditure as a share of gross valued added, 2016 (or
nearest year)
% BERD / GVA
50
40 Japan
United States
30
Belgium
20
16.6
14.6 OECD Average
10 11.6
4.7
0.9 0.8 0.4 0.3 0.2
0
Electronic & Air & Pharmaceuticals Total Mining & Total services Utilities Agriculture, Construction
optical products spacecraft manufacturing quarrying forestry & fishing
Source: OECD Analytical Business Enterprise R&D, Structural Analysis and System of National Accounts databases.
Figure 10.14. Annual approvals of new medicines per billion USD pharmaceutical business expenditure on R&D in the
United States, inflation-adjusted, 1980 to 2017
Number of other NDAs/BLAs Number of NMEs/new BLAs All approvals per USD bn pharma BERD
Number of approvals, 3-year-average Number of approvals per USD bn BERD
146 20
126
106 15
86
10
66
46 5
26
6 0
Source: United States Food and Drug Administration; Pharmaceutical Research and Manufacturers of America.

215
11. AGEING AND LONG-TERM CARE
Demographic trends
Life expectancy and healthy life expectancy at age 65
Self-rated health and disability at age 65 and over
Dementia
Safe prescribing in older populations
Safe long-term care
Recipients of long-term care
Informal carers
Long-term care workers
Long-term beds in facilities and hospitals
Long-term care spending and unit costs
international law.
217
Demographic trends
In recent decades, the share of the population aged 65 years above the OECD average of 10.1%) by 2050. Among OECD
or older has nearly doubled on average across OECD partner countries, the speed of ageing has been slower than
countries. The proportion of the population aged 65 years or OECD members, though rapid ageing in large countries
over increased from less than 9% in 1960 to more than 17% in including Brazil and China will accelerate in the coming
2017. Declining fertility rates and longer life expectancies decades.
(see indicator on “Life expectancy” in Chapter 3) have meant One of the major implications of rapid population ageing is
that older people make up an increasing proportion of the the decline in the potential supply of labour in the economy,
population in OECD countries. even despite recent efforts by countries to extend working
Across OECD countries on average, the share of the lives. Moreover, despite the gains in healthy life expectancy
population aged 65 and over is projected to continue seen in recent years (see indicator on “Life expectancy and
increasing in the coming decades, rising from 17.4% in 2017 healthy life expectancy”), population ageing will likely lead
to 27.1% by 2050 (Figure 11.1). In five OECD countries (Italy, to greater demand for labour-intensive long-term care.
Portugal, Greece, Japan, and Korea), the share of the Between 2015 and 2030, the number of older people in need
population aged 65 and over will exceed one-third by 2050. of care around the world is projected to increase by 100
At the other end of the spectrum, the population aged 65 and million (ILO and OECD 2019[1]). Countries such as the United
over in Israel, Mexico and Australia will represent less than States are already facing shortages of long-term care
20% of the population in 2050, due to higher fertility and workers, and in the coming years, more will find themselves
migration rates. under pressure to recruit and retain skilled long-term care
While the rise in the population aged 65 and over has been staff (see indicator on “Long-term care workers”).
striking across OECD countries, the increase has been
particularly rapid among the oldest – people 80 years of age
and older. Between 2017 and 2050, the share of the
population 80 and above will more than double on average
in OECD countries, from 4.6% to 10.1%. At least one in ten
Data on the population structure have been extracted
people will be 80 or older in nearly half (17) of OECD
from the OECD historical population data and
countries by 2050, while in six countries (Lithuania, Portugal,
projections (1950-2050). The projections are based on
Italy, Greece, Korea and Japan), more than one in eight
the most recent “medium-variant” population
people will be 80 or older.
projections from the United Nations, World Population
While most OECD partner countries have a younger age Prospects – 2019 Revision.
structure than many OECD members, population ageing will
nonetheless occur rapidly in the coming years – sometimes
at a faster pace than among OECD countries. In China, the
share of the population aged 65 and over will increase much
more rapidly than in OECD countries, more than doubling
References
from 10.6% in 2017 to 26.3% in 2050. The share of the Chinese [2] Muir, T. (2017), “Measuring social protection for long-term
population aged 80 and above will rise even more quickly, care”, OECD Health Working Papers, No. 93, OECD Publishing,
increasing more than three-fold from 1.8% in 2017 to 8.1% in Paris, https://dx.doi.org/10.1787/a411500a-en.
2050. Brazil – whose population aged 65 and over was barely [1] OECD and ILO (2019), “New job opportunities in an ageing
half of the OECD average in 2017 – will see similarly rapid society”, https://www.oecd.org/g20/summits/osaka/ILO-OECD-
growth, with nearly 22% of the population projected to be G20-Paper-1-3-New-job-opportunities-in-an-ageing-society.pdf.
aged 65 or over by 2050. [3] OECD (2015), Fiscal Sustainability of Health Systems: Bridging
The speed of population ageing has varied markedly across Health and Finance Perspectives, OECD Publishing, Paris, http://
OECD countries, with Japan in particular experiencing rapid dx.doi.org/10.1787/9789264233386-en.
ageing over the past three decades (Figure 11.2). In the [4] OECD (2017), Pensions at a Glance 2017: OECD and G20 Indicators,
coming years, Korea is projected to undergo the most rapid OECD Publishing, Paris, https://doi.org/10.1787/
population ageing among OECD members, with the share of pension_glance-2017-en.
the population 80 and above quintupling from well below [5] United Nations (2019), “2019 Revision of World Population
the OECD average in 2017 (3% versus 4.6%), to 15.1% (well Prospects”, United Nations, https://esa.un.org/unpd/wpp/.

Demographic trends
Figure 11.1. Share of the population aged over 65 and 80 years, 2017 and 2050
Population aged 65 years and over Population aged 80 years and over
2017 2050
Korea 13.8 Japan 8.5

Japan 27.7 Korea 3.0
Greece 21.7 Greece 6.8
Portugal 21.3 Italy 6.9
Italy 22.4 Portugal 6.2
Lithuania 19.5 Lithuania 5.6
Spain 19.1 Germany 6.1
Latvia 20.0 Spain 6.2
Poland 16.7 Finland 5.3
Slovenia 19.1 Latvia 5.3
Germany 21.3 Slovenia 5.2
Slovak Republic 15.3 Switzerland 5.1
Czech Republic 19.0 Austria 4.9
Finland 21.1 Netherlands 4.5
Hungary 18.8 France 6.0
Estonia 19.5 Poland 4.2
Switzerland 18.2 OECD36 4.6
Austria 18.6 United Kingdom 4.9
OECD36 17.4 Estonia 5.4
China 10.6 Belgium 5.6
Netherlands 18.7 Norway 4.2
France 19.5 Denmark 4.4
Ireland 13.6 Canada 4.3
United Kingdom 18.2 New Zealand 3.6
Norway 16.8 Czech Republic 4.0
Canada 16.9 Slovak Republic 3.2
Denmark 19.2 Hungary 4.4
Belgium 18.6 Sweden 5.1
Iceland 14.0 Ireland 3.2
Russian Federation 14.0 Luxembourg 3.9
New Zealand 15.1 United States 3.8
Luxembourg 14.3 China 1.8
Sweden 19.8 Iceland 3.6
United States 15.6 Chile 2.3
Brazil 8.9 Russian Federation 3.3
Chile 10.9 Australia 3.9
Costa Rica 7.9 Brazil 1.9
Turkey 8.4 Costa Rica 1.7
Australia 15.4 Colombia 1.5
Colombia 7.9 Turkey 1.7
Mexico 7.2 Israel 2.9
Israel 11.5 Mexico 1.6
Indonesia 5.6 Indonesia 0.8
India 6.0 India 0.9
South Africa 5.3 South Africa 0.9
0 5 10 15 20 25 30 35 40 45 0 5 10 15 20
% %
Source: OECD Health Statistics 2019, OECD Historical Population Data and Projections Database, 2019.
Figure 11.2. Trends in the share of the population aged over 80 years, 1990-2050
OECD Korea Japan Partner countries¹ World

%
18
16 Japan
14
Korea
12
10
OECD
8
6 Partner countries
4
2 World
0
1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
1. Partner countries include Brazil, China, Colombia, Costa Rica, India, Indonesia, the Russian Federation and South Africa.
Source: OECD Historical Population Data and Projections Database, 2019.

