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Changes in the Number of Physicians and Hospital Bed Capacity in Europe

Open AccessPublished:September 25, 2022DOI:https://doi.org/10.1016/j.vhri.2022.07.003

      Highlights

      • Although the number of physicians was 33% higher in 1980 in Eastern Europe than in Western Europe, by 2018 the number of physicians was 5% higher in Western Europe.
      • COVID-19 pointed to how important it is to improve hospital bed capacity and to develop human resources.

      Abstract

      Objectives

      Our aim was to examine the numbers of practicing physicians and total numbers of hospital beds in European Organisation for Economic Co-operation and Development countries.

      Methods

      Data analyzed were derived from the “Organisation for Economic Co-operation and Development Health Statistics 2020” database between 1980 and 2018. The selected countries were compared according to the type of healthcare system and geographical location by parametric and nonparametric tests.

      Results

      In 1980, Bismarck-type systems showed an average number of physicians of 2.3 persons/1000 population; in Beveridge-type systems, it was 1.7 persons. By 2018, it leveled out reaching 3.9 persons in both healthcare system types. In 1980, average physician number/1000 was 2.5 persons in Eastern Europe; in Western Europe, it was 1.9 persons. By 2018 this proportion changed with Western Europe having the higher number (3.7 persons; 3.9 persons). In 1980, average number of hospital beds/1000 population was 9.6 in Bismarck-type systems whereas in Beveridge-type systems it was 8.8. By 2018, it decreased to 5.6 in Bismarck-type systems (−42%) and to 3.1 in Beveridge-type systems (−65%). In 1980, the average number of hospital beds/1000 population in Eastern Europe was 10.3; in Western Europe, it was 8.5. By 2018, the difference between the 2 regions did not change.

      Conclusions

      Although the number of physicians was 33% higher in 1980 in Eastern Europe than in Western Europe, by 2018 the number of physicians was 5% higher in Western Europe. In general, regardless of the healthcare system and geographical location, the proportion of physicians per 1000 population has improved due to a larger decrease in the number of hospital beds.

      Keywords

      Introduction

      Global shortages in healthcare workforce have become urgent challenge healthcare systems have to tackle. Several factors contribute to this phenomenon that threatens the sustainability of healthcare systems by shortage of and inequality within health workforce, coupled with demands posed by an aging society in terms of an increasing need for chronic care and burnout experienced by physicians.
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      Our study aimed to examine the numbers of practicing physicians and total numbers of hospital beds in European OECD countries. According to our hypothesis, there are significant differences in the number of physicians and the number of hospital beds related to the healthcare system and geographical location. We also assume that the decrease in the number of hospital beds and the increase in the number of physicians appear as a trend between 1980 and 2018; therefore, the capacity of human resources (physicians) and infrastructure (hospital beds) would increase the resilience of the healthcare system, in case of unexpected emergencies or epidemics.

      Methods

      Our analysis was based on data derived from the “OECD Health Statistics 2020” database
      OECD health statistics 2020. OECD Health Database.
      (data retrieved according to a previous database update as of November 20, 2020) for the period between 1980 and 2018 including the following indicators: “practicing physicians (density per 1000 population [head counts])” and “total hospital beds (per 1000 population).” A total of 24 European OECD countries were selected for analysis.

