Density of physicians
The national density of practicing physicians varied across the 15 countries, with a 2.4-fold difference between the country with the highest (Austria, national average 518.3 per 100,000 population in 2017) and lowest physician density (Poland, 241.6, per 100,000) (Fig. 1). The average national physician density across 14 countries (excluding Czech Republic and Sweden as data were only available up to 2013/2016) in 2016 was 361.6 physicians per 100,000 population which is close to the EU28 average of 360.1 in the same year (15, 33).
Comparing physician densities at regional NUTS 2 level showed large imbalances in the distribution of physicians across countries. Rates varied widely across regions, ranging from 152.1 physicians in Romania (South-Muntenia) and 158 physicians in west-central Poland (Wielkopolskie province) to 694.8 physicians in the metropolitan region of Praha (Czech Republic, data refer to 2013) and 685 physicians per 100,000 population in the Vienna region (Austria) (Fig. 1). Overall, there was a 4.5-fold difference between the two regions with the highest and lowest density, more than twice as high compared to national density levels.
Within countries, regional imbalances also existed. The Netherlands and the Czech Republic had the highest within-country differences in terms of physician density (4.5-fold and 2.9-fold, respectively). The lowest geographical imbalances were found for Croatia and Bulgaria. In all countries, except Bulgaria, the highest rates of physicians per population were identified in areas with highest population densities, where capitals or large cities are located. The capital regions of Praha (694.8), Vienna (685) and Bratislava (635.4) showed the highest regional density levels of physicians, followed by Hambourg (622.1 physicians per 100,000 inhabitants (Table 2). By contrast, physician density was lowest in sparsely populated regions in Belgium, Croatia, Denmark, Slovenia or less densely populated areas in Bulgaria, Czech Republic, Germany, Hungary, Netherlands, Austria, Poland, Sweden, Switzerland. However, in three countries the most sparsely populated areas had among the highest national physician rates per capita: Bulgaria (North West, 447.6 physicians), Hungary (Southern Transdanubia 328.2 physicians) and Poland (Podlaskie 274.5 physicians per 100,000 population).
Notes: Data end points refer to the region (NUTS2) with the highest and lowest density of physicians, and national average across all NUTS2 regions. Year: 2017, except for: Czech Republic (2013), Denmark (2016), Hungary (2016), Poland (2016), Sweden (2016). 1 In Belgium, a minimum threshold of activities (500 consultations per year) is set for general practitioners to be considered to be practising, resulting in an under-estimation compared with other countries which do not set such a threshold (OECD 2018, Health at Glance 2018).
Regions with highest/lowest physician densities by country: Austria (Vienna/Burgenland), Switzerland (Zurich/Central Switzerland), Germany (Hambourg/Brandenburg), Bulgaria (North West/North Central), Sweden (Stockholm/North-Central Sweden), Denmark (Capital/North Jutland), Czechia (Praha/Central Bohemia), Netherlands (Utrecht/Flevoland), Slovakia (Bratislava/West Slovakia), Croatia (Continental Croatia/Adriatic Croatia), Hungary (Central Hungary/North Hungary), Slovenia (West Slovenia/East Slovenia), Belgium (Brabant Wallon/Luxembourg), Romania (Bucharest-Ilfov/South-Muntenia), Poland (Łódzkie/Wielkopolskie province).
Sources: EUROSTAT data on physicians by NUTS2 region
Growth of the physician workforce at national and regional level between 2005 and 2017
Analysis of growth rates at regional level showed that physician rates increased in 117 out of 121 regions. Growth rates were highest in regions with low initial physician supply: in Romania (South-West Oltenia CAGR 2008–2017: 4.04%), Denmark (Sjaelland CAGR 2007–2016: 3.37%), Slovenia (Eastern Slovenia CAGR 2008–2017: 3.25%), Hungary (Central Transdanubia CAGR 2005–2017: 3.21%), Croatia (Adriac Croatia CAGR 2010–2017: 2.65%) and Austria (Burgenland CAGR 2005–2017: 2.22%) (Table 2). Yet, four regions in four different countries have seen a decrease of physician densities: Central Bohemia in the Czech Republic (CAGR 2005–2013: -1.05%), Flevoland in the Netherlands (CAGR − 0.59%), Wielkopolskie in Poland (CAGR 2005–2016: -0.91%) and Central Hungary, the region with the capital Budapest (CAGR 2005–2016: -0.49%).
Despite comparatively higher growth rates in several regions with originally low density levels in six countries (as above), within-country differences of physician ratios have widened between 2005 and 2017 in eight countries (Belgium, Croatia, Czech Republic, Netherlands, Germany, Romania, Poland, Slovakia), while differences decreased in seven countries (Austria, Bulgaria, Denmark, Hungary, Slovenia, Sweden, Switzerland). The widening of within-country disparities in some countries was in part due to rapid growth of physician ratios in regions with high initial physician supply, namely in metropolitan regions in the Netherlands, Germany and Slovakia (Utrecht, Hambourg, Bratislava) (Table 2). In Romania, within-country differences have widened despite high growth rates in some regions (with low initial physician density) also due to continuously low physician density in South-Muntenia, the surrounding area of the capital region Bucharest-Ilfov. Also, cross-country differences of physician density rates increased in this period. The difference of physician per population rates between Poland, the country with the lowest physician density both in 2005 and 2017, and Austria, the country with the highest density in 2005 and 2017, increased from 217.9 in 2005 to 276.7 per 100,000 population in 2017.
