Download Canada, France, Germany, Italy, Japan, Spain, UK, USA

EphMRA Foundation Committee Report – Doctor Statistics in Canada, France, Germany, Italy, Japan, Spain, UK,
USA 2008
From EphMRA
This project fulfils a long standing need of international pharmaceutical researchers for
better access to doctor universe statistics. There has been a high level of interest in this
project and we hope it helps meet your needs.
The brief was to establish Doctor numbers/populations and bring this data together in one
report. This report will help researchers to have greater confidence in the representation
of doctor samples.
The sources of the data are shown and given in as much detail as possible according to
what is available in each country. Of course standardized data is not available across all
countries and so the best available has been included in this report.
This project is an EphMRA funded research project and the project was awarded after a
Request for Proposals on Doctor Statistics was sent out and the resulting proposals
evaluated.
The content of this report is confidential and intended for the sole use of EphMRA
members. We accept no liability for any errors in the report, nor from any use of the
data.
Getting accurate doctor statistics can be notoriously difficult and the figures
included here should be considered as ‘reasonable best estimates’ given the variety of
assumptions underlying the data. Any assumptions made or points of clarification have
been outlined where appropriate in the report. This report reflects the work and views of
the commissioned agency and not EphMRA.
Should you have any questions or comments about this report then please feel free to
contact EphMRA as follows:
Bernadette Rogers
EphMRA General Secretary
[email protected]
www.ephmra.org
Feedback is always welcomed as we use this input to further improve other funded
projects.
2
EphMRA Foundation Committee Report – Doctor Statistics in Canada, France, Germany, Italy, Japan, Spain, UK,
USA 2008
Contents
Pg #
1
Acknowledgements
12
2
Report Author Biographies
13
3
Introduction
14
4
Objectives
15
5
Methodology
16
6
Sources of Information
17
6.1
URLs Consulted
17
6.2
Direct Consultations by e-mail, fax or telephone
20
6.3
Summary of Relevant Facts and Strategies for Updating Data
23
7
How to interpret the Statistical Data
33
8
CANADA
36
8.1
Introduction to Canada
37
8.2
Canada’s healthcare system
39
8.3
Service delivery
43
8.3.1
Public services
43
8.3.2
Primary/ ambulatory care
43
8.4
Secondary/inpatient, specialized ambulatory care and long
term care
Healthcare financing and expenditure
45
8.5
Resources
46
8.6
The Canadian pharmaceuticals market
47
8.7
Bibliography
50
8.3.3
44
Table 1
Total Physicians by Specialty and Gender
51
Table 2
Total Physicians by Specialty and Age
53
Table 3
Results from the National Physician Survey 2004
Questionnaire (work Setting)
55
9
10
FRANCE
56
9.1
Introduction to France
57
9.2
France’s healthcare system
59
9.3
Healthcare insurance
60
9.4
Service delivery
62
9.4.1
Public hospitals
63
9.4.2
Private hospitals
63
9.4.3
Not-for-profit hospitals
64
9.5
Healthcare financing and expenditure
64
9.6
Resources
65
9.7
The French pharmaceuticals market
66
9.8
Bibliography
70
Table 1
Total Physicians by Specialty and Gender
71
Table 2
Total Physicians by Specialty and Age
73
Table 3
Total Physicians by specialty and Major Professional
Activity
75
GERMANY
77
10.1 Introduction to Germany
78
10.2 Germany’s healthcare system
80
10.3 Healthcare insurance
81
10.4 Service delivery
82
10.4.1 Ambulatory care
84
10.4.2 Hospital care
85
10.5 Healthcare financing and expenditure
86
10.6 Resources
87
10.7 The German pharmaceuticals market
89
10.8 Bibliography
93
Table 1
Total Physicians by Specialty and Gender
94
Table 2
Total Physicians by Specialty and Age
96
4
Table 3
11
12
Total Physicians by Specialty and Major Professional
Activity
98
ITALY
100
11.1 Introduction to Italy
101
11.2 Italian healthcare system
103
11.3 Healthcare insurance
104
11.4 Service delivery
104
11.5 Healthcare financing and expenditure
104
11.6 Resources
106
11.7 Italian pharmaceutical market
106
11.8 Bibliography
110
Table 1
111
Total Physicians by Specialty and Gender
JAPAN
113
12.1 Introduction to Japan
114
12.2 Japan’s healthcare system
116
12.3 Public healthcare insurance in Japan
116
12.4 Hospitals remain the first port-of-call
117
12.5 Service delivery
119
12.6 Healthcare financing and expenditure
120
12.7 Resources
121
12.8 Japanese pharmaceutical market
122
12.9 Bibliography
125
Table 1
Total Physicians by Specialty and Gender
126
Table 2
Total Physicians by Specialty and Age
128
5
13
SPAIN
130
13.1 Introduction to Spain
131
13.2 Spanish healthcare system
134
13.3 Healthcare insurance
136
13.4 Service delivery
136
13.5 Healthcare financing and expenditure
137
13.6 Resources
139
13.7 Spanish pharmaceutical market
140
13.8 Bibliography
143
Table 1
Total Physicians by Specialty and Gender
144
Table 2
Total Physicians by Specialty and Age
146
Table 3a
Total Physicians by Gender and Major Professional Activity,
1999
Total Physicians by Age and Major Professional Activity,
1999
148
Table 3b
14
148
UK
149
14.1 Introduction to the UK
150
14.2 The UK healthcare system
151
14.3 Healthcare insurance
153
14.4 Service delivery
154
14.5 Healthcare financing and expenditure
154
14.6 Resources
156
14.7 The UK pharmaceutical market
156
14.8 Bibliography
159
England
160
Table 1
Total Physicians by Specialty and Gender
161
Table 2
Total Physicians by Specialty and Age
164
Table 3
Medical Staff by specialty and Grade
167
6
Northern Ireland
171
Table 1
Total Physicians by Specialty and Gender
172
Table 2
Total Physicians by Specialty and Age
173
Table 3
Medical Staff by Specialty and Grade
174
Scotland
176
Table 1
Total Physicians by Specialty and Gender
177
Table 2
Total Physicians by Specialty and Age
180
Table 3
Medical Staff by Specialty and Grade
183
Wales
15
189
Table 1
Total Physicians by Specialty and Gender
190
Table 2
Total Physicians by Specialty and Age
193
Table 3
Medical Staff by Specialty and Grade
196
UK (Consolidated Data)
199
Table 1
Total Physicians by Specialty and Gender
200
Table 2
Total Physicians by Specialty and Age
202
Table 3
Medical Staff by Specialty and Grade
204
USA
206
15.1 Introduction to the United States of America
207
15.2 The US healthcare system
208
15.3 Healthcare insurance
209
15.4 Service delivery
211
15.5 Healthcare financing and expenditure
213
15.6 Resources
215
15.7 The US pharmaceutical market
216
15.8 Bibliography
220
Table 1
221
Total Physicians by Specialty and Gender
7
Table 2
Total Physicians by Specialty and Age
223
Table 3
Total Physicians by Specialty and Professional Activity
225
Table 4
Total Physicians by Specialty, Age & Gender
234
Table 5
D.O.s by Specialty & Age
236
Table 6
Number of Osteopathic Physicians
238
Table 7
Active D.O.s by gender
238
Table 8
Active D.O.s by age category
238
Table 9
Active (in patient care) D.O.s by self-identified specialty
239
category
Table 10
Physicians by Age & Location
240
Table 11
Total Physicians by professional activity and Location
242
List of Figures
1
2
3
4
5
CANADA
Figure 1: Geopolitical map of Canada
38
Figure 2: Healthcare provision in Canada
43
FRANCE
Figure 3: A geographical map of France
58
Figure 4: The French healthcare system
60
GERMANY
Figure 5: Map of Germany showing states and key cities
79
Figure 6: Structure of the German healthcare system
80
Figure 7: German healthcare insurance coverage by type, 2003
82
Figure 8: A number of governmental bodies, physician and pharmacist
associations, and industry associations impact healthcare provision in
Germany
ITALY
86
Figure 9: Map of Italy showing key cities and regiones
102
Figure 10: Organizational structure of the Italian healthcare system
103
JAPAN
Figure 11: Geographical map of Japan with location and names of
prefectures
Figure 12: Stakeholders impacting healthcare provision in Japan
115
119
8
6
7
8
SPAIN
Figure 13: Map of Spain
132
Figure 14: Demographic distribution of Spain’s population, 2005
133
Figure 15: The Spanish healthcare system
135
Figure 16: Allocation of pharmaceutical R&D funds, 2000
141
UK
Figure 17: Map of the UK
150
Figure 18: Structure of the UK health service
153
USA
Figure 19: USA political map
207
Figure 20: Healthcare structure in the US
209
9
List of Tables
1
2
3
CANADA
Table 1: Population of provinces and territories of Canada, 2002 and 2006
39
Table 2: An overview of services, financing and delivery within the
Canadian healthcare system
Table 3: Canadian healthcare spending statistics, 2003
44
Table 4: Canadian physician and nurse numbers
46
Table 5: Pharmaceutical sales (Ex - mfr; Constant 2005 US$)
47
Table 6: Canadian retail sales by therapeutic category, 2005
48
45
FRANCE
Table 7: French healthcare spending statistics
65
Table 8: French physician and nurse numbers
65
Table 9: French retail sales by therapeutic category, 2005
66
Table 10: Pharmaceutical reforms in France, 2001-2006
68
GERMANY
Table 11: German healthcare spending statistics
87
Table 12: German physician and nurse numbers
88
Table 13: The German Hospital sector – Key figures 1991 and 2004
89
Table 14: Pharmaceutical reforms in Germany, 2000-2006
92
10
4
5
6
7
8
ITALY
Table 15: Italian healthcare spending statistics
105
Table 16: Italian physician and nurse numbers
106
Table 17: Italian retail sales by therapeutic category, 2005
107
Table 18: Pharmaceutical reforms in Italy, 2001-2006
108
JAPAN
Table 19: Key Japanese health expenditure indicators, 2004
120
Table 20: Physicians and Nurses
121
Table 21: The number of hospitals, GP clinics, dental clinics, plus beds, in
Japan in 2001
Table 22: Japanese pharmaceutical sales by therapeutic category, 2005
122
123
SPAIN
Table 23: Spanish healthcare spending statistics
138
Table 24: Spanish physician and nurse numbers
139
UK
Table 25: Key health expenditure indicators
155
Table 26: UK physicians and nurses, 2005
156
Table 27: UK retail sales by therapeutic category, 2005
157
Table 28: Evolution of generic / brand share of market value in the UK,
2000-2004
USA
158
Table 29: Leading Types of Private Insurance in the US
210
Table 30: Source of Health Coverage
211
Table 31: Access to healthcare providers according to different health
plans
Table 32: Key US health expenditure indicators, 2005
213
Table 33: Sources of US health spending, 2004
214
Table 34: Destination of Health Spending, 2004
215
Table 35: Physicians and Nurses
216
Table 36: Generic and branded trends in the US, 2004-2005
217
Table 37: US retail sales by therapeutic category, 2005
218
214
11
1. Acknowledgements
We would like to thank the following people for their help and time given to this project.