      Grouping of Countries

      Differences between European OECD countries were examined from 2 different aspects: type of healthcare system and geographical location.
      Regarding the type of healthcare system, we considered 2 basic health insurance system models originating in Europe: we differentiated between countries having Bismarckian-type and Beveridge-type health system. Nevertheless, salient differences between Beveridge and Bismarck systems could be defined; actually both of them are financed out of public budget. Healthcare systems of the selected countries were grouped, as traditionally, according to method of financing when studying the 2 indicators. Thus, Austria, Belgium, the Czech Republic, Estonia, France, Germany, Hungary, Lithuania, Luxembourg, The Netherlands, Poland, Slovakia, Slovenia, and Switzerland belonged to countries having a Bismarckian system, and Denmark, the United Kingdom, Finland, Greece, Ireland, Italy, Norway, Portugal, Spain, and Sweden comprised the group of countries with Beveridge-type healthcare systems. In the present study, we focused specifically on the 2 major healthcare systems given that in most of these countries these systems have been functioning for a longer period of time. During the period under examination (1980-2018), some countries witnessed major changes in their healthcare systems: Greece in 1983 and Spain in 1986 started to change from a Bismarck-type system to a Beveridge-type healthcare. After the regime change, subsequent to the socialist Semashko model, the Czech Republic from 1992, Estonia from 1992, Poland from 1999, Lithuania from 1991, Hungary from 1989, and Slovakia from 1994 introduced a social health insurance system.
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      We distinguished 2 groups from a geographical point of view: Austria, Belgium, Denmark, the United Kingdom, Finland, France, Greece, The Netherlands, Ireland, Germany, Luxembourg, Norway, Italy, Portugal, Spain, Sweden, and Switzerland belonged to the group of Western European countries, and the Czech Republic, Estonia, Lithuania, Poland, Hungary, Slovakia, and Slovenia comprised the group of Eastern European countries.

      Description of OECD Indicators

      In the case of practicing physicians, data retrieved included licensed physicians, interns, and residents working under supervision and salaried or self-employed physicians.
      The indicator of total number of hospital beds includes all beds maintained and provided with healthcare staff for patients referred to healthcare institutions (including general hospitals, mental health hospitals, and other specialized hospitals).

      Statistical Methods

      In our quantitative, retrospective study, we performed descriptive statistics (mean, standard deviation) and comparative database analysis. The type of healthcare system (Bismarckian vs Beveridge) and Eastern versus Western European countries were compared with a special focus on years 1980, 1990, 2000, 2010, and 2018. Normality testing of distribution was done by Shapiro-Wilk test. In the case of a normal distribution, independent t tests were used for the comparison of the years 1980, 1990, 2000, 2010, and 2018 upon analyzing Bismarck- and Beveridge-type countries and Eastern European versus Western European countries. Where nonnormal distribution was found, Mann-Whitney test was used. The grouping by healthcare system and geographical location was also analyzed by cluster analysis. For the period 2010 to 2014 and 2015 to 2018 (sufficient data were available), Classify, TwoStep Cluster Analysis was performed based on the proportion of number of hospital beds and physicians. Using Pearson’s correlation, we analyzed the relationship between the number of hospital beds and physicians in those countries where data were available for both indicators, for the years 1980, 1990, 2000, 2010, and 2018. A 95% confidence interval was considered statistically significant (P < .05). Statistical analysis was performed by using SPSS 25.0 software (IBM SPSS Statistics 25.0 software).

      Results

      Number of Practicing Physicians

      Changes in the number of practicing physicians and the total number of hospital beds between 1980 and 2018 are presented in Table 1.
      Table 1Changes in the number of practicing physicians and total number of hospital beds (1980-2018).
      Indicator19801990200020102018
      Number of countriesAverageSDNumber of countriesAverageSDNumber of countriesAverageSDNumber of countriesAverageSDNumber of countriesAverageSD
      Practicing physicians (density per 1000 population [head counts])
      Bismarckian countries72.30.6372.80.55122.90.57123.30.73113.90.69
      Beveridge countries41.70.2832.10.4472.90.5273.60.5363.90.70
      Eastern European countries42.50.7942.80.5672.90.5763.00.6853.70.58
      Western European countries71.90.3362.40.64123.00.54133.50.62123.90.72
      OECD average--2.10.59--2.60.61--2.90.53--3.40.66--3.90.67
      Total hospital beds (per 1000 population)
      Bismarckian countries59.62.6279.02.57127.31.30146.31.20135.61.22
      Beveridge countries68.83.5276.53.02104.61.28103.70.97103.10.63
      Eastern European countries410.32.46410.02.8467.51.1976.41.0575.91.03
      Western European countries78.53.29106.92.64165.61.83174.71.71163.91.41
      OECD average--9.23.02--7.82.98--6.11.87--5.21.71--4.51.60
      OECD indicates Organisation for Economic Co-operation and Development.
      Between 1980 and 2018, in Bismarck-type countries, the number of practicing physicians per 1000 population increased from 2.3 to 3.9 persons (+67%). Between 1980 and 2018, in Beveridge-type countries, the number of practicing physicians per 1000 population increased from 1.7 to 3.9 persons (+123%).
      We did not find significant changes in the years 1980, 1990, 2000, 2010, and 2018 when comparing Bismarckian- and Beveridge-type countries with each other (P = .089, P = .077, P = .900, P = .254, and P = .969, respectively) (Fig. 1).
      Figure thumbnail gr1
      Figure 1Changes in the number of practicing physicians in Europe (1980-2018).
      With respect to geographical location, between 1980 and 2018, the number of practicing physicians per 1000 population increased from 1.9 to 3.9 persons (+109%) in Western European countries.
      In the group of Eastern European countries, between 1980 and 2018, the number of practicing physicians per 1000 population increased from 2.5 to 3.7 persons (+50%).
      We did not find significant changes in the years 1980, 1990, 2000, 2010, and 2018 when comparing Western and Eastern European countries with each other (P = .131, P = .325, P = .799, P = .140, and P = .632, respectively) (Fig. 1).
      We concluded that, in the OECD countries analyzed, the average number of practicing physicians per 1000 population increased from 2.1 to 3.9 persons (+84%).