219
All OECD countries have experienced tremendous gains in that can disproportionately affect older populations, and be
life expectancy at age 65 for both men and women in recent prepared to address them, including by ensuring high
decades. On average across OECD countries, life expectancy influenza vaccination rates.
at age 65 increased by 5.5 years between 1970 and 2017
(Figure 11.3). Four countries (Australia, Finland, Korea, and
Japan) enjoyed gains of more than seven years over the Definition and comparability
period; only one country (Lithuania) experienced an
increase in life expectancy at age 65 of less than two years Life expectancy measures how long on average a
between 1970 and 2017. person of a given age can expect to live, if current
On average across OECD countries, people at age 65 could death rates do not change. However, the actual age-
expect to live a further 19.7 years. Life expectancy at age 65 is specific death rate of any particular birth cohort
more than 2.5 years higher for women than for men of the cannot be known in advance. If rates are falling, as has
same age. This gender gap has not changed substantially been the case over the past decades in OECD countries,
since 1970, when life expectancy at age 65 was 2.9 years actual life spans will be higher than life expectancy
longer for women than men. Life expectancy at age 65 was calculated using current death rates. The methodology
highest for women in Japan (24.4 years) and for men in used to calculate life expectancy can vary slightly
Switzerland (20 years). Among OECD countries, life between countries. This can change a country’s
expectancy at age 65 in 2017 was lowest for women in estimates by a fraction of a year. Life expectancy at age
Hungary (18.4 years), and for men in Latvia (14.1 years). 65 is the unweighted average of the life expectancy at
age 65 of women and men. Gains in life expectancy
While all OECD countries experienced gains in life
were calculated as the difference in the number of
expectancy at age 65 between 1970 and 2017, not all
years gained in life expectancy between the periods
additional years are lived in good health. The number of
2002-2007 and 2012-2017.
healthy life years at age 65 varies substantially across OECD
countries (Figure 11.4). In Europe, an indicator of disability- Disability-free life expectancy (or “healthy life years”)
free life expectancy known as “healthy life years” is is defined as the number of years spent free of activity
calculated regularly, based on a general question about limitation. In Europe, this indicator is calculated
disability in the European Union Statistics on Income and annually by Eurostat for EU countries and some EFTA
Living Conditions (EU-SILC) survey. On average across OECD countries. The disability measure is based on the
countries participating in the survey, the number of healthy Global Activity Limitation Indicator (GALI) question,
life years at age 65 was 9.6 for women and 9.4 for men – a which comes from the EU-SILC survey. The question
markedly smaller difference than that of general life asks: “For at least the past six months, have you been
expectancy at age 65 between men and women. Healthy life hampered because of a health problem in activities
expectancy at age 65 was above 15 years for both men and people usually do? Yes, strongly limited / Yes, limited /
women in Norway, Sweden and Iceland; for men, this was No, not limited”. While healthy life years is the most
nearly three years above the next-best performing countries comparable indicator to date, there are still problems
(Ireland and Spain). Healthy life expectancy at 65 was less with translation of the GALI question, although it does
than five years for both men and women in the Slovak appear to satisfactorily reflect other health and
Republic and Latvia. In the Slovak Republic and Latvia, disability measures (Jagger et al., 2010[1]).Data on the
women spend nearly 80% of additional life years in poor population structure have been extracted from the
health, compared with less than 30% in Norway, Sweden OECD historical population data and projections
and Iceland. (1950-2050). The projections are based on the most
recent “medium-variant” population projections from
Gains in life expectancy at age 65 have slowed in recent
the United Nations, World Population Prospects – 2019
years (Figure 11.5). Life expectancy at age 65 increased by 11
Revision.
months on average in OECD countries between 2002 and
2007; between 2012 and 2017, countries added just over
seven months to life expectancy at age 65. Gains in life
expectancy at age 65 accelerated in just eight OECD
countries (Chile, Greece, Israel, Japan, Latvia, Lithuania, References
Slovak Republic and Turkey) between 2012-2017 compared [1] Jagger, C. et al. (2010), “The Global Activity Limitation
with 2002-2007; in Iceland, life expectancy at age 65 declined Indicator (GALI) Measured Function and Disability Similarly
between 2012 and 2017. The slowdown in life expectancy at across European Countries”, Journal of Clinical Epidemiology,
age 65 in 2012-2017 compared with 2002-2007 may be Vol. 63, pp. 892-899.
partially explained by the severe influenza epidemic of [2] Mäki, N. et al. (2013), “Educational Differences in Disability-
2014-2015, which affected frail and older populations in free Life Expectancy: A Comparative study of Long-standing
particular. As population ageing continues, OECD countries Activity Limitation in Eight European Countries”, Social
will need to anticipate health challenges, like flu outbreaks, Science & Medicine, Vol. 94, pp. 1-8.

Figure 11.3. Life expectancy at age 65, 1970 and 2017 (or nearest year)
1970 2017
Years
30
25
20
15
10
5
0

Figure 11.4. Life expectancy and healthy life years at age 65, by sex, 2017 (or nearest year)
Women Men
Healthy life years Life expectancy with activity limitation
23.6 54% France 53% 19.6

23.4 47% Spain 36% 19.3
22.8 57% Switzerland 50% 20.0
22.4 56% Italy 51% 19.2
22.1 70% Portugal 57% 18.3
22.1 57% Finland 52% 18.4
22.1 62% Luxembourg¹ 48% 18.8
21.9 47% Belgium 44% 18.5
21.7 67% Slovenia 59% 17.6
21.6 26% Norway 18% 19.3
21.5 65% Austria 59% 18.5
21.5 27% Sweden 20% 19.2
21.4 37% Ireland 34% 19.0
21.4 64% Greece 56% 18.6
21.3 29% Iceland¹ 20% 19.3
21.2 55% OECD26 48% 17.8
21.2 42% Germany 37% 18.1
21.2 55% Netherlands 46% 18.7
21.1 47% United Kingdom 44% 18.8
20.8 42% Denmark 39% 18.2
20.8 71% Estonia 63% 15.6
20.2 57% Poland 48% 15.9
19.8 57% Czech Republic 53% 16.2
19.4 71% Lithuania 60% 14.4
19.1 79% Slovak Republic 75% 15.3
19.0 78% Latvia 71% 14.1
18.4 64% Hungary 54% 14.5
30 20 10 0 0 10 20 30
Years Years
Note: Data comparability is limited because of cultural factors and different formulations of question in EU-SILC.
1. Three-year average (2015-17).
Source: Eurostat Database.
Figure 11.5. Slowdown in life expectancy gains
2002-2007 2012-2017
Gains in months over the 5-year period
35
30
25
20
15
10
5
0
-5


221
Even as life expectancy at age 65 has increased across OECD

countries, many adults spend a high proportion of their Definition and comparability
older lives in poor or fair health (see indicator on “Life
expectancy and healthy life expectancy”). In 2017, more Self-reported health reflects people’s overall
than half the population aged 65 and over in 35 OECD perception of their own health, including both physical
countries reported being in poor or fair health (Figure 11.6). and psychological dimensions. Typically, survey
Older people in eastern European OECD countries report respondents are asked a question such as: “How is
some of the highest rates of poor or fair health, with more your health in general: very good, good, fair, poor, very
than three-quarters of people aged 65 and over reporting poor?”. OECD Health Statistics provides figures related
their health to be fair, bad or very bad in Lithuania, Latvia, to the proportion of people rating their health to be
Estonia, Hungary, Poland, and the Slovak Republic. High “fair/bad/very bad” combined.
rates of poor health are also reported in Portugal and Korea. Caution is required in making cross-country
Women are slightly more likely to report being in poor or fair comparisons of perceived health status for at least two
health than men: 59% of women report their health to be reasons. First, people’s rating of their health is
fair, bad or very bad on average across OECD countries, subjective and can be affected by cultural factors.
compared with 54% of men. Less than 40% of the total Second, there are variations in the question and
population aged 65 and over reported being in poor or fair answer categories used to measure perceived health
health in five European countries (Norway, Ireland, across surveys/countries. In particular, the response
Switzerland, Sweden and the Netherlands). The lowest rate scale used in Australia, Canada, New Zealand and the
of poor or fair health for women was reported in Ireland United States is asymmetrical (skewed on the positive
(31%), while men reported the lowest rate of poor or fair side), including response categories: “excellent, very
health in Norway (also 31%). good, good, fair, poor”. The data reported in OECD
In all OECD countries with available data, older people in the Health Statistics refer to respondents answering one of
lowest income quintile are more likely to rate their health as the two negative responses (fair, poor). By contrast, in
poor or fair (two in three people) than those in the top most other OECD countries, the response scale is
income quintile (less than one in two) (Figure 11.7). In every symmetrical, with response categories: “very good,
country except Luxembourg, the gap between self-reported good, fair, poor, very poor”. The data reported from
poor or fair health among people in the lowest and highest these countries refer to the last three categories (“fair,
income quintiles is larger than 14 percentage points. In five poor, very poor”). This difference in response
countries – Iceland, Norway, Finland, Sweden and Ireland – categories may introduce an upward bias in the results
adults aged 65 and over in the lowest income quintile are from those countries that use an asymmetrical scale.
more than twice as likely to report living in poor or fair The category of limitations in daily activities is
health, compared with adults in the highest income measured by the Global Activity Limitation
quintile. Indicator (GALI) question, which comes from the EU-
Across 26 European OECD countries, 50% of people aged 65 SILC survey. The question is: “For at least the past six
and over reported having at least some limitations in their months, have you been hampered because of a health
daily activities: 33% reported some limitations and a further problem in activities people usually do: yes, strongly
17% reported severe limitations (Figure 11.8). Many of the limited; yes, limited; no, not limited?”. People in
countries reporting the highest rates of self-rated poor institutions are not surveyed, resulting in an under-
health also reported high rates of limitations in daily estimation of disability prevalence. Again, the
activities in adults aged 65 and over. In the Slovak Republic measure is subjective, and cultural factors may affect
and Latvia, three in four adults aged 65 and over reported at survey responses.
least some limitations to activities of daily living, while in
Latvia, the Slovak Republic and Estonia one in four adults
aged 65 and over reported severe limitations. In contrast,
about one in five people aged 65 and over in Sweden (21%) References
and Norway (22%) reported having limitations in their daily
activities, with fewer than one in 12 reporting severe [1] Hirosaki, M. et al. (2017), “Self-rated Health Is Associated with
Subsequent Functional Decline Among Older Adults in
limitations in both countries.
Japan”, International Psychogeriatrics, Vol. 29, No. 9,
pp. 1475-1483, http://dx.doi.org/10.1017/S1041610217000692.
[2] Schnittker, J. and V. Bacak (2014), “The Increasing Predictive
Validity of Self-Rated Health”, PLoS ONE, Vol. 9, No. 1, e84933,
https://doi.org/10.1371/journal.pone.0084933.