Without their assistance this report could not have been completed successfully:
o Holly Bodger (Electronic Publishing Manager, Canadian Medical Association,
Canada)
o Dr. ssa Anna Rita Mascolini (Federazione Nazionale degli Ordini dei, Italy)
o Dr. Massimo Fabri (FIMMG Nazionale, Italy)
o Ms.Tanabe (Ministry of Health Labour and Welfare, Japan)
o Dr Miguel Angel García Pérez (Fundación CESM, Spain)
o Naomi Sang (The Information Centre for health and social care, UK)
o Jacqueline Liddicoat (Department of Health, Social Services and Public Safety,
Northern Ireland)
o Celina Davis (Healthcare Information Group, Scotland)
o Vivien Trew (Health Statistics and Analysis Unit, Wales)
Whilst every effort has been made to keep errors to a minimum, we recognize that minor
faults can occur. Please contact us via EphMRA if you spot any mistakes and
inaccuracies within this report. This report reflects the views and research of the
commissioned team, the Datamonitor Healthcare Consulting Team, rather than EphMRA.
12
2. Report Author Biographies
The team from Datamonitor Healthcare Consulting comprised of four key members
headed up by Dr Duncan Emerton, Managing Consultant within the group. Assistance
was provided by Venkateshwara Rao Gunnam (Senior Consultant), Aparna Anantharaju,
(Associate Consultant), and Shilpa Didla (Associate Consultant).
Dr Duncan Emerton, Managing Consultant (Project Director)
Dr Emerton joined Datamonitor in December 2004 from Pfizer Global Pharmaceuticals
(UK) Ltd. During his tenure at Pfizer his primary focus was on Pfizer’s endocrinology
portfolio where he was involved in clinical development, sales and marketing activities.
Prior to joining Pfizer, Dr Emerton worked in a variety of roles within pre-clinical and
clinical drug development, during which he gained experience in the implementation and
management of Phase I–IV clinical trials for several pharmaceutical and biotechnology
companies—including
Sanofi-Synthélabo,
Merck
&
Co,
Pharmacia,
ExonHit
Therapeutics SA and Cytos Biotechnology AG—mainly in the areas of cardiology,
neurology and vaccines. Since joining Datamonitor, Dr Emerton has worked on company
analysis, therapy area analysis focused on the cardiovascular market and is currently
involved in projects focusing on new product market assessments, providing market
forecasting support, assessing the impact of generics on branded pharma companies and
supporting licensing deals for EU pharma companies. Dr Emerton holds a PhD in
Microbial Biotechnology from the University of Kent and a BSc (Hons) in Medical
Biochemistry from the University of Surrey. Dr Emerton can be reached at
[email protected] or +44 (0) 20 7675 7000.
13
3. Introduction
Following the completion of the Doctor Universe Statistics Report in 2003, the EphMRA
Foundation Committee looked to update and expand its research to include new
countries/regions and specialties. Subsequently, EphMRA initiated an update of the 2003
Doctor Universe Statistics Report to ensure data is as up to date as possible. Datamonitor
Healthcare Consulting submitted a proposal to update the report, which was accepted by
EphMRA.
The structure of this report will be as follows:
o Objectives
o Research methodology
o Main findings of the research of each country/region broken down into qualitative
and quantitative reports
14
4. Objectives
The objectives of this research were as follows:
o The primary objective of this project is to update the physicians statistics in the
original report (published in 2003) and where possible augment the study with
additional data describing the physician landscape in each of USA, Japan,
France, Germany, Italy, Spain, UK and Canada.
o Establish mechanisms for the periodical update of this information.
o Create a list of the sources used and contacted for update of this report and create
a database.
o New for 2007/8: provide a comprehensive qualitative section for each country
explaining: the healthcare system, payment and reimbursement, how healthcare is
delivered – e.g. the role of community vs. hospital HCPs, pharmacists and dentists
(also includes nurses), urban vs. rural distribution, explanations about specialty
nomenclature and categorization
15
5. Methodology
The study consists of three parts:
PART I
o Using information sources identified in 2003 report identify directly published
updates of statistics from relevant country authorities.
PART II
o Supplement the sources (identified in 2003 report) with additional country
specific sources by a thorough secondary research program.
o Where gaps in the data are still present contact relevant health authorities directly
in each country to assess potential current or future availability of data.
PART III
o In this part of the project, the physician’s statistical data were analyzed and
tabulated. The data is tabulated in the Microsoft Excel program for each of the
countries covered for easy usage and is also compiled in Microsoft Word as a
report.
16
6. Sources of Information
6.1. URLs consulted
The URLs (websites) that were consulted by country were as follows:
CANADA
Canadian Medical Association
http://www.cma.ca/index.cfm/ci_id/16959/la_id/1.htm#1
Canadian Institute for Health Information
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=statistics_results
_topic_physicians_e
National Physician Survey
http://www.nationalphysiciansurvey.ca/nps/results/physicians-e.asp
FRANCE
The French Medical Council (Le Conseil National De l’Ordre des
Medecins: Exercise Professionnel).
http://www.conseilnational.medecin.fr/?url=demographie/index.php&open=3#3
GERMANY
The German Medical Association
http://www.bundesaerztekammer.de/page.asp?his=0.3.5008
ITALY
Italian Medical Association
http://fnomceo.it/Servizi/STATISTICA%20LUGLIO%202005/sta%2
07_2005.htm
Italian General Practitioners / Family Doctor Association
http://www.fimmg.org/
17
JAPAN
Statistics Bureau Director General for Policy Planning (Statistical
Standards) & Statistical Research and Training Institute
http://www.stat.go.jp/data/nenkan/zuhyou/y2122000.xls
SPAIN
Ministry of Health and Consumption
http://www.msc.es/novedades/docs/necesidadesEspeciales06_30.pdf
UK
England
The Information Centre, National Health Service
http://www.ic.nhs.uk/statistics-and-data-collections/workforce/nhsstaff-numbers/nhs-hospital-and-community-staff-hchs-2006
Northern Ireland
Department of Health, Social Service and Public Safety
http://www.dhsspsni.gov.uk/index/stats_research/work_force/statsresearch.htm#wfcurpubs
Scotland
Information Services Division, NHS National Services Scotland
http://www.isdscotland.org/isd/workforcestatistics.jsp?pContentID=1348&p_applic=CCC&p_service=Content.
show&
Wales
The National Assembly for Wales
http://www.statswales.wales.gov.uk/ReportFolders/reportfolders.aspx
?IF_ActivePath=P,280,1274
18
USA
American Medical Association: Physician Statistics
http://www.aoa-net.org/
American Osteopathic Association
http://www.osteopathic.org/index.cfm?PageID=aoa_annualrprt
19
6.2. Direct consultations by e-mail, fax or telephone.
CANADA
Direct Contact
Holly Bodger
Electronic Publishing Manager,
Canadian Medical Association
1867 Alta Vista Drive
Ottawa, Ontario
K1G 3Y6
Tel: 613-731-8610 x 2281
Fax: 613-565-7704
E-mail: [email protected]
ITALY
Direct Contact
Dr. ssa Anna Rita Mascolini
Manager of the international department
FNOMCeO
Federazione Nazionale degli Ordini dei
Piazza Cola di Rienzo 80/A
80/A - 00192 Roma.