      Total Number of Hospital Beds

      Between 1980 and 2018, in Bismarck-type countries, the average total number of hospital beds per 1000 population decreased from 9.6 to 5.6 (−42%). Between 1980 and 2018, in Beveridge-type countries, the average total number of hospital beds per 1000 population decreased from 8.8 to 3.1 (−65%).
      Regarding the years 1980 and 1990, we did not find significant changes upon comparing Bismarckian- and Beveridge-type countries (P = .662 and P = .127, respectively). Nevertheless, the comparison of the years 2000, 2010, and 2018 revealed significant results (P < .001, P < .001, and P < .001, respectively) (Fig. 2).
      Figure thumbnail gr2
      Figure 2Changes in the total number of hospital beds in Europe (1980-2018).
      With respect to geographical location, between 1980 and 2018, the average total number of hospital beds per 1000 population decreased from 8.5 to 3.9 (−54%) in Western European countries.
      Between 1980 and 2018, within the group of Eastern European countries, the average total number of hospital beds per 1000 population decreased from 10.3 to 5.9 (−43%).
      No significant changes were found in the year 1980 (P = .366) and 1990 (P = .071) upon comparing Eastern with Western European countries, nonetheless, selected years of 2000, 2010, and 2018 showed significant results (P = .026, P = .026, and P = .003, respectively) (Fig. 2).
      We concluded that, in the OECD countries analyzed, the average total number of hospital beds per 1000 population decreased from 9.2 to 4.5 (−51%).

      Proportion of the Number of Hospital Beds and Practicing Physicians (2010-2014 and 2015-2018)

      Based on the factor analysis, 2 clusters can be distinguished. In one of them, Western European countries (n = 9) were mostly covered by Beveridge healthcare system (except Switzerland and The Netherlands), where there are more physicians on fewer beds (ratio less than 1): 0.67 to 1.26 between 2010 and 2014 and 0.54 to 1.09 between 2015 and 2018. The other cluster included mostly Eastern European countries (n = 11) (except Austria, Belgium, France, Germany, and Luxembourg) with a predominantly Bismarckian health system (excluding the Czech Republic, Hungary, Lithuania, and Poland), where fewer physicians have access to more beds (ratio more than 1): 1.55 to 2.96 between 2010 and 2014 and 1.37 to 2.78 between 2015 and 2018. In Austria, for example, a remarkably high number of hospital beds is associated with a similarly high number of physicians (7.3; 5.2), whereas in the United Kingdom a relatively low number of hospital beds is associated with a low number of physicians (2.5; 2.8) (Fig. 3).
      Figure thumbnail gr3
      Figure 3Comparison of some countries by practicing physicians and hospital beds per 1000 population (2018).
      AUT indicates Austria; BEL, Belgium; CHE, Switzerland; CZE, Czech Republic; DNK, Denmark; ESP, Spain; EST, Estonia; FRA, France; GBR, United Kingdom; HUN, Hungary; IRL, Ireland; ITA, Italy; LTU, Lithuania; NLD, The Netherlands; NOR, Norway; SVN, Slovenia.
      The factor analysis revealed that the 2 clusters were separated only according to their geographical location, and no significant results were obtained for the healthcare system.
      There was no significant correlation based on the number of physicians and hospital beds in 1980 (r = 0.885; P = .115; n = 4), in 1990 (r = 0.786; P = .115; n = 5), in 2000 (r = 0.283; P = .271; n = 17), in 2010 (r = 0.031; P = .901; n = 19), and in 2018 (r = 0.226; P = .400; n = 16).

