Differences in health expenditure in 29 European countries

Abstract Introduction Health expenditures are subjected to major pressures due to concurring needs and priorities. There is heterogeneity in countries across common types of health expenditure. This study aims to quantify year-to-year absolute and relative differences as well as relative inequalities in health expenditure across 29 European Economic Area (EEA) countries over a 27-year period, providing a comprehensive perspective on differences among different types of health expenditure and how this has evolved over time. Methods We used data from the Institute for Health Metrics and Evaluation (IHME) Financing Global Health database, covering 1995-2021 for 29 EEA countries, except Liechtenstein. We analyzed total and per capita health expenditure and its components: government health spending, prepaid private health spending, out-of-pocket spending, and development assistance for health. Year-on-year absolute and relative changes were calculated, along with the Gini index to quantify yearly inequality. Results All countries except Greece exhibited an overall increase in two or more types of health expenditure. France had the largest absolute year-to-year increase ($35.1 million (8.6%) between 2020 and 2021), while Spain recorded the largest drop (-$729,831 (5.4%) between 2012 and 2013). The lowest Gini coefficients (<0.4), indicating relatively equal distribution, were found for government and prepaid private health spending (per capita). In contrast, development assistance (both total and per capita) and total prepaid private spending showed the highest inequality (Gini > 0.7). Conclusions Health expenditure in Europe varies widely by country, year, and spending type. High inequality in development assistance and private spending highlights gaps in financing equity. These findings underscore the need for more context-aware strategies to promote fair and sustainable health system financing. Key messages • Health expenditure across European countries varies widely by country, year, and spending type, with some types showing much higher inequality than others. • Government and prepaid private health spending are relatively evenly distributed, while development assistance and private spending are highly unequal between countries.