Tel: 06362031
E-mail: [email protected]
Direct Contact
Dr. Massimo Fabri
Centro Studi FIMMG Nazionale
FIMMG Nazionale
(Italian General Practitioners / Family Doctor Association)
Piazza G. Marconi, 25
00144 Roma.
Tel: 0654896625
E-mail: [email protected]
JAPAN
Direct Contact
Ms.Tanabe,
Statistics and Information Department,
Ministry of Health Labour and Welfare,
Japan
Tel:03-5253-1111/03-3595-2958
E-mail id: [email protected]
20
SPAIN
Direct Contact
Dr Miguel Angel García Pérez
Fundación CESM
c/ Veneras 9-4º
28013 Madrid
Tel: +34 91 559 14 02
E- mail id: [email protected]
UK
England
Direct Contact
Naomi Sang
Workforce Information Officer,
The Information Centre for health and social care,
1 Trevelyan Square, Boar Lane,
Leeds, LS1 6AE.
Tel:0113 2547270
E-mail id: [email protected]
Northern Ireland
Direct Contact
Jacqueline Liddicoat
Workforce Statistics
Department of Health, Social Services and Public Safety,
Northern Ireland Government
Tel: 028 9052 2509
E-mail id: [email protected]
[email protected]
21
Scotland
Direct Contact
Celina Davis
Costs & Workforce Team
Healthcare Information Group
ISD Scotland
Gyle Square, 1 South Gyle Crescent
Edinburgh, EH12 9EB
Tel: 0131 275 6199
E-mail id: [email protected]
Wales
Direct Contact
Vivien Trew
Health Statistics and Analysis Unit
Welsh Assembly Government
Tel: (029) 2082 5080
f: (029) 2082 5350
E-mail id: [email protected]
USA
Physician Characteristics and Distribution in the US
2007 Edition
Author: AMA
Bibliographic Data
ISBN: 978-1-57947-782-0, 400 pages, soft cover.
Mail Orders
Order Department
American Medical Association
PO Box 930876
Atlanta, GA 31193-0876 Call Toll Free
Tel:800 621-8335
Fax: 312 464-5600
Secure Online Orders
www.amabookstore.com
22
6.3. Summary of relevant facts and strategies for updating data
CANADA
Relevant facts
o Statistics related to the physician numbers by specialty &
gender and specialty & age group in Canada are available from
Canadian Medical Association (CMA).
o Statistics related to the Physician numbers by nature of work
setting are available from National Physician Survey, carried
out by the College of Family Physicians of Canada (CFPC), the
Canadian Medical Association (CMA) and the Royal College of
Physicians and Surgeons of Canada (RCPSC) and the Canadian
Institute for Health Information and Health Canada.
Strategies for updating data
o Physician statistics by specialty & gender and specialty & age
group are updated regularly by the Canadian Medical
Association (CMA). So the best strategy is to check the URL
(website) address of CMA.
o Physician statistics by professional activity is collated from the
National Physician Survey. The survey is carried out once in
every 3 years. The survey for 2007 was completed in November
2007.
23
FRANCE
Relevant facts
o Physician statistics in France are available from The French
Medical Council (Ordre National des Medecins; Conseil
National de l'Ordre) by specialty & gender, specialty & age
group and by specialty & professional activity.
Strategies for updating data
o The data is updated by "The French Medical Council (Ordre
National des Medecins; Conseil National de l' Ordre)" annually.
So it is recommended to check the URL (website) address of
this association.
24
GERMANY
Relevant facts
o Physician statistics in Germany are available from "The
German Medical Council (Bundesarztekammer)" by specialty
& gender, specialty & age group and by specialty &
professional activity.
Strategies for updating data
o The frequency of data update by "The German Medical
Council (Bundesarztekammer)" is annually. So it is
recommended to check the URL (website) address of this
association.
25
ITALY
Relevant facts
o Only statistics sorted by specialty and age could be obtained in
Italy.
o Italian physician statistics sorted by specialty & gender are
available from FNOMCeO (Federazione Nazionale degli Ordini
dei - Italian Medical Council).
o GP statistics sorted by specialty and age are provided by
FIMMG Nazionale (Italian General Practitioners / Family
Doctor Association).
Strategies for updating data
o The frequency of data update by "The Italian Medical Council
(FNOMCEO)" is not clearly known. 2005 physician statistics
are available on the FNOMCEO website; however,
supplemental but un-published statistics were provided by the
Italian Medical Council when contacted directly.
o The best strategy for regular updates therefore is to be contact
FNOMCEO for the latest available statistics.
o GP statistics are updated by FIMMG Nazionale (Italian General
Practitioners / Family Doctor Association) annually and data
can be obtained by contacting the association.
26
JAPAN
Relevant facts
o Physician statistics in Japan are available from "Data based on
the survey of Physicians, Dentists and Pharmacists". This is
collated by Statistics and Information Department, Minister's
Secretariat, Ministry of Health, Labour and Welfare (MHLW).
o The data can be obtained directly from the Statistics and
Information Department of MHLW.
o The data is available by main field of specialty, gender and age
group.
o General practitioners/ Family Doctors in Japan work as GPs
with an additional specialty.
o In Japan, cancer is treated by individual specialists based on the
location of tumor.
Strategies for updating data
o The frequency of data update by the Statistics and Information
Department, Ministry of Health, Labour and Welfare is not
known. There is no update/ survey undertaken since 2004.
o The best strategy is to get into direct contact with the Statistics
and Information Department, Ministry of Health, Labor and
Welfare and request for the latest version of "Survey of
Physicians, Dentists and Pharmacists". The survey results are
available in Japanese language and need to be translated into
English.
27
SPAIN
Relevant facts
o CESM Foundation (Confederacion Espanola de Sindicatos
Medicos) provides the number of physicians by specialty and
gender.
o The 2005 data for the current report has been obtained by
contacting the CESM. The data was taken from a report
published by the Ministry of Health and Consumption, Spain,
that has been compiled from multiple sources: regional health
service workforces, hospital statistics, etc.
o The data for the number of physicians by professional activity
have not been updated by the CESM since the survey from
which the numbers were obtained in the older report (2003),
has not been conducted again.
Strategies for updating data
o For any updates regarding the physicians, it is recommended
to approach the CESM and the Ministry of Health and
Consumption, in order to find out the latest dates of data
updating.
28
UK
Relevant facts
England
o The Physician numbers by specialty & Gender, specialty & age
and specialty & professional activity can be obtained from The
Information Centre, Medical and Dental Workforce Census,
National Health Service (NHS).
Northern Ireland
o Statistics related to the physician numbers by specialty in
Northern Ireland has to be directly requested from the
Workforce Statistics, Department of Health, Social Services and
Public Safety.
o Statistics related to the General Practitioners in Northern Ireland
is available from Medical Directorate, Central Services Agency.
Scotland
o Statistics related to the physician numbers by specialty &
gender, specialty & age and specialty & professional activity
can be sourced from Information and Statistics Division,
National Health Service, Scotland.
Wales
o Statistics related to the physician numbers in Wales is available
from The National Assembly for Wales.
29
UK
Strategies for updating data
England
o Physician statistics by specialty & gender and specialty &
professional activity are updated annually by The Information
Centre, Medical and Dental Workforce Census, National Health
Service (NHS) and can be accessed by checking the URL
(website) address.
o Physician statistics by specialty and age has to be requested
directly from The Information Centre, Medical and Dental
Workforce Census, National Health Service (NHS) and is not
available at the URL (website) address.
Northern Ireland
o In some of the specialties, there are very limited numbers of
physicians in Northern Ireland. Hence, to avoid the issue of
'Disclosure of personal information', the data is not published by
the Workforce Statistics, Department of Health, Social Services
and Public Safety.
o However, on contacting the authorities, the information related
to 'specialty and gender' can be obtained from the Workforce
Statistics division, Department of Health, Social Services and
Public Safety.
o Statistics related to the General Practitioners can be sourced
from the URL (website) address.
30
UK
Strategies for updating data
Scotland
o Physician statistics by specialty & gender, specialty & age
group and specialty & professional activity is published
annually by the Information and Statistics Division, National
Health Service, Scotland. This data can be accessed by checking
the URL (website) address.
Wales
o Physician statistics by specialty & gender, specialty & age
group and specialty and professional activity are updated
annually by the National Assembly for Wales in its Statistics for
Wale’s database.
o However, the data for this report has been obtained by
contacting the Health Statistics and Analysis Unit as the latest
data available on their website is for the year 2005.
31
USA
Relevant facts
o The data for the number of Physicians by specialty, gender, age,
major professional activity is published by the American
Medical Association.
o The data for the current report has been obtained from the AMA
publication titled, "Physician Characteristics and Distribution in
the US, 2007 Edition". This Edition contains the data for the
year 2005.
o The updated version of this purchased report, with the data for
2006, will be available by the month of December, 2007.
o The Osteopathic physician numbers can be obtained from the
American Osteopathic Association Website.