Figure 11.6. Adults aged 65 and over rating their own health as fair, bad, or very bad, 2017 (or nearest year)
Total Female Male

% reporting to be in fair, bad or very bad health
100
80
60
93.0
79.4
77.6
20.1
85.7
90.7
40
21.8
13.4
74.9
74.8
81.5
82.2
82.4
80.6
66.5
65.8
65.3
60.1
59.4
58.2
58.1
56.8
56.8
56.6
53.0
51.4
46.7
42.6
42.2
41.6
39.8
20 39.1
34.3
32.3
32.9
26.0
Note: Numbers are close together for males and females for Canada, the United States, Australia, the United Kingdom and the Czech Republic. Data for
New Zealand, Canada, the United States and Australia biased downwards relative to other countries and so are not directly comparable.
Figure 11.7. Adults aged 65 and over rating their own health as fair, bad, or very bad, by income, European countries, 2017
(or nearest year)
Lowest quintile Highest quintile

% reporting to be in fair, bad or very bad health
100
80
60
40
20
0

Figure 11.8. Limitations in daily activities in adults aged 65 and over, European countries, 2017 (or nearest year)
Some limitations Severe limitations

%
100
80
60
49.1
48.1
33.0
42.1
40.2
37.6
40
21.0 40.4
20.8 29.5
20.6 42.4
20.2 31.8
18.9 39.6
21.9 23.0
18.2 33.5
17.3 32.8
16.7 27.1
12.8 40.6
15.7 36.5
15.4 36.1
10.1 30.8
13.2 24.0
12.4 20.5
18.7 9.6
9.9 38.0
7.4 14.6
9.3 30.2
8.2 13.2
8.8 40.1
20
26.8
26.7
25.9
25.1
23.3
22.5


223
Dementia
Dementia represents one of the greatest challenges be prescribed an antipsychotic medication than men
associated with population ageing. Dementia describes a (Figure 11.10).
variety of brain disorders, including Alzheimer’s disease,
which progressively lead to brain damage and cause a
gradual deterioration of a person’s functional capacity and Definition and comparability
social relations. Despite billions of dollars spent on research
into dementia-related disorders, there is still no cure or even The prevalence estimates in Figure 11.9 are taken from
substantially disease-modifying treatment for dementia. the World Alzheimer Report 2015, which includes a
Nearly 20 million people in OECD countries are estimated to systematic review of studies of dementia prevalence
have dementia in 2019. If current trends continue, this around the world. Prevalence by country has been
number will more than double by 2050, reaching nearly estimated by applying these age-specific prevalence
41 million people across OECD countries. Age remains the rates for the relevant region of the world to population
greatest risk factor for dementia: across the 36 OECD estimates from the United Nations (World Population
countries, average dementia prevalence rises from 2.3% Prospects: the 2017 Revision). Differences between
among people aged 65-69 to nearly 42% among people aged countries are therefore driven by the age structure of
90 or older. This means that as countries age, the number of populations – i.e. countries with older populations
people living with dementia will also increase – particularly have more people with dementia. The World
as the proportion of the population over 80 rises. Already, Alzheimer Report 2015 analysis includes studies
countries with some of the oldest populations in the OECD – carried out since 1980, with the assumption that age-
including Japan, Italy, and Germany – also have the highest specific prevalence is constant over time. This
prevalence of dementia. Across OECD countries on average, assumption is retained in the construction of this
15 people per 1 000 population are estimated to have indicator, so that fixed age-specific prevalence rates
dementia (Figure 11.9). In seven countries, more than 20 are applied for both 2017 and 2050. Although gender-
people per 1 000 population are living with a dementia specific prevalence rates were available for some
disorder. By 2050, all but three OECD countries (Slovak regions, overall rates were used in this analysis.
Republic, Israel and Hungary) will have a dementia Antipsychotics are defined consistently across
prevalence of more than 20 people per 1 000 population, countries using Anatomical Therapeutic Classification
while in four countries (Japan, Italy, Portugal and Spain), (ATC) codes. The numerator includes all patients on
more than one in 25 people will be living with dementia. the medications register with a prescription for a drug
Even without an available treatment, however, there is within ATC subgroup N05A. The denominator is the
much that health and social care systems can do to improve total number of people on the register. Most countries
care and the quality of life for people living with dementia are unable to identify which prescriptions relate to
and their families. In recent years, at least 25 OECD countries people with dementia, so the antipsychotics indicator
have developed or announced national plans or strategies covers all people aged 65 and over. For the Netherlands
for dementia, and there is growing attention to reducing and Sweden, the denominator covers all people aged
stigma around dementia and better adapting communities 65 and over who have received at least one
and care facilities to meet the needs of people with prescription of any type, so may slightly overestimate
dementia (OECD, 2018[1]). the antipsychotics prescription rate in comparison
with other countries. In Latvia, the numerator includes
Although antipsychotic drugs can reduce the behavioural
only prescriptions made in primary care. Because
and psychological symptoms that affect many people with
many antipsychotics prescriptions are made by
dementia, the availability of effective non-pharmacological
specialists, this likely undercounts the proportion of
interventions, as well as the associated health risks and
people who received a prescription. Some caution is
ethical issues of antipsychotic medications, means that they
needed when making inferences about the dementia
are only recommended as a last resort. However, the
population, since it is not certain that a higher rate of
inappropriate use of these drugs remains widespread and
prescribing among all those aged 65 and over
reducing their overuse is a policy priority for many OECD
translates into more prescriptions for people with
countries. Across 16 OECD countries in 2017, more than 5%
dementia. Nonetheless, measuring this indicator,
of adults aged 65 and over received a prescription for
exploring the reasons for variation and reducing
antipsychotic medicines. This masks the wide variation in
inappropriate use can help to improve the quality of
prescribing rates between countries. Excluding Latvia,
dementia care.
antipsychotic prescribing varies by a factor of three and a
half across most OECD countries, from 29 prescriptions per
1 000 people aged 65 and over in Sweden, to more than 99
prescriptions per 1 000 in Ireland. Moreover, age-
standardised rates of antipsychotic prescribing were higher References
for women than for men in every OECD country. Across 16 [1] OECD (2018), Care Needed: Improving the Lives of People with
OECD countries on average, women were 23% more likely to Dementia, OECD Health Policy Studies, OECD Publishing,
Paris, https://dx.doi.org/10.1787/9789264085107-en.

Dementia
Figure 11.9. Estimated prevalence of dementia, 2019 and 2050
2019 2050
People with dementia per 1 000 population
50
43.1
42.7
41.8
40.5
45
38.9
38.9
36.8
35.6
40
33.6
33.5
33.3
32.8
31.9
30.7
30.6
35
29.3
29.1
28.3
28.2
28.1
28.1
27.8
27.4
26.0
25.9
25.8
30
25.3
25.0
24.8
24.4
24.3
23.7
23.6
22.9
22.7
22.4
21.8
25
20.0
18.4
18.4
17.9
16.8
20
11.7
11.6
15
10
5.8
Source: OECD analysis of data from the World Alzheimer Report 2015 and the United Nations.
Figure 11.10. Antipsychotic prescribing rates by sex, 2017 (or nearest year)
Women Men
Per 1 000 people 65+
120
100
80
60
40
20
1. Data for Latvia includes only patients receiving a prescription in primary care. 2. Data for the Netherlands and Sweden refers to all people with at least
one prescription of any kind.