Similar to the trends at regional level, all countries showed a continuous growth of their physician workforce at national level. The average physician density increased from 314.7 practicing physicians per 100,000 population in 2005 to 370.7 in 2017 (or latest available year), which is an increase of CAGR 1.27%. Growth rates were highest in countries that started with comparably low physician densities, namely in Romania (CAGR 2008–2017: 2.83%), the Netherlands (CAGR 2.18%) and in Slovenia (CAGR 2.17%). In contrast, physician rates only increased marginally in the Czech Republic (CAGR 2005–2013: 0.43%) and in Belgium (CAGR 0.60%) (Table 2).
Density of nurses and midwives
Across the eight countries included in the analysis for nurses and midwives, there were on average 866.1 nurses and midwives per 100,000 population in 2014. The Nordic countries had the highest nurse and midwife rates, about twice as high as the average nurse and midwife density: Denmark showed the highest density with 1,702.5 nurses and midwives, followed by Sweden (1,188.5). Countries with the lowest national densities were Bulgaria (483) and Poland (578.8). Across all countries, the national differences of nurse and midwife densities in Europe were higher than for physicians, varying by a factor of 3.5 between Denmark and Bulgaria (Table 3 and Fig. 2).
Notes: Data end points refer to the region (NUTS2) with the highest and lowest density of nurses and midwives, and national average across all NUTS2 regions, Year 2015, except for: Denmark (2014) and Sweden (2014).
Regions with highest/lowest physician densities by country: Denmark (North Jutland/Capital region), Sweden (Upper Norrland/Stockholm), Slovenia (West Slovenia/East Slovenia), Czechia (Praha/Central Bohemia), Hungary (South Transdanubia/Central Transdanubia), Croatia (Contintental Croatia/Adriatic Croatia), Poland (Lubelskie/Wielkopolskie), Bulgaria (North-West/North-East).
Sources: EUROSTAT 2019 data on nurses and midwives by NUTS2 region
Similar to physicians, there were also large differences of nurse/midwife per population rates across regions, ranging from 1,867.5 nurses and midwives per 100,000 population in Denmark (North Jutland) to 425.7 in Bulgaria (North-East) (Fig. 2), equal to a 4.3-fold difference. Within countries, the largest geographical imbalance of nurses and midwives was reported in the Czech Republic (2.2-fold) (see Fig. 2).
In five of eight countries, the concentration of nurses and midwives was higher in less populated areas while in more densely populated areas densities were lower. In particular, in the Nordic countries, there was a clear inverse relationship of the urban-rural divide that was observed for physicians. In Sweden and Denmark, regions with lowest population densities showed the highest nurse and midwife rates while capital regions with highest population densities had the lowest rates. For example, the most sparsely populated region in northern Sweden (Upper Norrland with 3.4 people per sq km) showed the highest nurse/midwife ratio (1,344.6) while the capital area with highest populated density (Stockholm 339.4 people per sq km) had the lowest nurse densities in 2014 (1,070.7). Also, regions in Bulgaria (North-West), Hungary (South Transdanubia) and Poland (Lubelskie), among the most sparsely populated regions, had highest nurse and midwife density rates. Only in three countries, the Czech Republic, Croatia and Slovenia the density of nurses was similar to those of physicians, with the highest nurse/midwife rates in capital regions. However, the geographical aggregation in Slovenia and Croatia consisted of only two NUTS 2 regions and does not allow for an in-depth distinction between areas (Table 3).
Growth of the nurse and midwife workforce at national and regional level between 2005 and 2015
Over time, density rates among nurses and midwives increased in all eight countries from on average 797.2 nurses and midwives per 100,000 population in 2005 to 866.6 in 2014 (CAGR 2005–2014: 0.84%). The relatively low increase is mainly linked to negative growth of nurse and midwife density rates in the Czech Republic (CAGR 2005–2013: -0.13%) and moderate growth rates in Poland and Sweden. Countries with the strongest increase of nurses and midwives per population are Slovenia (CAGR 2005–2015: 1.52%), Croatia (CAGR 2005–2015: 1.43%) and Denmark (CAGR 2005–2014: 1.52%) (Table 3). Out of the 54 regions included in the analysis, 11 regions reported a negative compound growth rate of nurse and midwives between 2005 and 2015. Five of these regions are in Poland, five in the Czech Republic and one in Hungary. Five of these areas already had among the lowest nurse and midwife density levels in 2005. Similar to physicians, the divergence of national nurse and midwife densities between countries with the highest and lowest densities both in 2005 and 2014 (Bulgaria and Denmark) has become larger, increasing from 1010.5 in 2005 to 1215.5 nurses and midwives per 100,000 population in 2014.