Strategies for updating data
o "Physician Characteristics and Distribution in the US" is a
statistical report on the US physicians that is published every
year, by the American Medical Association.
o To update the data, this report can be purchased from the AMA,
the purchase details can be found on the Associations Website.
o The Osteopathic Physician numbers are updated and published
annually, by the American Osteopathic Association on their
Website
32
7. How to interpret the statistical data
GENERAL CRITERIA
o The physician statistics in each of the countries covered in the project scope was
categorized into three tables:
•
•
•
Table No.1 Physicians by specialty and gender
Table No.2 Physicians by specialty and age
Table No.3 Physicians by specialty and main professional activity
o Table No.1 includes the physician statistics, by specialty, distribution by gender
and the proportion of each gender by specialty.
o Table No.2 includes the physician statistics by specialty, and their distribution
into the following age groups: under 35, from 35 to 44, from 45 to 54, from 55 to
64 and 65 and over.
o As there is a wide variation in the availability of the specialist data by main
professional activity, there is a variation in the data included in Table 3 across the
countries and is described in special situations section.
o The statistics are presented by covering in detail the various specialties. The
specialties break up in each country is as per the official data availability in the
respective countries.
o All the data in the various tables correspond to the ‘Active Physicians’ –
practicing physicians. Statistics in France and United States includes data other
than the active physicians like unemployed physicians, retired physicians or
physicians exercising a professional activity other than patient care.
o In each of the tables, the total number of physicians is presented in the beginning
and in bold, for a fast reference of the total number of physicians.
o To facilitate data comprehension, the specialties were organized into alphabetical
order, using the same terminology.
o At the end of each table can be found the specialties and sub specialties included
in a more general or well known specialty, and the source of the data.
33
SPECIFIC SITUATIONS
o Italy includes only Table No.1 (specialties per gender).
o Japan does not include Table No. 3 (specialties per activity).
o The age group distribution in Table No.2 is different in the following countries as
the official data is available only in those age groups:
•
In Germany, the German Medical Association provides the data in with
the age distribution into the following age groups: under 34, from 35 to
39, from 40 to 49, from 50-59, from 60 to 53 and from 66 and over.
•
In Spain, the CESM Foundation (Confederacion Nacional de Sindicatos
Medicos) uses age distribution into the following age groups: under 36,
from 36 to 45, from 46 to 55, from 56 to 65 and 65 and over.
o In accordance with the official data availability in each of the countries covered,
Table No. 3 has the following characteristics:
•
The statistics in Germany, France and United States are presented by
specialty and by the activity as given below:
§
§
§
•
Office based
Hospital based
Other (different from patient care)
In Canada the data coverage is based on the Physician Resource
Questionnaire survey results. The data distribution covers the physician’s
preferences for various types of practice settings.
34
•
Since 1999, there was no survey being undertaken in Spain for the
statistics related to the professional activity of the physicians. As per the
study in the year 1999, data was grouped according to gender and age, in
terms of:
§
§
§
§
•
Activity in the private sector
Activity in the public sector (public sector GPs, specialist
physician public sector, other activities public sector)
MIR (Physicians in training)
No professional practice
In UK the data is distributed according to the form or grade in which the
activities in the Hospitals of the Public Health System are organized
hierarchically, functionally and employment-wise by specialty. The main
grades are as follows:
§
§
§
§
§
§
§
Consultant (including Director of Public Health)
Staff Grade
Associate Specialists
Registrar Group / Specialist Registrar
Senior House Officers / Foundation Year 2
House Officers / Foundation Year 1
Hospital Practitioner / Clinical Assistant
o In Spain & Northern Ireland, as the physician statistics by specialty and age
groups / grades were not available, estimated data was presented. The assumption
was the break up (proportion) of the specialists into various age groups/ grades to
the total number of physicians in each specialty is similar to that of in the earlier
published report in the year 2003. The statistics by specialty and distribution by
gender is available in these countries.
o In Northern Ireland, the data is not available owing to the issue of personal
information disclosure.
35
8. Canada
36
8.1. Introduction to Canada
Canada is a country occupying most of northern North America, and is the world's
second-largest country by total area, extending from the Atlantic Ocean to the Pacific
Ocean and northward into the Arctic Ocean. Canada shares land borders with the United
States to the north-west and south. Inhabited first by aboriginal peoples, Canada was
founded in 1867 as a union of British colonies (some of which were formerly French
colonies). It gained independence from the United Kingdom in an incremental process
that ended in 1982. It remains a Commonwealth Realm with Queen Elizabeth II as its
Head of State.
Canada is a federal constitutional monarchy with parliamentary democracy. Comprising
10 provinces and three territories (Figure 1), it is a bilingual and multicultural country,
with both English and French as official languages at the federal level. A technologically
advanced and industrialized nation, Canada maintains a diversified economy that is
heavily reliant upon its abundant natural resources and upon trade—particularly with the
US, with which Canada has had a long and complex relationship.
37
Figure 1:
Geopolitical map of Canada
Source: www.wikipedia.org
DATAMONITOR
The provinces are responsible for most of Canada's social programs (such as health care,
education, and welfare) and together collect more revenue than the federal government,
an almost unique structure among federations in the world. Using its spending powers,
the federal government can initiate national policies in provincial areas, such as the
Canada Health Act; the provinces can opt out of these, but rarely do so in practice.
Equalization payments are made by the federal government to ensure that reasonably
uniform standards of services and taxation are kept between the richer and poorer
provinces. All provinces have unicameral, elected legislatures headed by a Premier
selected in the same way as the Prime Minister of Canada. Each province also has a
Lieutenant-Governor representing the Queen, analogous to the Governor General of
38
Canada, appointed on the recommendation of the Prime Minister of Canada, though with
increasing levels of consultation with provincial governments in recent years.
At the end of 2006, Canada’s population was approximately 32.6 million, 85% of whom
were residents of only four provinces—Ontario, Quebec, British Columbia and Alberta.
Between 2002 and 2006, Canada’s population remained relatively stable, growing by less
than 1% from 31.4 million in 2002 to 32.6 million in 2006 (Statistics Canada,
www.statcan.ca; accessed May 2007).
Table 1:
Population of provinces and territories of Canada, 2002 and 2006
Province
Population
2002
Population
2006
Growth
2002-06
(%)
Ontario
Quebec
British Columbia
Alberta
Manitoba
Saskatchewan
Nova Scotia
New Brunswick
Newfoundland and Labrador
Prince Edward Island
Northwest Territories
Yukon Territory
Nunavut
12,102,000
7,445,700
4,115,400
3,116,300
1,155,600
995,900
934,500
750,300
519,400
136,900
41,500
30,100
28,700
12,687,000
7,651,500
4,310,500
3,375,800
1,177,800
985,400
934,400
749,200
509,700
138,500
41,900
31,200
30,800
0.95
0.55
0.93
1.61
0.38
-0.21
0.00
-0.03
-0.38
0.23
0.19
0.72
1.42
Total
31,372,300
32,623,700
0.79
Source: www.statcan.ca
DATAMONITOR
8.2. Canada’s healthcare system
Canada's healthcare system has been a work in progress since its inception. Reforms have
been made over the past four decades and will continue in response to changes within
medicine and throughout society. The basics, however, remain the same - universal
coverage for medically necessary healthcare services provided on the basis of need, rather
than the ability to pay.
39
Canada's national health insurance program, often referred to as ’Medicare‘, is designed
to ensure that all residents have reasonable access to medically necessary hospital and
physician services, on a prepaid basis. Instead of having a single national plan, it has a
national program that is composed of 13 interlocking provincial and territorial health
insurance plans, all of which share certain common features and basic standards of
coverage. Framed by the Canada Health Act (CHA), the principles governing the
healthcare system are symbols of the underlying Canadian values of equity and solidarity.
Roles and responsibilities for Canada's healthcare system are shared between the federal
and provincial-territorial governments. Under the Canada Health Act, the federal health
insurance legislation, criteria and conditions are specified that must be satisfied by the
provincial and territorial healthcare insurance plans in order for them to qualify for their
full share of the federal cash contribution, available under the Canada Health Transfer
(CHT). Provincial and territorial governments are responsible for the management,
organization and delivery of health services for their residents.
Primary healthcare is the foundation of the Canadian healthcare system, and is the first
point of contact people have with the healthcare system. This could be through a doctor, a
nurse, another health professional, or perhaps through phone or computer-based services.
Primary healthcare involves providing services, through teams of health professionals, to
individuals, families and communities. It also incorporates a proactive approach to
preventing health problems and ensuring better management and follow-up once a health
problem has occurred. These services are publicly funded from general tax revenues
without direct charges to the patient.
A patient may be referred for specialized care at a hospital or long-term care facility or in
the community. The majority of Canadian hospitals are operated by community boards of
trustees, voluntary organizations or municipalities. For the most part, healthcare services
provided in long-term institutions are paid for by the provincial and territorial
governments, while room and board are paid for by the individual; in some cases these
payments are subsidized by the provincial and territorial governments.
40
Alternatively, healthcare services may be provided in the home and/or community.
Referrals to home care can be made by doctors, hospitals, community agencies, families
and potential residents. These services, such as specialized nursing care, homemaker
services and adult day care, are provided to people who are partially or totally
incapacitated. Needs are assessed, and services are coordinated to provide continuity of
care and comprehensive care.
The provinces and territories also provide coverage to certain groups of people (e.g.,
seniors, children and social assistance recipients) for health services that are not generally
covered under the publicly funded healthcare system. These supplementary health
benefits often include prescription drugs, dental care, vision care, medical equipment and
appliances (prostheses, wheelchairs, etc.), independent living and the services of allied
health professionals, such as podiatrists and chiropractors. The level of coverage varies
across the country. Many Canadians have supplemental private insurance coverage
through group plans, which covers the cost of these supplementary services.