225
Prescribing is a critical component of care for older people. prescribed for older adults for anxiety and sleep disorders.
Ageing and multimorbidity often require older patients to Long-term use of benzodiazepines can lead to adverse
take multiple medicines (polypharmacy) for long periods of events (falls, road accidents and overdoses), tolerance,
their lives. While polypharmacy is in many cases justified dependence and dose escalation. As well as the period of
for the management of multiple conditions, inappropriate use, there is concern about the type of benzodiazepine
polypharmacy increases the risk of adverse drug events prescribed, with long-acting types not recommended for
(ADEs), medication error and harm, resulting in falls, older adults because they take longer for the body to
episodes of confusion and delirium. Various initiatives to eliminate (OECD, 2017[4]). Inappropriate prescribing of
improve medication safety and prevent harm involve benzodiazepines has been targeted as a priority area to
regular medicine reviews and increased coordination improve the rational use of medicines among older
between prescribing networks of doctors and pharmacists populations by Choosing Wisely (2019[5]).
along the patient care pathway. ADEs cause 8.6 million There was a decline in the use of benzodiazepines between
unplanned hospitalisations in Europe every year (Mair et al., 2012 and 2017 across OECD countries on average
2017[1]). Polypharmacy is one of the three key action areas of (Figure 11.13). The largest decline in chronic usage was seen
the third WHO Global Patient Safety Challenge (WHO, in Iceland and Finland, and Korea and Norway experienced
2019[2]). the largest decline in usage of long-acting benzodiazepines.
Across a selection of 14 countries with broader data The large variation can be explained in part by different
coverage, polypharmacy rates among older people vary reimbursement and prescribing policies for
more than 11-fold across countries with broader data benzodiazepines, as well as by differences in disease
coverage, with Turkey reporting the lowest rates, and prevalence and treatment guidelines.
Luxembourg the highest. Among countries with only
primary care data, polypharmacy rates vary almost three-
fold, with Finland reporting the lowest rate and Korea the
highest (Figure 11.11). These large variations can be Definition and comparability
explained in part by the establishment of targeted
polypharmacy initiatives in some countries, including See the “Definition and comparability” box on “Safe
related reimbursement and prescribing policies. Countries primary care – prescribing” in Chapter 6 for more
that cannot separate prescription data from primary and details regarding the definition and comparability of
long-term care show higher average and larger variation of prescription data across countries.
polypharmacy rates than countries with only primary care
data.
Opioids are often used to treat pain (see indicators “Opioids
use” in Chapter 4 and “Safe primary care - prescribing” in References
Chapter 6) and are associated with high rates of emergency
[5] Choosing Wisely (2019), Choosing Wisely, https://
admissions caused by ADEs among older adults (Lown
www.choosingwisely.org/.
Institute, 2019[3]). Figure 11.12 indicates that across all
countries except Canada, the overall volume of opioids [3] Lown Institute (2019), Medication Overload: America’s Other
consumed is highest among older people. On average across Drug Problem, https://lowninstitute.org/wp-content/uploads/
2019/04/medication-overload-lown-web.pdf.
OECD countries, older people consume 1.5 times more than
the average volume of those aged 50-69, and nearly five [1] Mair A, F., H. Alonso A and E. al. (2017), The Simpathy
times more than the volume consumed by those aged 18-49. consortium. Polypharmacy Management by 2030: a patient safety
Luxembourg shows the highest opioids volumes among challenge, SIMPATHY Consortium, Coimbra, http://
www.simpathy.eu/.
older adults, and Turkey the lowest. This variation can be
explained in part by differences in clinical practice in pain [4] OECD (2017), Tackling Wasteful Spending on Health, OECD
management, as well as differences in regulation, legal Publishing, Paris, https://dx.doi.org/10.1787/9789264266414-
frameworks of opioids, prescribing policies and treatment en.
guidelines. [2] WHO (2019), The Pursuit of Responsible Use of Medicines: Sharing
and Learning from Country Experiences, https://www.who.int/
Despite the risk of adverse side effects such as fatigue,
medicines/areas/rational_use/en/.
dizziness and confusion, benzodiazepines are often

Figure 11.11. Polypharmacy in adults aged 75 and over: primary and long-term care, 2017 (or nearest year)
Countries with data on primary care only Countries with data on primary and long-term care
% of population aged 75 and over % of population aged 75 and over
87.0
100 100
68.1
66.0
63.3
59.6
80 80
54.8
52.4
51.4
52.1
48.3
47.7
44.5
43.8
60 60
36.1
23.3
40 40
7.5
20 20
0 0
Note: Chronicity defined based on use above 90 DDDs/days in a given year, except in results for Turkey, Ireland, Denmark, Finland and Portugal which
instead use number of prescriptions (four and over) in a given year. Dermatologicals for topical use are excluded.
Figure 11.12. Opioid prescriptions across age groups, 2017 (or nearest year)
18-49 years 50-69 years 70 years and over

DDDs per 1 000 population, per day
71.6
69.3
80
56.1
51.8
53.6
70
56.3
48.3
43.1
41.5
60
34.9
34.6
33.0
32.4
30.9
50
29.1
28.2
24.8
24.0
24.0
23.1
22.8
22.8
22.0
21.3
21.3
40
18.3
17.7
16.2
15.8
12.2
11.6
11.2
30
9.6
9.0
8.5
7.6
7.5
6.9
6.2
6.0
20
4.7
4.3
3.1
2.9
2.7
1.9
1.2
0.4
0.4
0.2
0.0
10
0
Note: Data excludes products used in the treatment of addiction.

Figure 11.13. Trends in benzodiazepine use in adults aged 65 and over, 2012-17 (or nearest years)
Chronic benzodiazepine use Long-acting benzodiazepine use
2012 2017
Per 1 000 population, aged 65 years and over Per 1 000 population, aged 65 years and over
140 250
120
200
100
110.3
80 150
146.3
137.4
73.1
60 100
65.5
104.0
105.2
55.8
52.8
40
49.5
83.1
16.0
50
74.6
40.7
10.6
10.1
66.9
33.9
7.5
20
30.8
5.1
50.2
54.0
52.0
32.9
14.6
15.1
20.8
22.9
21.1
14.6
2.3
1.2
18.0
0.3
0.1
0.3
0 0

227
Safe long-term care
As populations across OECD countries continue to age, an

increasing number of people will require support from long- among participating LTC facilities. Facilities in ECDC
term care (LTC) services, including nursing homes and LTC data included: general nursing homes, mixed long-
living facilities (see indicator on “Recipients of long-term term care facilities and residential homes, and
care”). Providing safe care for these patients is a key excluded specialised long-term care facilities, as
challenge for OECD health systems, as residents of LTC defined by the ECDC. Only nursing homes were
facilities are more frail and sicker, and present a number of included in CDC data. Point-prevalence surveys
other risk factors for the development of patient safety currently represent the best tool for collecting
events, including healthcare-associated infections (HAIs) internationally comparable data, but they are subject
and pressure ulcers (OECD/European Commission, 2013[1]). to possible biases due to facility selection, local
HAIs can lead to significant increases in patient morbidity, recording practices or observer training. Countries
mortality and cost for the health system. In the acute care noted as having poor data representativeness had low
sector, HAIs alone are estimated to make up 3-6% of hospital participation among LTC facilities, which may lead to
budgets (Slawomirski et al., 2017[2]). These infections are large variance or biased estimates.
also generally considered to be preventable through Pressure ulcers in prevalence estimates include all
standard prevention and hygiene measures. The most grades or categories, including grade I. Accuracy of
commonly occurring HAIs in LTC facilities include urinary recognising pressure ulcers may vary considerably,
tract infections, lower respiratory tract infections, skin and particularly as this measurement was not the core
soft tissue infections (Suetens et al., 2018[3]). purpose of data collection. HAI data included
In 2016-17, the average prevalence of HAIs among LTC healthcare-associated pneumonia, urinary tract
facility residents in OECD countries was 3.8% (Figure 11.14). infections, surgical site infections, Clostridium difficile
This proportion was lowest in Lithuania, Hungary, Sweden, infections and primary bloodstream infections.
Germany, and Luxembourg (less than 2%), and highest in Resistance proportion data are based on a composite
Denmark, Portugal, Greece and Spain (over 5%). antibiotic resistance indicator developed by the ECDC
(Suetens et al., 2018).
The impact of HAIs is increased by the rise of antibiotic-
resistant bacteria, which can lead to infections that are Both HAI and pressure ulcer prevalence data are
difficult or even impossible to treat. Figure 11.15 shows the unadjusted. Many factors – including increased patient
proportions of bacteria isolated from LTC residents that are age, limited mobility and use of invasive medical
resistant to antibiotics. On average, over one quarter of devices – may increase the risk of developing either an
isolates were resistant to antibiotics. This is nearly HAI or a pressure ulcer and may influence the
equivalent to levels seen in acute care hospitals, where variability of rates between countries. One of these
antibiotic resistance is considered a major threat. factors – the proportion of residents with limited
mobility – is noted by country in the relevant figures.
Pressures ulcers are another important patient safety
concern in LTC facilities. A pressure ulcer is an injury to the
skin or underlying tissue resulting from sustained pressure;
they occur frequently in patients with limited mobility.
Pressure ulcers can lead to complications including References
infections, and cost up to EUR 170 per patient per day in LTC [4] Demarré, L., et al. (2015). “The cost of prevention and
settings (Demarré et al., 2015[4]). treatment of pressure ulcers: a systematic review”,
Across OECD countries on average, the observed prevalence International journal of nursing studies, Vol. 52, No. 11, pp.
rate of pressure ulcers in selected LTC facilities was 5.35 1754-1774.
(Figure 11.16). The highest rates of pressure ulcer prevalence [1] OECD/European Commission (2013), A Good Life in Old Age?
were observed in Spain, Italy and Portugal, at nearly twice Monitoring and Improving Quality in Long-term Care, OECD
the OECD average, while Lithuania, Hungary and Health Policy Studies, OECD Publishing, Paris, https://doi.org/
Luxembourg reported the lowest rates at under 3%. 10.1787/9789264194564-en.
[3] Suetens, C. et al. (2018), “Prevalence of healthcare-associated
infections, estimated incidence and composite
antimicrobial resistance index in acute care hospitals and
long-term care facilities: results from two European point
Definition and comparability prevalence surveys, 2016 to 2017”, Euro Surveill., Vol. 23, No.
46, https://doi.org/10.2807/1560-7917.ES.2018.23.46.1800516.
Data came from point-prevalence surveys conducted
between 2016 and 2017 by the European Centre for [2] Slawomirski, L., A. Auraaen and N. Klazinga (2017), “The
Disease Control and Prevention (ECDC) and the economics of patient safety: Strengthening a value-based
approach to reducing patient harm at national level”, OECD
Centers for Disease Control and Prevention (CDC)
Health Working Papers, No. 96, OECD Publishing, Paris, https://
doi.org/10.1787/5a9858cd-en.