      Discussion

      In our study, we examined aspects of human resources in healthcare in 24 European OECD countries through examining numbers of practicing physicians and total numbers of hospital beds.
      In 1980, Bismarckian countries had a higher number of practicing physicians per 1000 population (2.3 persons) than Beveridge-type countries (1.7 persons). This difference was more moderate in 2010; there was a change to the opposite with Beveridge-type countries having a higher number. By 2000 and 2018, the difference between the 2 types of healthcare systems had disappeared completely with both groups of countries having an average of 3.9 to 3.9 physicians per 1000 population in 2018.
      From a geographical perspective, a different picture could be drawn: in 1980, the average number of physicians per 1000 population was higher in Eastern Europe (2.5 persons) than Western Europe (1.9 persons). This difference was more moderate in 2000 and 2018. From 2000 there was a change to the opposite with Western European countries reporting a higher number. Several factors contribute to the migration of physicians from Eastern to Western European countries.
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      Limitations

      With regard to all the indicators we analyzed, the amount and composition of data available for selected years and countries varied. We may have encountered differences with respect to data collection methods, data sources, and definitions applied by the different countries. There might be significant differences in the proportion of long-term care beds among the observed countries; hence, further investigations would be also indicated regarding acute care beds. Healthcare systems are currently undergoing changes. The boundaries between traditional, separate systems have gradually faded away.
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      The research is not intended to describe counterfactual data (eg, change in gross domestic product percentage spending) that would reflect on the performance or effectiveness of healthcare systems.

      Conclusions

      The fact that socialist healthcare systems laid considerable emphasis on human resources management and supply was one of the greatest of their strengths.
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      Our study led to the conclusion that, between 1980 and 2018, European OECD countries experienced an increase in the number of practicing physicians and a reduction in the total number of hospital beds. From the point of view of healthcare, initial differences in the number of practicing physicians leveled out by 2000 and 2018; from a geographical aspect, differences became more moderate. Although Eastern Europe had a 33% higher number of physicians in 1980 than Western Europe, by 2018 this number was 5% higher in Western Europe. Between 1980 and 2018, Beveridge-type systems experienced a higher reduction (−65%) in hospital beds than Bismarckian systems (−42%). Nevertheless, in general, regardless of the healthcare system and geographical location, the proportion of physicians per 1000 people has improved due to a larger decrease in the number of hospital beds.
      During the COVID-19, pandemic decision makers in many countries realized that the hospital structure that had developed during the past decades reached the limit of its capacity. The other cornerstone of the pandemic was the availability of physicians and other healthcare professionals.
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      Article and Author Information

      Author Contributions: Concept and design: Elmer, Endrei, Boncz
      Acquisition of data: Elmer, Németh, Horváth, Pónusz, Kívés, Danku, Csákvári, Ágoston
      Analysis and interpretation of data: Elmer, Endrei, Németh, Horváth, Pónusz, Kívés, Danku, Csákvári, Ágoston, Boncz
      Drafting of the manuscript: Elmer, Endrei, Boncz
      Critical revision of the paper for important intellectual content: Endrei, Ágoston, Boncz
      Statistical analysis: Elmer, Németh, Pónusz, Kívés, Danku, Csákvári
      Obtaining funding: Endrei, Boncz
      Administrative, technical, or logistic support: Horváth
      Supervision: Elmer, Endrei, Kívés, Boncz
      Conflict of Interest Disclosures: The authors reported no conflicts of interest.
      Funding/Support: The research was financed by the Thematic Excellence Program 2021 Health Sub-programme of the Ministry for Innovation and Technology in Hungary, within the framework of the EGA-10 project of the University of Pécs.
      Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

      Acknowledgment

      The authors thank Sára Jeges, PhD, who provided statistical support and contributed to the writing of this article.

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