Canada has a predominantly publicly financed health system with services provided
through private (for-profit and not-for-profit) and public (arm’s-length or state-run)
bodies. There are 13 single-payer, universal systems for “medically necessary” services –
largely hospital and physician services which are “insured services” under the federal
Canada Health Act. The 13 provinces and territories vary considerably in terms of the
financing, administration, delivery modes and range of public health care services. The
federal government is responsible for collecting and providing health data, research and
regulatory infrastructure, in addition to directly financing and administering a number of
health services for selected population groups.
Under the Canada Health Act, all residents of a province are eligible to receive “insured
services” free at the point of delivery. These “insured services” under the Act include
virtually all hospital, physician (including some dental surgery) and diagnostic services.
Services excluded from this package include most dental care, most vision care, longterm care, home care, and pharmaceuticals prescribed outside of hospitals. According to
41
the Health systems in Transition (HiT) report, 33.8% of all prescription drugs, 21.7% of
all vision care and 53.6% of all dental care are funded through private health insurance
(HiT Summary, World Health Organisation, 2005). Provinces vary in the extent to which
non-Canada Health Act insured services are covered or subsidized in the provincial
health plans. Out-of-pocket payments constitute the most important source of financing
for private health goods and services, like vision care, over-the-counter medication, and
complementary and alternative medicines and therapies. About 20% of prescription drugs
are financed through out-of-pocket payments.
The third largest source of health care financing is complementary private health
insurance. The majority of private health insurance is employment-based insurance and
designed to provide coverage for health goods and services not covered by Medicare
(Canada's national health insurance program). Although largely employment-based and
paid for by employees and employers (and in few cases purchased solely by individuals,
e.g. the self-employed), private health insurance is supported through tax expenditure
subsidies. Private health insurance that attempts to provide a private alternative to
medically necessary hospital and physician services is prohibited by a range of provincial
regulations. Figure 2 gives an overview of the healthcare provision in Canada.
42
Figure 2:
Healthcare provision in Canada
Source: Health systems in transition, 2005
DATAMONITOR
8.3. Service delivery
8.3.1. Public services
The federal, provincial and territorial governments, as well as regional health authorities,
perform discrete functions like population health assessment, disease and injury control
and emergency preparedness. In addition, the Canadian Public Health Association is a
voluntary organization dedicated to improving the state of public health in Canada.
8.3.2. Primary/ ambulatory care
Family physicians, serve as the patient’s first point of contact; they are gate-keepers to
higher levels of the health system. Patients are free to choose a family physician who
typically works independently on a fee-for-service basis. Increased focus on primary care
has been associated with some jurisdictions replacing fee-for-service remuneration with
alternative payment contracts for physicians, improving access to essential services, and
43
accelerating the development of telehealth applications in rural and remote areas of the
country.
8.3.3. Secondary/inpatient, specialized ambulatory care and long term
care
All secondary, tertiary and emergency care, as well as the majority of specialized
ambulatory care and elective surgery, is performed within hospitals. Hospitals specialize
in acute and emergency care, while primary care is left to family physicians or
community-based facilities, and long-term care to nursing homes and similar institutions,
which are either run by the regional health authorities, or are independent private-forprofit or not-for profit organizations. Table 2 gives an overview of financing and delivery
of the main healthcare services in Canada.
Table 2:
An overview of services, financing and delivery within the Canadian healthcare
system
Service
Hospitals
Physicians
Dentists and Optometrists
Prescription Drugs
Non-Prescription Drugs
Source: internal secondary research
Financing
Delivery
100% publicly funded for
medically necessary services,
Mix of public and
private payment for upgraded private hospitals, but all
are non-profit and are
accommodations or services not
deemed medically necessary
highly regulated.
100% publicly funded for Physicians are in private
medically necessary services;
practice and paid by
private payment services not Medicare on a fee-fordeemed medically necessary.
service basis
Mostly private although some
provinces provide public funding
for children and the elderly
Private
Mix of public and private
(supplemental insurance + out of
pocket) payment with 60/40
emphasis on private payment.
(Applies to retail channel/Products
consumed in hospitals are paid
publicly.) With the exception of
British Columbia.
Private
Private (Out-of-Pocket)
Private
DATAMONITOR
44
8.4. Healthcare financing and expenditure
Within the publicly funded healthcare system, health expenditures vary across the
provinces and territories. This is, in part, due to differences in the services that each
province and territory specifies to be medically necessary and to demographic factors
such as a population's age. Other factors, for example, areas where there are small and/or
scattered populations, may also have an impact on healthcare costs. Table 3 illustrates
WHO statistics derived from the World Health Statistics 2006 and The World Health
Report, 2006 Edition.
Table 3:
Canadian healthcare spending statistics, 2003
Value
2003
Indicator
Total expenditure on health as percentage of gross domestic product
General government expenditure on health as percentage of total expenditure on
health
Private expenditure on health as percentage of total expenditure on health
General government expenditure on health as percentage of total government
expenditure
External resources for health as percentage of total expenditure on health
Social security expenditure on health as percentage of general government
expenditure on health
Out-of-pocket expenditure as percentage of private expenditure on health
Private prepaid plans as percentage of private expenditure on health
Per capita total expenditure on health at average exchange rate
Per capita total expenditure on health at international dollar rate
Per capita government expenditure on health at average exchange rate
Per capita government expenditure on health at international dollar rate
9.9%
69.9%
30.1%
16.7%
0.0%
2.1%
49.6%
42.3%
US$2,669
US$2,989
US$1,866
US$2,090
Source: WHO sources World Health Statistics 2006 and The World Health Report,
DATAMONITOR
2006 Edition
According to the Canadian Institute for Health Information, total health expenditure in
Canada was $131.4 billion in 2004, with this number expected to grow to $139.8 billion
in 2005 and $148.0 billion in 2006, a year-on-year increase of 6.4% and 5.9%,
respectively. Health expenditure in 2004 continued the trend of relatively strong growth
that has been seen since 1997, following 6 years when annual growth rates averaged
0.8% in real terms. The modest rates of growth during the early to mid-1990s reflected a
45
flattening of the historic growth curve. From 1975 to 1991 the annual average rate of
growth was 3.8%. The trend since 1997 appears to be largely due to reinvestment by
federal, provincial and territorial governments after a period of fiscal restraint during the
early and mid-1990s (Canadian Institute for Health Information. National Health
Expenditure Trends, 1975–2005).
8.5. Resources
Despite the high level of health expenditure in Canada, there are few physicians per
capita. In 2005, Canada had only 2.2 practicing physicians per 1,000 population and 10
qualified nurses per 1,000 population. The number of nurses per capita has started to rise
since 2002. Table 4 gives the absolute number and density of physicians and nurses in the
recent years.
Table 4:
Canadian physician and nurse numbers
Resource indicator
Physicians (number)
Physicians (density per 1,000 population)
Nurses (number)
Nurses (density per 1,000 population)
Source: OECD Healthcare Statistics, various years are indicated
Value (year)
66, 583 (2003)
2.2(2005)
309, 576 (2003)
10.0 (2005)
DATAMONITOR
The number of acute care hospital beds in Canada was 2.9 per 1, 000 population in 2004
(OECD Health data, 2007). There has been a decline in the number of hospitals in the
recent years. There was a 20% drop in the total number of hospitals offering inpatient
care from the mid-1980s to the mid- 1990s and hospital admissions declined by 12.8%
from 1995 to 2001. However, on the whole, average length of stay actually increased by
1.4%, with considerable variation across provinces. For a complete review of the most up
to date physician statistics, please refer to the Canadian physician statistics section of this
report.
46
8.6. The Canadian pharmaceuticals market
There is increasing demand for new pharmaceuticals in Canada due to the ageing
population and high per-capita consumption. But extremely long approval times,
mandatory low prices, spotty patent protection and complex regulations, which vary from
province to province are some negative factors of the Canadian market.
The Canadian pharmaceutical market amounted $13.68 billion in 2005 (internal
secondary research; see bibliography for details), translating to spending of $429 per
person. The Canadian pharmaceutical industry employs about 22,000 people. Branded
products accounted for 57% of prescriptions and 82% of sales in 2005. In the retail
channel, generics accounted for 43% of prescription volume and 18% of value in 2005.
Generics are not subject to price controls and are 78% higher, on average than in the US.
Generic substitution is allowed by law.
As indicated in table 4, retail pharmacies, which accounted for 88.4% of total sales, grew
more slowly (6.4%) than hospitals (14.5%) in the 2004-2005 period. The relatively high
levels of hospital growth can be attributed to increased use of expensive
biopharmaceuticals and oncology therapies. Retail performance was slowed because of
patents expirations; a lack of major launches; cost containment measures etc. At end-user
prices, OTC sales accounted for 16.8% of sales (internal secondary research; see
bibliography for details).
Table 5:
Pharmaceutical sales (Ex - mfr; Constant 2005 US$)
Year
Retail
Sales
$m
2004
2005
11,364
12,090
Source: internal secondary research
Growth
Retail as %
of total
Hospital
Sales
$m
9.7%
6.4%
89.2%
88.4%
1,386
1,585
Growth
Total
Sales
$m
Growth
8.3%
14.5%
12,742
13,675
9.6%
7.3%
DATAMONITOR
47
The following table shows retail sales by therapeutic category in 2005. Almost 45% of
retail sales were made by cardiovascular and central nervous system therapeutic
categories.