Safe long-term care
Figure 11.14. Percentage of long-term care facility residents with at least one healthcare-associated infection, 2016-17
% of LTC residents
10
8
6.3
8.5
5.9
5.2
4.9
4.9
4.9
6
4.3
3.9
3.9
3.8
3.5
3.5
3.0
4
2.1
1.9
1.7
1.6
1.0
0.9
2
0
1. Limited country representativeness 2. Under 40% of residents sampled were wheelchair-bound or bedridden. 3. Between 40% and 50% of residents
sampled were wheelchair-bound or bedridden.
Source: ECDC.
Figure 11.15. Proportion of antimicrobial-resistant bacterial isolates from healthcare-associated infections in long-term
care, 2016-17
% resistance
50
35.5
32.8
46.2
40
42.9
26.7
26.3
24.4
30
17.9
17.8
12.5
20
6.8
10
0
Finland Austria Belgium Ireland France OECD10 Netherlands Spain Italy Poland Portugal
Note: Based on composite antibiotic resistance indicator developed by ECDC. Only countries with over 15 bacterial isolates were included.
Source: ECDC.
Figure 11.16. Percentage of long-term care facility residents with at least one pressure ulcer, 2016-17
% of LTC residents
15
9.7
9.9
13.1
8.4
7.3
10
5.7
5.7
5.3
4.8
4.3
4.0
3.7
3.7
3.6
3.4
3.2
2.8
5
1.9
0.9
1. Under 45% of residents sampled were wheelchair-bound or bedridden. 2. Over 45% of residents sampled were wheelchair-bound or bedridden. 3. No
data available on the proportion of wheelchair-bound or bedridden residents.
Source: ECDC, CDC.

229
Across OECD countries, an average of 10.8% of people aged institutional care, but an even larger decrease in the number
65 and over received long-term care (LTC) in 2017. This of “curators” appointed by local government to care for
represents a 5% increase compared with 2007 (Figure 11.17). people at home.
More than one in five people aged 65 and over received LTC
services in Switzerland (22%) and Israel (20%), compared
with less than 5% in the Slovak Republic (4%), Canada (4%), Definition and comparability
Ireland (3%), Portugal (2%), and Poland (1%).
The majority of LTC recipients are older adults (Figure 11.18). LTC recipients are defined as people receiving long-
Although LTC services are also delivered to younger disabled term care by paid providers, including
groups, people are more likely to develop disabilities and non‑professionals receiving cash payments under a
need support from LTC services as they age. In 2017, just 21% social programme. They also include recipients of cash
of LTC recipients on average across OECD countries were benefits such as consumer-choice programmes, care
younger than 65, while a further 27% were between 65 and allowances or other social benefits granted with the
79. Adults aged 80 and over represent the majority of LTC primary goal of supporting people with LTC needs. LTC
recipients in OECD countries. On average in OECD countries, institutions refer to nursing and residential care
51% of LTC recipients were aged 80 and above in 2017. In facilities that provide accommodation and LTC as a
Japan, two-thirds of LTC recipients were 80 and over, while package. LTC at home is defined as people with
people aged 0-64 represented just 3% of LTC recipients. functional restrictions who receive most of their care
at home. Home care also applies to the use of
While population ageing is a significant driver of the growth
institutions on a temporary basis, community care and
in LTC users over time, the cross-country variation in the
day-care centres and specially designed living
proportion of older LTC recipients suggests that other
arrangements. Data for Poland, Ireland, Canada, the
drivers – notably publicly funded LTC services – also
Slovak Republic, Iceland and Belgium are only
determine LTC use. For example, Israel has one of the
available for people receiving LTC in institutions, so
youngest populations among OECD countries but a greater
the total number of recipients will be underestimated.
than average proportion receive LTC. Because data on
In Estonia, data on recipients of home care refer only to
people receiving care outside public systems are more
those who have a “curator” appointed by local
difficult to collect and may be underreported, figures for
government. Other social services, without a personal
countries that rely more heavily on privately-funded care
care component, are not included in the data. It is
may be artificially low. Cultural norms around the degree to
possible that some of the decrease in recipients
which families look after older people may also be an
reflects the replacement of curators with these other
important driver of the utilisation of formal services (see
services.
indicator on “Informal carers”).
Data on LTC services are difficult to collect in many
Many people in need of LTC care wish to remain in their
countries and there are some known limitations of the
homes for as long as possible. In response to these
figures. Data for some countries refers only to people
preferences, and the high costs of care facility-based LTC,
receiving publicly funded care, while other countries
many OECD countries have developed services to support
include people who are paying for their own care.
home-based care for older adults. Between 2007 and 2017,
the proportion of LTC recipients who received care at home
rose by 6%, from 64% to 68% (Figure 11.19). Increases have
been particularly large in Portugal, Australia, Sweden,
Germany and the United States. In Germany, part of the References
increase was due to policy reforms expanding the definition [1] Colombo, F. et al. (2011), Help Wanted? Providing and Paying for
of long-term care and therefore increasing the number of Long-Term Care, OECD Health Policy Studies, OECD
benefit recipients. While the proportion of LTC recipients Publishing, Paris, http://dx.doi.org/10.1787/9789264097759-en.
living at home has increased over the past decade in most [2] Muir, T. (2017), “Measuring social protection for long-term
OECD countries, it has declined significantly in Estonia, care”, OECD Health Working Papers, No. 93, OECD Publishing,
where there has been a significant increase in the use of Paris, https://dx.doi.org/10.1787/a411500a-en.

Figure 11.17. Share of adults aged 65 and over receiving long-term care, 2007 and 2017 (or nearest year)
2007 2017
%
25
22.4
15.6
20
13.9
13.2
12.4
20.2
11.9
10.8
10.5
15
9.9
9.8
16.2
15.7
8.8
8.3
14.7
6.0
10
13.0
11.4
4.2
10.9
10.1
1.9
0.9
5
4.1
3.4
1. Include only recipients of LTC in institutions. 2. Refers to people receiving care through the National Network of Integrated Continuing Care. 3. Refers
to social-insurance funded LTC only: the fall in recent years largely reflects the transfer of many LTC services to municipalities in 2015.
Figure 11.18. Long-term care recipients by age, 2017 (or nearest year)
0-64 65-79 80+

%
100
30 3
35 4
27 10
29 13
33 16
25 17
25 18
28 19
27 21
26 22
27 23
24
22 25
26
17 26
29
30
31
32
35
80
60
34
24
22
22
26
22
43
40
67
63
61
58
58
57
56
53
53
52
51
51
50
47
47
47
20
44
43
42
31
1. Data refer to people receiving care through the National Network of Integrated Continuing Care.
Figure 11.19. Long-term care recipients aged 65 and over receiving care at home, 2007 and 2017 (or nearest year)
2007 2017
%
100
92
80
76
75
75
74
67.5
73
73
67
66
80
59
58
55
83
60
74
70
32
59
57
40
52
20
1. Data refer to people receiving care through the National Network of Integrated Continuing Care.

231
Informal carers
Family and friends are the most important source of care for that there is a risk that fewer people will be willing and able
people with long-term care (LTC) needs in OECD countries. to provide informal care in the future. Coupled with the
Because of the informal nature of the care they provide, it is effects of an ageing population, this could lead to higher
not easy to get comparable data on the number of people demand for professional LTC services. Public LTC systems
caring for family and friends across countries, nor on the will need adequate resources to meet increased demand
frequency of their caregiving. The data presented in this while maintaining access and quality.
section come from national or international health surveys
and refer to people aged 50 years and over who report
providing care and assistance to family members and
friends.
On average across OECD countries for which data is Informal carers are defined as people providing any
available, around 13% of people aged 50 and over report help to older family members, friends and people in
providing informal care at least weekly. The share of people their social network, living inside or outside their
aged 50 and over providing informal care is close to 20% in household, who require help with everyday tasks. The
the Czech Republic, Austria, Belgium, the United Kingdom, data relate only to the population aged 50 and over,
France, and Germany, and less than 10% in Portugal, and are based on national surveys for Australia (Survey
Sweden, Poland, the United States, Ireland, and Greece of Disability, Ageing and Carers, SDAC), the United
(Figure 11.20). There is also variation in the intensity of the Kingdom (English Longitudinal Study of Ageing, ELSA),
care provided. The lowest rates of daily care provision are the United States (Health and Retirement Survey, HRS)
found in Sweden, Greece, Switzerland, Denmark and the and an international survey for other European
Netherlands – in most of which the formal LTC sector is well countries (Survey of Health, Ageing and Retirement in
developed and public coverage is comprehensive. Europe, SHARE). Data for Ireland were taken from its
Intensive caregiving is associated with a reduction in labour 2016 census.
force attachment for caregivers of working age, higher Questions about the intensity of care vary between
poverty rates, and a higher prevalence of mental health surveys. In SHARE, carers are asked about how often
problems. Many OECD countries have implemented policies they provided care in the last year; this indicator
to support family carers with a view to mitigating these includes people who provided care at least weekly. It is
negative impacts. These include paid care leave (e.g. important to highlight the change of methodology in
Belgium and France), flexible work schedules (e.g. Australia SHARE wave 7, in which over four fifths of the
and the United States), respite care (e.g. Austria, Denmark, respondents answered the SHARELIFE part of the
France, and Germany) and counselling/training services (e.g. questionnaire only instead of the panel interview. In
Sweden). Moreover, a number of OECD countries provide ELSA, people are asked if they have provided care in
cash benefits to family caregivers or cash-for-care the last week, which may be broadly comparable with
allowances for recipients which can be used to pay informal “at least weekly”. Questions in HRS and SDAC are less
caregivers, or periods of paid leave for informal carers comparable with SHARE. Carers in HRS are included if
(OECD, 2018[1]). In France, evidence suggests that even they provided more than 200 hours of care in the last
short-term respite care solutions for older people with year. In SDAC, a carer is defined as someone who has
Alzheimer’s disease may significantly reduce informal provided ongoing informal assistance for at least six
caregivers’ psychological burden (Rapp, Apouey and Senik, months. People caring for disabled children are
2018[2]). excluded for European countries but included in data
On average across OECD countries, 61% of those providing for the United States and Australia. However, the
daily informal care are women (Figure 11.21). Greece and United States data only include those caring for
Portugal have the greatest gender imbalance, with over 70% someone outside their household. Australia and
of informal carers being women. Around two-thirds of Ireland consider all informal carers together. As a
carers are looking after a parent or a spouse, but patterns of result, data for Australia, Ireland and the United States
caring vary for different age groups. Younger carers (aged may not be comparable with other countries’ data.
between 50 and 65) are much more likely to be caring for a
parent (Figure 11.22). They are more likely to be women and
may not be providing care every day. Carers aged over 65 are
more likely to be caring for a spouse. Caring for a spouse References
tends to be more intensive, requiring daily care, and men
[1] OECD (2018), Care Needed: Improving the Lives of People with
and women are equally likely to take on this role.
Dementia, OECD Health Policy Studies, OECD Publishing,
The fact that fewer people provide daily care in countries Paris, https://dx.doi.org/10.1787/9789264085107-en.
with stronger formal LTC systems suggests that there is a [2] Rapp, T., B. Apouey and C. Senik (2018), “The impact of
trade-off between informal and formal care. Declining institution use on the wellbeing of Alzheimer’s disease
family size, increased geographical mobility and rising patients and their caregivers”, Social Science and Medicine,
participation rates of women in the labour market mean http://dx.doi.org/10.1016/j.socscimed.2018.04.014.

Informal carers
Figure 11.20. Share of informal carers among population aged 50 and over, 2017 (or nearest year)
Daily Total Weekly
% among population aged 50+
25
20
8.1
15
9.1
8.1
8.5
8.6
4.7
11.6
6.3
9.9
9.9
5.9
10
18.2
8.2 2.1
6.3
8.2 1.2
4.7
5.1
6.7 1.7
11.6
4.7 1.8
11.2
2.8 6.4
10.4
10.0
9.3
9.0
8.4
7.2
7.2
7.0
6.7
6.1
5.9
5.5
5.3
5.3
5.2
0
1. The United Kingdom refers to England.

Note: The definition of informal carers differs between surveys (see the “Definition and comparability” box). The United Kingdom and the United States
include informal weekly carers. Australia and Ireland include all informal carers together.
Source: Survey of Health, Ageing and Retirement in Europe, wave 7 (2017); Survey of Disability, Ageing and Carers for Australia (2015); English
Longitudinal Study of Ageing, wave 8 (2017); Health and Retirement Survey for the United States, wave 13 (2016); Census 2016 for Ireland.
Figure 11.21. Share of women among informal daily carers aged 50 and over, 2017 (or nearest year)
% women
90
76.0
70.1
66.7
80
64.3
63.5
63.3
62.1
61.8
61.6
61.4
61.2
61.0
60.8
60.2
60.1
59.2
59.1
59.1
59.0
57.8
56.7
56.0
70
52.9
60
50
40
30
20
10
0
1. The United Kingdom refers to England.

Note: The definition of informal carers differs between surveys (see the “Definition and comparability” box).
Source: Survey of Health, Ageing and Retirement in Europe, wave 7 (2017); Survey of Disability, Ageing and Carers for Australia (2015); English
Longitudinal Study of Ageing, wave 8 (2017); Health and Retirement Survey for the United States, wave 13 (2016); Census 2016 for Ireland.
Figure 11.22. Share of informal carers in the European population aged 50 and over, by recipients of care and age, daily
and weekly, 2017
Care to parents Care to spouse
Daily care Weekly care
% %
16 16
14 14
12 12
10 10
8 8
6 6
4 4
2 2
0 0
50 55 60 65 70 75 80 85+ 50 55 60 65 70 75 80 85+
Age of carer Age of carer
Note: Data refer to the population aged 50 and over for countries included in SHARE wave 7.
Source: Wave 7 of the Survey of Health, Ageing and Retirement in Europe (2017).

233
Long-term care (LTC) is a labour-intensive service, and employed on a part-time basis. Part-time work is
formal care is in many cases a necessary complement to particularly widespread among personal carers and home-
informal, unpaid work in supporting people with LTC needs based workers. The fact that basic LTC services are mostly
(see indicators on “Informal carers”). Formal LTC workers needed for reduced hours at specific times of the day may
are defined as paid staff – typically nurses and personal contribute to explain such high rates. In addition, half of LTC
carers – who provide care and/or assistance to people workers experience shift work and almost one quarter are
limited in their daily activities at home or in institutions, on temporary contracts. Further, while LTC tends to be
excluding hospitals. There are on average five LTC workers demanding, both physically and mentally, pay is often low.
per 100 people aged 65 and over across 28 OECD countries,
ranging from 13 in Norway to less than one in Greece,
Poland, and Portugal (Figure 11.25).
In more than half of OECD countries, population ageing has Definition and comparability
outpaced the growth of LTC supply. The LTC workforce has
stagnated or declined even in countries where the LTC LTC workers are defined as paid workers who provide
supply is much higher than the OECD average (such as care at home or in institutions (outside hospitals).
Denmark, the Netherlands, Norway, and Sweden). Nine They include qualified nurses and personal care
countries experienced an overall increase in their LTC workers providing assistance with activities of daily
supply between 2011 and 2016. As populations continue to living (ADL) and other personal support. Personal care
age, demand for LTC workers is likely to rise. Responding to workers include different categories that may be called
increasing demand will require policies to improve different names in different countries. Because
recruitment; improve retention; and increase productivity. personal care workers may not be part of recognised
occupations, it is more difficult to collect comparable
Less than one-quarter of LTC workers hold tertiary
data for this category of LTC workers across countries.
education across OECD countries (see Figure 11.23). This can
LTC workers also include family members or friends
be explained by the fact that personal care workers
who are employed under a formal contract by the care
represent 70% of the LTC workforce on average in OECD
recipient, an agency, or public and private care service
countries, and up to 90% in a few countries (Estonia,
companies. They exclude nurses working in
Switzerland, Korea, Israel, and Sweden). Only Germany,
administration. The numbers are expressed as head
Hungary, and Switzerland have a supply of nurses greater
counts, not full-time equivalents. Data refer only to
than the supply of personal care workers. Very few countries
workers employed in the public sector for some
currently require personal care workers to hold minimum
countries, but include workers in the private and not-
education levels, licences and/or certifications. Despite
for-profit sectors for others. Data from the Czech
being mostly staffed by lower-skilled workers, LTC involves
Republic and Japan are based on surveys of
spending significant time delivering more complex tasks
establishments, meaning that people who work in
than basic care. Personal care workers do not always have
more than one establishment are double-counted.
sufficient knowledge and training, which can affect the
quality of care delivered.
Working conditions in this sector tend to be relatively poor.
This tends to affect women disproportionately as, on
average, women hold about 90% of the jobs in the LTC References
sector. For instance, 45.5% of LTC workers work part-time in [1] OECD (2018), Care Needed: Improving the Lives of People with
OECD countries (Figure 11.24.) In northern and central Dementia, OECD Health Policy Studies, OECD Publishing,
European countries, more than half of workers are Paris, https://dx.doi.org/10.1787/9789264085107-en.