Table 6:
Canadian retail sales by therapeutic category, 2005
Category
Cardiovascular
Central Nervous System
Alimentary/ Met
Respiratory
Anti-Infectives
Musculoskeletal
Genitourinary
Cytostatics
Blood Agents
Dermatologicals
Sensory Organs
Diagnostic Agents
Systemic Hormones
Miscellaneous
Hospital Solutions
Parasitology
Total
Source: internal secondary research
$m
% Change
3,017
2,367
1,721
878
619
683
582
638
345
405
217
274
99
122
3
25
8%
7%
5%
9%
7%
-10%
5%
13%
14%
6%
9%
10%
9%
9%
-13%
13%
11,995
8%
DATAMONITOR
R&D spending in Canada has declined in recent years, with total R&D spending falling
by 2% year-on-year since 2003. Of this R&D spending, investment in industry-sponsored
clinical trials $419/person in 2004 (Calon, 2006). Additionally, Canada is a major source
of grey market drugs coming into the United States. The combination of internet
technology and mail order pharmacies greatly increased the prevalence of the practice.
However, due to increased focus on drug safety, patent expiration on a number of leading
drugs, strengthening of the Canadian versus the US dollar and restricted availability of
supplies, cross-border trade declined from $491 million in 2004 to $351 million in 2005
(internal secondary research; see bibliography for details). Canada maintains a high level
of population health and has undergone a series of reforms. Some challenges like the
48
ageing population, increasing health care expenditure, particularly for pharmaceuticals,
lengthy waiting times, and shortages of human resources, need to be addressed.
49
8.7. Bibliography
o Calon, F. (2006). Non-patentable drugs and the cost of our ignorance. CMAJ. 174
(4).
o World Health Organization (2005) Health systems in transition 2005 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies. Available from:
http://www.euro.who.int/Document/E87954.pdf> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=can&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=can&indicators=healthpersonnel> [Accessed October 2007].
o OECD data (2007) OECD Health data 2007 [Internet].
Available from:
<http://www.oecd.org/dataoecd/46/33/38979719.pdf> [Accessed October 2007].
o VOI Consulting (2006) PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
50
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL
MALE
%
FEMALE
%
TOTAL PHYSICIANS
63,819
43,062
67
20,757
33
FAMILY PHYSICIANS
32,784
20,688
63
12,096
37
Family Medicine
15,832
8,447
53
7,385
47
General Practice
16,952
12,241
72
4,711
28
MEDICAL SPECIALISTS
22,742
15,629
69
7,113
31
Clinical Specialists
21,275
14,674
69
6,601
31
2,628
1,947
74
681
26
Community Medicine
419
253
60
166
40
Dermatology
526
323
61
203
39
Diagnostic Radiology
2,087
1,562
75
525
25
Emergency Medicine
541
439
81
102
19
6,922
5,080
73
1,842
27
1,025
871
85
154
15
Clinical Immunology/Allergy
141
102
72
39
28
Endocrinology/Metabolism
380
202
53
178
47
Anesthesiology
Internal Medicine
Cardiology
Gastroenterology
511
408
80
103
20
2,440
1,918
79
522
21
Geriatric Medicine
211
105
50
106
50
Hematology
297
187
63
110
37
Infectious Diseases
200
118
59
82
41
Medical Oncology
364
226
62
138
38
Nephrology
464
316
68
148
32
Respiratory Medicine
568
437
77
131
23
Rheumatology
321
190
59
131
41
48
General Internal Medicine
Medical Genetics
66
34
52
32
Neurology
743
577
78
166
22
Nuclear Medicine
233
191
82
42
18
49
37
76
12
24
Occupational Medicine
51
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
Pediatrics
Physical Medicine / Rehabilitation
Psychiatry
Radiation Oncology
TOTAL
MALE
%
FEMALE
%
2,209
1,147
52
1,062
48
369
258
70
111
30
4,131
2,576
62
1,555
38
352
250
71
102
29
1,467
955
65
512
35
Anatomical Pathology
747
449
60
298
40
General / Clinical Pathology
290
220
76
70
24
Laboratory Specialists
Hematological Pathology
62
39
63
23
37
Medical Biochemistry
89
69
78
20
22
243
149
61
94
39
36
29
81
7
19
8,260
6,713
81
1,547
19
320
294
92
26
8
1,879
1,586
84
293
16
260
242
93
18
7
Obstetrics / Gynecology
1,694
979
58
715
42
Ophthalmology
1,114
902
81
212
19
Orthopedic Surgery
1,270
1,180
93
90
7
Otolaryngology
634
538
85
96
15
Plastic Surgery
493
428
87
65
13
Urology
596
564
95
32
5
33
32
97
1
3
Microbiology & Infectious Diseases
Neuropathology
Surgical Specialists
Cardiovascular / Thoracic Surgery
General Surgery
Neurosurgery
Medical Scientists
Source: CMA (2007) Number and percent distribution of physicians by specialty and sex, Canada 2007 [internet], CMA. Available from:
<http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Statistics/06SpecSex.pdf> [Accessed September 2007]
52
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006
Table No 2. Total Physicians by Specialty and Age
TOTAL PHYSICIANS
63,819
4,210
16,334
19,813
14,654
7,688
UNKNOWN
AGE
1,120
FAMILY PHYSICIANS
32,784
2,412
8,470
10,593
7,636
3,041
632
Family Medicine
15,832
1,995
6,227
4,796
2,328
463
23
General Practice
16,952
417
2,243
5,797
5,308
2,578
609
MEDICAL SPECIALISTS
22,742
1,346
5,643
6,962
5,249
3,180
362
Clinical Specialists
21,275
1,313
5,365
6,416
4,881
2,960
340
2,628
167
670
937
548
265
41
419
17
78
149
131
41
3
526
15
117
154
144
89
7
2,087
121
541
584
450
351
40
SPECIALTY
Anesthesiology
Community Medicine
Dermatology
Diagnostic Radiology
Emergency Medicine
Internal Medicine
Cardiology
TOTAL
UNDER 35
35-44
45-54
55-64
65 AND OVER
541
51
187
177
108
11
7
6,922
559
1,960
1,901
1,485
886
131
1,025
44
310
329
247
83
12
2
Clinical immunology / Allergy
141
10
48
30
37
14
Endocrinology / Metabolism
380
35
122
109
64
41
9
Gastroenterology
511
52
144
146
111
48
10
2,440
215
557
473
578
558
59
General Internal Medicine
Geriatric Medicine
211
8
72
89
33
8
1
Hematology
297
22
80
107
56
23
9
Infectious Diseases
200
16
77
68
32
2
5
Medical Oncology
364
25
124
113
69
29
4
Nephrology
464
68
181
123
51
33
8
Respiratory Medicine
568
43
156
203
128
30
8
Rheumatology
321
21
89
111
79
17
4
66
4
18
17
17
8
2
Neurology
743
38
192
212
164
133
4
Nuclear Medicine
233
10
55
92
45
30
1
49
0
10
10
27
1
1
Medical Genetics
Occupational Medicine
53
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
Pediatrics
Physical Medicine / Rehabilitation
Psychiatry
Radiation Oncology
Laboratory Specialists
TOTAL
UNDER 35
35-44
45-54
55-64
65 AND OVER
313
UNKNOWN
AGE
36
2,209
154
541
641
524
369
19
99
114
85
47
5
4,131
137
790
1,304
1,093
759
48
352
21
107
124
60
26
14
1,467
33
278
546
368
220
22
Anatomical Pathology
747
17
153
296
191
76
14
General / Clinical Pathology
290
4
49
89
63
84
1
62
3
10
19
20
8
2
Hematological Pathology
Medical Biochemistry
89
1
11
31
29
15
2
243
8
48
97
56
32
2
36
0
7
14
9
5
1
8,260
452
2,221
2,258
1,760
1,443
126
320
11
93
87
78
47
4
1,879
108
504
472
381
386
28
260
11
84
62
54
43
6
Obstetrics/Gynecology
1,694
106
456
475
383
261
13
Ophthalmology
1,114
47
246
347
257
201
16
Orthopedic Surgery
Microbiology & Infectious Diseases
Neuropathology
Surgical Specialists
Cardiovascular / Thoracic Surgery
General Surgery
Neurosurgery
1,270
69
364
352
257
197
31
Otolaryngology
634
42
168
156
126
130
12
Plastic Surgery
493
28
123
159
107
70
6
Urology
596
30
183
148
117
108
10
33
0
0
0
9
24
0
Medical Scientists
Source: CMA (2007) Number of physicians by specialty and age, Canada, 2007 [internet], CMA. Available from: <http://www.cma.ca/multimedia/CMA/Content_Images/Inside_cma/Statistics/02SpecAge.pdf> [Accessed
September 2007]
54
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN CANADA 2006
Table No 3. Results from the National Physician Survey 2004 Questionnaire (work Setting)
GP/FP OR SPECIALIST
SEX
PHYSICIAN WORK
SPECIAL
NOT
SETTING
GP/FP
MALE
FEMALE
ISTS
STATED
Number of respondents
11,041
10,255
13,454
6,885
957
Private office/clinic (excluding
70.40%
50.10%
62.30%
59.00%
49.50%
free standing walk-in clinics)
Community clinic / Community
13.70%
6.40%
8.00%
14.60%
8.70%
health centre
Free-standing walk-in clinic
14.40%
1.20%
8.00%
8.60%
4.90%
12.40%
9.60%
7.70%
6.50%
6.10%
5.40%
8.10%
Academic health sciences centre
11.20%
46.00%
27.90%
26.80%
37.30%
23.80%
28.70%
29.80%
27.70%
19.70%
37.30%
28.00%
Community hospital
Emergency department
(community hospital or
academic health sciences)
Nursing home/Home for the
aged
Administrative office
39.30%
45.10%
44.40%
38.10%
39.70%
51.60%
46.20%
42.30%
38.40%
31.50%
40.20%
42.10%
23.50%
10.60%
18.40%
15.30%
16.70%
37.30%
23.00%
15.60%
10.50%
4.90%
17.70%
17.30%
24.60%
2.20%
15.00%
12.20%
9.00%
13.80%
13.20%
15.10%
14.90%
11.10%
9.50%
13.80%
6.70%
6.30%
7.20%
5.00%
7.60%
2.20%
4.90%
8.70%
7.60%
4.50%
7.80%
6.50%
1.70%
5.60%
4.20%
2.40%
3.80%
1.90%
4.40%
4.10%
3.30%
2.00%
4.10%
3.60%
0.50%
2.80%
1.90%
1.10%
1.90%
0.80%
1.30%
1.80%
1.80%
2.30%
2.00%
1.60%
11.30%
5.80%
7.80%
10.40%
7.80%
6.30%
8.70%
10.30%
7.80%
7.40%
7.80%
8.60%
0.80%
0.60%
0.70%
0.50%
2.50%
0.50%
0.50%
0.60%
0.80%
1.40%
0.70%
0.70%
Research unit
Free-standing
laboratory/Diagnostic clinic
Other
No response
AGE GROUP
ALL
PHYSICI
ANS
21,296
1,829
5,294
6,622
4,461
2,066
NOT
KNOWN
1,024
58.00%
56.50%
62.20%
65.10%
64.10%
50.90%
60.70%
16.00%
11.70%
10.50%
7.40%
6.50%
8.90%
10.20%
<35
35-44
45-54
55-64
65+
Note: Column totals exceed 100% as this question allowed for multiple responses.