Figure 11.23. Long-term care workers by education level, 2016
High education Medium education Low education

% among LTC workers
100
11
12
12
29 8
8
15
15
15
19
20
20
21
24
27
28
30
80
37
38
39
44
60
50
80
74
50
68
60
76
74
63
90
84
74
58
75
40
63
42
45
65
59
64
51
20
35
26
20
19
17
17
15
15
15
14
12
11
4
6
5
2
5
5
7
0
9
Note: EU-Labour Force Survey (LFS) data based on ISCO 4 digit and NACE 2 digit. 1. Interpret with caution as sample sizes small. 2. Based on ISCO 3 digit
and NACE 2 digit.
Source: EU-LFS; ASEC-CPS for the United States; Census 2016 for Canada; LFS for Israel; Survey on Long-term Care Workers FY for Japan.
Figure 11.24. Share of long-term care workers who work part-time, 2016
% of part-time workers in LTC workforce
100
90
94.6
66.6
87.0
80
60.6
60.3
59.7
57.8
55.6
70
51.4
49.1
45.5
42.9
60
40.8
39.2
36.0
34.0
32.6
50
29.9
28.7
26.9
22.3
40
17.5
30
7.3
20
10
0
Note: EU-Labour Force Survey (LFS) data based on ISCO 4 digit and NACE 2 digit. 1. Interpret with caution as sample sizes small. 2. Based on ISCO 3 digit
and NACE 2 digit. 3. Covers only those working mostly full-time or part-time. 4. Covers only those with a permanent position.
Source: EU-LFS; ASEC-CPS for the United States; Census 2016 for Canada; LFS for Israel; Survey on Long-term Care Workers FY for Japan; National Health
Insurance System for Korea; OECD estimate based on national source for Australia.
Figure 11.25. Long-term care workers per 100 people aged 65 and over, 2011 and 2016 (or nearest year)
2011 2016
Per 100 people aged 65 and over
16
14
12 11.1
10 7.9 12.4 12.7
8 5.9
4.5 4.8 5.1
6 8.0 8.1
7.6
4 1.5 1.9 2.3 2.3 2.3 6.2
2 0.1 0.5 0.8 4.9 5.3 5.7
0 2.2 3.3 3.5 3.6 4.0 4.1
Note: EU-Labour Force Survey (LFS) data based on ISCO 4 digit and NACE 2 digit.1. Based on ISCO 3 digit and NACE 2 digit. 2. Interpret with caution as
sample sizes small. 3. The decrease in the Netherlands partly due to a methodological break in 2012, as well as reforms.
Source: EU-LFS and OECD Health Statistics 2018, with the exception of the Quarterly LFS for the United Kingdom and the Current Population Survey
(ASEC-CPS) for the United States; Eurostat Database for population demographics.

235
While countries have increasingly taken steps to ensure that facilities may be the most appropriate option – for example
people in need of long-term care (LTC) services who wish to for people living alone and requiring round-the-clock care
live at home for as long as possible can do so, many people and supervision (Wiener et al., 2009[1]) or people living in
will at some point require LTC services that cannot be remote areas with limited home care support. It is therefore
delivered at home. The number of beds in LTC facilities and important that countries retain an appropriate level of
in LTC departments in hospitals offers a measure of the residential LTC capacity, and that care facilities develop and
resources available for delivering LTC services to individuals apply models of care that promote dignity and autonomy.
outside their home. This includes ensuring that staff working in LTC facilities
Across OECD countries, there were 47 beds per 1 000 people are appropriately trained and receive the support they need
aged 65 and over in 2017 (Figure 11.26). The vast majority of to discourage high turnover and facilitate the recruitment
beds – 44 per 1 000 people aged 65 and over – were located in and retention of high-quality care workers (see indicator on
LTC facilities, with just three LTC beds per 1 000 people in “Long-term care workers”).
hospitals. The number of LTC beds per 1 000 people aged 65
and over varies enormously between OECD countries.
Luxembourg, the country with the highest number (82.8 Definition and comparability
beds), had more than 18 times more beds than Greece (4.5
beds), the country with the lowest number in 2017. Five LTC facilities refer to nursing and residential care
countries – Italy, Latvia, Poland, Turkey and Greece – had facilities that provide accommodation and LTC as a
fewer than 20 beds per 1 000 adults aged 65 and over. Four – package. They include specially designed facilities or
Luxembourg, the Netherlands, Belgium and Sweden – had hospital-like settings where the predominant service
more than 70 beds per 1 000 adults aged 65 and over. component is LTC for people with moderate to severe
functional restrictions. They do not include beds in
Between 2007 and 2017, OECD countries reduced the
adapted living arrangements for people who require
number of LTC beds in facilities by an average of 3.4 beds per
help while guaranteeing a high degree of autonomy
1 000 people aged 65 and over (Figure 11.27). However, the
and self-control. For international comparisons, they
change in the number of beds varied significantly between
should also not include beds in rehabilitation centres.
OECD countries. Over the ten-year period, Sweden, Iceland
and Finland each reduced the number of beds in LTC However, there are variations in data coverage across
facilities by 15 or more per 1 000 people aged 65 and over. At countries. Several countries only include beds in
the other end of the spectrum, Korea increased the number publicly funded LTC facilities, while others also
of LTC beds by 36 over the same period. These substantial include private facilities (both for-profit and not-for-
changes have been largely driven by changes in policies over profit). Some countries also include beds in treatment
the period. Reductions in the number of facility-based LTC centres for addicted people, psychiatric units of
beds in Sweden have been driven by a move towards general or specialised hospitals, and rehabilitation
community-based LTC service provision, while in Korea, the centres.
massive increase in capacity followed the introduction of a
public LTC insurance scheme in 2008.
Providing LTC in facilities can be more efficient than
community care for people with intensive needs, owing to References
economies of scale and the fact that care workers do not [2] Colombo, F. et al. (2011), Help Wanted? Providing and Paying for
need to travel to each person separately. However, it often Long-Term Care, OECD Health Policy Studies, OECD
costs public budgets more, since informal carers make less Publishing, Paris, http://dx.doi.org/10.1787/9789264097759-en.
of a contribution and LTC systems often pick up board, [3] Muir, T. (2017), “Measuring social protection for long-term
lodging and care costs. Facility-based LTC may also be care”, OECD Health Working Papers, No. 93, OECD Publishing,
against the preferences of LTC recipients, many of whom Paris, https://dx.doi.org/10.1787/a411500a-en.
wish to remain at home for as long as possible. Most
[1] Wiener, J. et al. (2009), “Why Are Nursing Home Utilization
countries have taken steps in recent years to support this Rates Declining”, Real Choice Systems Change Grant Program,
preference and promote community care. However, US Department of Health and Human Services, Centers for
depending on individual circumstances, a move to LTC Medicare and Medicaid Services.

Figure 11.26. Long-term care beds in facilities and hospitals, 2017 (or nearest year)
Institutions Hospitals
Per 1 000 population aged 65 and over
100
82.8
76.4
72.1
71.5
80
65.9
60.9
59.0
58.3
58.0
55.4
54.4
54.4
54.4
53.5
52.2
60
51.2
50.3
49.8
48.9
48.7
47.2
47.0
46.8
46.2
45.6
39.9
34.6
33.6
40
23.6
19.2
16.9
11.9
20
8.7
4.5
0
1. The numbers of LTC beds in hospitals are not available for Australia, Turkey and the United Kingdom.
Figure 11.27. Trends in long-term care beds in facilities and hospitals, 2007-17 (or nearest year)
Absolute difference in LTC beds per 1 000 population aged 65 and over, 2007-17
40
+36.1
30
20
+12.2
10
+5.4
+2.2 +1.4 +1.4
0
-0.4 -1.0 -1.3
-3.4 -3.5 -4.2
-4.9 -5.6 -5.9 -6.0
-10 -6.6 -7.8
-8.6 -9.9
-10.2
-13.9 -15.0
-20 -17.7 -18.8
-30
1. 2007 data refer to 2011.