Source: National Physician Survey (2006) Q1 National Data Work settings by FP/Specialist, Sex, and Age Group [internet], National Physician Survey. Available from: <http://www.nationalphysiciansurvey.ca/nps/results/PDFe/FP/Tables/National/Q01.pdf> [Accessed September 2007]
55
9. France
56
9.1. Introduction to France
France is divided into 26 administrative regions. 22 are in metropolitan France (21 are on
the continental part of metropolitan France; one is the territorial collectivity of Corsica),
and four are overseas regions. The regions are further subdivided into 100 departments
which are numbered (mainly alphabetically). This number is used in postal codes and
vehicle number plates amongst others. Four of these departments are found in the
overseas regions and are simultaneously overseas regions and overseas departments and
are an integral part of France (and the European Union) and thus enjoy a status similar to
metropolitan departments.
The 100 departments are subdivided into 341 arrondissements which are, in turn,
subdivided into 4,032 cantons. These cantons are then divided into 36,680 communes,
which are municipalities with an elected municipal council. There also exist 2,588
intercommunal entities grouping 33,414 of the 36,680 communes (i.e. 91.1% of all the
communes). Three communes, Paris, Lyon and Marseille are also subdivided into 45
municipal arrondissements (Figure 3).
57
Figure 3:
A geographical map of France
Source: www.wikipedia.org
DATAMONITOR
The regions, departments and communes are all known as territorial collectivities,
meaning they possess local assemblies as well as an executive. Arrondissements and
cantons are merely administrative divisions. However, this was not always the case. Until
1940, the arrondissements were also territorial collectivities with an elected assembly, but
these were suspended by the Vichy regime and definitely abolished by the Fourth
Republic in 1946. Historically, the cantons were also territorial collectivities with their
elected assemblies.
58
In addition to the 26 regions and 100 departments, the French Republic also has six
overseas collectivities, one sui generis collectivity (New Caledonia), and one overseas
territory. Overseas collectivities and territories form part of the French Republic, but do
not form part of the European Union or its fiscal area. The Pacific territories continue to
use the Pacific franc whose value is linked to that of the euro. In contrast, the four
overseas regions used the French franc and now use the euro.
9.2. France’s healthcare system
The health care system is regulated by two main players; the state – the National
Assembly, the government and ministries – and the statutory health insurance funds. The
local communities play a relatively lesser role in regulating the system.
At the national level, the National Assembly has sought to improve the system with
annual Acts on Social Security Funding since 1996. It set the national ceiling for health
insurance spending. Recent changes have included improving insurance benefits for selfemployed people, setting up funds for the modernization of hospitals and developing
pharmaceutical information. Directorates in the Ministry of Health responsible for health
policy, hospital and health care, social security and financial matters and social policy.
The state exercises its trusteeship through central, regional and departmental services.
There are two large organizations that work under the Ministry of Health: General Health
Management and Hospital and Healthcare Management.
Under the direction of these two large organizations are numerous health care facilities
and agencies. The Ministry also has directorates of health and social affairs at the local
regional levels, such as the regional hospital agencies, the regional unions of the health
insurance funds and the regional unions of self-employed doctors. Figure 4 gives an
overview of the healthcare system in France.
59
Figure 4:
The French healthcare system
Source: internal secondary research
DATAMONITOR
9.3. Healthcare insurance
The French population is almost universally covered (99% of the population) by statutory
health insurance (Assurance-Maladie), a branch of the social security system (Sécurité
Sociale). The national health insurance agency is the Caisse National d’Assurance
Maladie (National Fund for Sickness Insurance). Affiliation to Assurance-Maladie is by
means of different schemes, determined by the individual’s social and/or professional
category. The main scheme, the Régime Général, covers employees and pensioners from
trade and industry sectors, as well as their families and thus, accounts for approximately
80% of the French population. In addition, more than 80% of French people have
supplemental insurance with private insurers (Mutuelles) often provided by their
employers, which usually covers the cost of healthcare not otherwise covered by social
security insurance, such as the proportion of the cost of prescribed products normally
paid by the patient. According to figures from the OECD, private insurance accounted for
12.7% of total health expenditure in France in 2001.
60
Within the statutory health insurance system, patients have a free choice of general
practitioner and pharmacist, free access to specialists, and also a free choice amongst
public and private (approved) hospitals should they require hospitalization. There was in
the past no obligation on patients to present first to their GP in order to gain access to
specialists, unlike in the UK for example, and therefore GPs sometimes did not know
which drugs a specialist had prescribed, and vice versa, leaving the way open to drug
interactions. It was relatively common for “doctor-hopping” to occur, thus making it
difficult for doctors to have access to a patient’s complete medical history.
An agreement aimed at addressing this problem was finalized in 1998, after lengthy
negotiations, between the French general practitioners union, MG France, and the
national drug insurance agency, Caisse National d’Assurance Maladie (CNAM). This
agreement is based on the concept of the “gatekeeper GP” (médecin référent). Under this
scheme, patients can volunteer to register and stay with one GP, receiving in return
benefits such as dispensation from prior payment of the doctor’s fee. They also undertake
to consult the GP first rather than go directly to a specialist, other than in exceptional
circumstances, and if they do see a specialist they undertake to ensure that the médecin
référent is kept informed. In order to encourage GPs to participate in this scheme they are
offered a yearly allowance of $70 (€45.73) per registered patient. Participating doctors
agree to prescribe a certain percentage of generic products and they receive certain
“prescription supports”, involving the use of databases, particularly of pharmaceutical
products, prescribing guidelines and medico-economic information. It should be
emphasized, however, that participation in this médecin référent scheme is not obligatory
for either doctors or patients, and thus the problems of incomplete medical records and
“doctor-hopping” still continue.
61
9.4. Service delivery
Self-employed doctors, dentists and medical auxiliaries managed by local authorities and,
to a lesser extent, salaried staff in hospitals deliver primary and secondary health care. In
general, patients pay the provider and are subsequently reimbursed by their health
insurance fund. There is no gate keeping and patients have free choice of doctor.
In total, there are 3,171 healthcare establishments which offer 4,857,698 hospital beds for
long-term care and 45,727 beds for short-term care (Embassy of France in the United
States, http://www.info-france-usa.org/atoz/health.asp). Of the total number of hospitals
in France, 25% are public hospitals, 33% are private non-profit hospitals and 40% are
private for-profit hospitals (HiT summary, 2004).
Within the public hospital system, there are four levels: general, providing acute, followup, rehabilitation and long-term care; regional, providing more highly specialized care
and teaching facilities; local, providing health and social care functions; and psychiatric.
Public and private hospitals provide different types of services. While the private sector is
focused on minor surgical procedures, the public and not-for-profit sector focuses more
on emergency admissions, rehabilitation, long-term care and psychiatric treatment. Day
surgery and “hospitalization at home” are being considered as alternative options.
According to the World Health Organization Regional Office for Europe, 1032 hospitals
(with 315,687 beds) which include regional, university, local and general hospitals fall
under the public hospital statute in 2006. Public hospitals include a diverse group of
institutions. For example, the Public Assistance Hospital of Paris employs over 80, 000
people while the smallest local hospital employs less than 300. Public hospitals constitute
65% of all inpatient beds in France (WHO regional office for Europe, 2004).