237
Compared to other areas of health care, spending on long- Hungary, Slovenia and Croatia. Only in Slovenia and Croatia
term care (LTC) has seen the highest growth in recent years would an older person with median income be able to afford
(see indicator on “Health expenditure by function” in the costs of institutional care from their income alone. All
Chapter 7). Population ageing leads to more people needing OECD countries have some form of social protection against
ongoing health and social care; rising incomes increase these high financial risks, and out-of-pocket costs that older
expectations on the quality of life in old age; the supply of people ultimately face tend to be lower in countries where
informal care is potentially shrinking; and productivity public expenditure on LTC is higher, such as in the
gains are difficult to achieve in such a labour-intensive Netherlands and Finland (Muir, 2017[1]).
sector. All these factors create upward cost pressures, and
substantial further increases in LTC spending in OECD
countries are projected for the coming years.
A significant share of the spending on LTC services is Definition and comparability
covered by government or compulsory insurance schemes.
Total government/compulsory spending on LTC (including LTC spending comprises both health and social
both the health and social care components) accounted for services to LTC dependent people who need care on an
1.7% of GDP on average across OECD countries in 2017 ongoing basis. Based on the System of Health
(Figure 11.28). At 3.7% of GDP, the highest spender was the Accounts, the health component of LTC spending
Netherlands, followed by Norway (3.3%) and Sweden (3.2%). relates to nursing care and personal care services (i.e.
In these countries, public expenditure on LTC was around help with activities of daily living). It also covers
double the OECD average. At the other end of the scale, palliative care and care provided in LTC institutions
Hungary, Estonia, Poland, and Latvia all allocated less than (including costs for room and board) or at home. LTC
0.5% of their GDP to the delivery of LTC services. This social expenditure primarily covers help with
variation partly reflects differences in the population instrumental activities of daily living. Progress has
structure, but mostly reflects the stage of development of been made in improving the general comparability of
formal LTC systems, as opposed to more informal LTC spending in recent years but there is still some
arrangements based mainly on care provided by unpaid variation in reporting practices between the health
family members. Generally, the health component of LTC and social components for some LTC activities in some
represents the vast majority of all LTC expenditure, but countries. Currently, LTC expenditure funded by
some issues remain around properly distinguishing governments and compulsory insurance schemes is
between health and social LTC in some countries. more suitable for international comparison as there is
more variation in the comprehensiveness of reporting
The way LTC is organised in countries affects the
of privately funded LTC expenditure across OECD
composition of LTC (health) spending and can also have an
countries. Finally, some countries (e.g. Israel and the
impact on overall LTC spending. Across OECD countries,
United States) can only report spending data for
around two-thirds of government and compulsory spending
institutional care, and hence underestimate the total
on LTC (health) was for inpatient LTC in 2017. These services
amount of spending on LTC services by government
are mainly provided in residential LTC facilities
and compulsory insurance schemes.
(Figure 11.29). Yet in Poland, Finland, Denmark, Lithuania,
Austria and Germany, spending on home-based LTC Long-term care institutions refer to nursing and
accounted for more than 50% of all LTC spending. Spending residential care facilities that provide accommodation
for home-based LTC can be on services provided by either and long-term care as a package. They are specially
professional LTC workers or informal workers, when a care designed institutions where the predominant service
allowance exists that remunerates the caregiver for the LTC component is LTC for dependent people with
services provided. moderate to severe functional restrictions. An older
person with severe needs is defined as someone who
The important role public schemes play in the financing of
requires 41.25 hours of care per week. A detailed
LTC can be explained by the substantial costs for care that
description of their needs can be found in Muir
older people with LTC needs face. These costs vary widely
(2017[1]).
between countries but are always high relative to median
incomes among elderly people. For institutional care, for
example, the costs for a person with severe LTC needs
represent between just under one the median disposable
income for individuals of retirement age and more than four References
times that income (Figure 11.30), depending on the country [1] Muir, T. (2017), “Measuring social protection for long-term
or region. Compared to the average income, costs are higher care”, OECD Health Working Papers, No. 93, OECD Publishing,
in Finland, Ireland and the Netherlands and lower in Paris, https://dx.doi.org/10.1787/a411500a-en.

Figure 11.28. Long-term care expenditure (health and social components) by government and compulsory insurance
schemes, as a share of GDP, 2017 (or nearest year)
Long-term care (health) Long-term care (social)

%
4 3.7 3.3 3.2
3 2.5
2.2 2.1
1.9 1.8 1.7 1.7 1.7
2 1.5 1.4 1.4 1.3 1.3
1.1 1.1 0.9
0.9 0.7 0.7 0.6
1 0.6 0.5 0.5 0.4
0.4 0.2 0.2
Note: The OECD average only includes 17 countries that report health and social LTC.
Figure 11.29. Government and compulsory insurance spending on LTC (health) by mode of provision, 2017 (or nearest year)
% Inpatient long-term care Home-based long-term care Other

100 2 1 1 7 4 7 5 3 5 4 5 1 5 1 1 1
19 17 10 14
1 8 11 11 14 21 15 19 23 26 26
80 30
16 26 31 33 40 44 49
27 44 57 58 64 66
60 19 81 81
96 91 88
40 82 82 81 79 78 76 75 74 73 66 64 64 62 59 56 55 51 51 51
20 41 40 35 34
19 19
0
Note: “Other” includes LTC in day care and outpatient settings.

Figure 11.30. Costs of institutional long-term care for an older person with severe needs, as a share of the median income
among people of retirement age and older, 2018 (or nearest year)
%
500
443
391
450
400 Subnational level
320
293
290
290
350
275
243
300
232
206
199
195
194
192
189
188
250
183
173
159
200
124
122
120
118
116
114
150
92
83
100
50
0
Note: Belgium refers to Flanders, Iceland refers to Reykjavik, Canada refers to Ontario, Estonia refers to Tallinn, Austria refers to Vienna, the United
States refers to (a) California and (b) Illinois, Italy refers to South Tyrol, and the United Kingdom refers to England.
Source: OECD Long-Term Care Social Protection questionnaire (2018) and OECD Income Distribution Database (2018).

239
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ISBN 978-92-64-38208-4 – 2019
OECD INDICATORS
Health at a Glance compares key indicators for population health and health system performance across
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ISBN 978-92-64-38208-4 (print)

Photo credits: Cover © kudla/Shutterstock.com; Images - Health status: © Thitiporn taingpan/Shutterstock.com,

Corrigenda to OECD publications may be found on line at: www.oecd.org/about/publishing/corrigenda.htm.

HEALTH AT A GLANCE 2019 © OECD 2019

4 HEALTH AT A GLANCE 2019 © OECD 2019

Chapter 1. Indicator overview: comparative performance of countries and major

Chapter 2. Measuring what matters for people-centred health systems. . . . . . . . . . . . . . . 39

Chapter 3. Health status. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Chapter 4. Risk factors for health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

HEALTH AT A GLANCE 2019 © OECD 2019

Diet and physical activity among adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Chapter 5. Access to care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

Chapter 6. Quality and outcomes of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Chapter 7. Health expenditure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

Chapter 8. Health workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

6 HEALTH AT A GLANCE 2019 © OECD 2019

Nursing graduates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184

Chapter 9. Health care activities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Chapter 10. Pharmaceutical sector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Chapter 11. Ageing and long-term care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

HEALTH AT A GLANCE 2019 © OECD 2019

This book has... StatLinks2

Barriers to access persist, particularly amongst the less well-off

Quality of care is improving in terms of safety and effectiveness, but more

• A deeper understanding of quality of care requires measuring what matters to people.

10 HEALTH AT A GLANCE 2019 © OECD 2019

example, following hip replacement, an individual’s quality of life – in terms of mobility,

HEALTH AT A GLANCE 2019 © OECD 2019

Structure of the publication

HEALTH AT A GLANCE 2019 © OECD 2019

Risk factors for health

Health care system performance

Access Quality Health expenditure and financing

Healthcare resources and activities (dashboard 5) Sub-sector analysis (dashboards 1 & 5)

Demographic, economic & social context

The second chapter provides a special focus on patient-reported outcomes and

14 HEALTH AT A GLANCE 2019 © OECD 2019

HEALTH AT A GLANCE 2019 © OECD 2019

OECD country ISO codes

Australia AUS Korea KOR

16 HEALTH AT A GLANCE 2019 © OECD 2019

Partner country ISO codes

Brazil BRA India IND

HEALTH AT A GLANCE 2019 © OECD 2019

Indicator overview: comparative

Health status Life expectancy – years of life at birth

20 HEALTH AT A GLANCE 2019 © OECD 2019

• Blue, when the country’s performance is close to the OECD average

Lower expenditure Higher expenditure Lower expenditure Higher expenditure

Higher health expenditure → Higher health expenditure →

Lower expenditure Higher expenditure Lower expenditure Higher expenditure

HEALTH AT A GLANCE 2019 © OECD 2019

Methodology, interpretation and use

HEALTH AT A GLANCE 2019 © OECD 2019

Figure 1.2. Snapshot on health status across the OECD

LOW OECD HIGH LARGEST IMPROVEMENT

Chronic disease morbidity Ireland Mexico