According to the World Health Organization Regional Office for Europe, there were
2139 private for profit and private not-for-profit healthcare facilities (with 170,382 beds)
in 2006. Private clinics were started by surgeons and obstetricians and eventually evolved
62
into private hospitals. Private for-profit hospitals constitute 20% of all inpatient beds in
France (WHO regional office for Europe, 2004). Not-for-profit private hospitals were
originally denominational and currently make up 14% of the inpatient services among
French Medical Care Institutions. They are financed through endowments like public
hospitals, but have the right to privacy like private clinics. About 15% of all inpatient
beds are provided by private not-for-profit hospitals (WHO regional office for Europe,
2004). The cooperation between the public and private sector in France produces a
healthcare system that is open to all, allows citizens to avoid waiting lists for surgeries,
and provides the latest in medical technology and treatment.
9.4.1. Public hospitals
Hospitals that fall under the public hospital statutes include regional, university, local and
general hospitals. Public hospitals are sometimes organized into groups, for example
those of the Assistance publique–Hôpitaux de Paris (Public Assistance Hospitals of
Paris), which employs over 80,000 people, while in comparison some small local
hospitals employ fewer than 300. Public hospitals provide approximately two-thirds of
the total number of hospital beds in France. In common with many countries, the trend is
towards a decrease in the number and duration of long-stay beds and an increase in the
number and duration of short-stay beds.
9.4.2. Private hospitals
Private hospitals were founded by surgeons and obstetricians, and originally each doctor
had absolute independence. However, a 1991 law now requires all doctors in private
clinics to share medical files with their colleagues, to create a Medical Care Commission
and to develop quality evaluation procedures. The use of private hospitals is relatively
common in France compared to the rest of Europe, and private hospitals often treat
patients referred from the public sector, which means that waiting lists are virtually
unknown in both the public and private sectors. Private hospitals are particularly active in
certain areas, treating more than 50% of surgical cases and 60% of cancer cases.
63
9.4.3. Not-for-profit hospitals
Not-for-profit establishments were originally denominational and currently make up
some 14% of the in-patient service amongst French medical care institutions. Healthcare
provision at the community level includes the following:
o office-based physicians (GPs or specialists);
o pharmacists;
o dentists;
o community nurses;
o ambulance services.
9.5. Healthcare financing and expenditure
The total expenditure on health care was 10.5% of gross domestic product (GDP) in
2004. In the same year, the total expenditure on health per capita was estimated at $3,
040. In 2004, 46.5% of the total health expenditure was spent on inpatient care, 26.1% on
outpatient care and 20.5% on drugs (HiT summary, 2004). Public expenditure constituted
78.4% of total health expenditure in 2004 while the private share amounted to 21.6%.
Out-of-pocket payments and supplementary private health insurance are both prevalent,
largely due to the number of services not covered by statutory health insurance and the
expense of co-payments. The following table (Table 7) shows the key health expenditure
indicators in 2004.
64
Table 7:
French healthcare spending statistics
Value
Indicator
Total expenditure on health as percentage of GDP
Public expenditure on health as percentage of total expenditure on health
Private expenditure on health as percentage of total expenditure on health
Out-of-pocket expenditure as percentage of private expenditure on health
Private prepaid plans as percentage of private expenditure on health
Per capita total expenditure on health
Source: WHO sources World Health Statistics
10.5% (2004)
78.4% (2004)
21.6% (2004)
34.9% (2004)
57.3% (2004)
$3,040 (2004)
DATAMONITOR
9.6. Resources
There are approximately 1.6 million health care professionals in France, accounting for
6.2% of the working population. In 2005, there were 4 physicians and 7 nurses per 1,000
population (OECD Health data, 2007). The distribution of doctors shows geographical
disparities with more number of doctors in Paris and the south of France. The number of
acute care hospital beds in France was 3.7 per 1,000 population in 2005 (OECD Health
data, 2007). The following table gives the absolute number and density of physicians and
nurses in the recent years (Table 8).
Table 8:
French physician and nurse numbers
Resource indicator
Physicians (number)
Physicians (density per 1,000 population)
Nurses (number)
Nurses (density per 1,000 population)
Source: OECD Healthcare Statistics, 2007
Value (year)
203,487 (2004)
4 (2005)
437,525 (2004)
7 (2005)
DATAMONITOR
For a complete review of the most up to date physician statistics, please refer to the
French physician statistics section of this report.
65
9.7. The French pharmaceuticals market
The French pharmaceutical market totaled €21.9 billion ($27.2 billion) in 2005. This
represented a 5% increase in local currency terms. Per person consumption was €348
($454; internal secondary research). France is the second largest market in Europe (after
Germany) and the fourth largest in the world (after the US, Japan and Germany). In
France, 90% of physician visits include a prescription (compares with 83% in Spain, 72%
in Germany and 43% in the Netherlands). All but 6% of sales take place within the
reimbursement system - either in hospitals (19% of total market) or in pharmacies (75%
of total market; France: Healthcare and pharmaceuticals background, 2006). OTC
products (some of which are reimbursed) accounted for €1.6 billion in 2005, a decline of
3% over 2004 (Pharma Market Letter, March 2006). Within the prescription drug market,
generics have 8% of sales, off-patents brands have 17% and patented products have 75%
(Pharma Market Letter, February 2006). Table 9 shows retail sales for the leading
therapeutic categories.
Table 9:
French retail sales by therapeutic category, 2005
Category
Cardiovascular
Central Nervous Sys
Alimentary & Metabolism
Respiratory
Anti- Infectives
Musculoskeletal
Genitourinary
Cytostatics
Blood Agents
Dermatologicals
Sensory Organs
Diagnostic Agents
Systemic Hormones
Miscellaneous
Hospital Solutions
Parasitology
Total
Source: internal secondary research
Sales 2005 $m
% change
5,104
3,562
3,079
1,911
1,962
1,221
1,189
1,284
1,045
619
475
376
397
102
34
48
4%
3%
0%
5%
9%
-1%
1%
19%
31%
3%
8%
8%
9%
3%
16%
8%
22,408
11%
DATAMONITOR
66
The majority of sales take place within the reimbursement system - either in hospitals
(19% of total market) or in pharmacies (75% of total market). OTC products (some of
which are reimbursed) accounted for $2.38 billion in 2005. Within the prescription drug
market, generics make up 8% of sales, off-patents brands have 17% and patented
products have 75%.
Of the three largest EU markets (France, Germany, UK), France has the least industryfavorable system. Prices are kept at very low levels, the launch of innovative products is
delayed by lengthy negotiations, the government forces substantial annual rebates from
manufacturers and promotional activities are taxed rather than counted as a business
expense. As shown in the table below, the government has launched a number of cost
control initiatives that work to the disadvantage of the research-based industry. The
following table (Table 10) shows the pharmaceutical reforms in 2005 and 2006.
67
Table 10:
Pharmaceutical reforms in France, 2001-2006
Year
Measure
2001
• Tax on promotional activities exceeding 14% of sales increased to 31% from
21%.
• 15% price cut on innovative drugs.
• 148 vasodilators removed from reimbursement lists
• Physicians agree that 25% of prescriptions will be written generically, and that
they will encourage patients to accept generic substitution.
Public awareness campaign launched to promote generic use.
• Announcement of 617 products of “insufficient” effectiveness to be moved from
65% to 35% reimbursement. Will be phased in from 2003-05.
• 82 products removed from reimbursement lists entirely.
• Partial reference pricing system (TFR - tariff forfaitaire de responsabilité)
introduced for categories with generic options. Patients must pay difference
between generic reimbursement rate and branded price.
• Tax raised on pharmaceutical promotional activity.
• 426 products to be removed from reimbursement lists entirely.
• Target growth rate for drug reimbursement set at 3% (down from 4% in 2003).
• Reimbursement on 29 vasodilators reduced to 35% from 65%.
• Changes brought on by the Healthcare Reform:
o Additional contribution equaling 0.6% of sales.
o A 10% reduction in the price of existing generics.
o Newly launched generics priced at 40% to 50% of original brand rather than
the previous 28%.
o Possibility of increased control over marketing (details have not been
worked out at this writing).
• Extension of the reference price groups (the TFRs - “Tarifs forfaitaires de
responsabilite”) by which off-patent brands are reimbursed at the price of
generics.
o TFR changes resulted in 30% average reduction on 18 product groups
• Cuts will be effective June 1, 2005
• 15% price cut on products with generic equivalents.
• Removed 152 products of dubious efficacy from reimbursement lists (another
round to follow).
• Turnover tax increased to 1.76% in 2006 from 0.6% (medical devices included
for first time).
• Continuation of mandatory rebates for spending over the budgeted amount.
• New tax on clinical research.
• Incremental tax on products receiving marketing authorizations from 2005 to
2008.
• Pharmacists to exercise rights of substitution on 70% of generic-eligible
prescriptions
2002
2003
2004
2005
2006
Source: Datamonitor research
DATAMONITOR
68
The general system for obtaining drugs involved the patient paying for the drug, being
reimbursed by their health insurance fund and complementary VHI. Recently, the third
party payment system has become more common, involving direct payment to the
pharmacist by the health insurance fund. This system of payment applies to about two
thirds of drug purchases. About 60% of the total expenditure on drugs, covering both
prescribed drugs and products purchased over the counter, is publicly funded; the
remainder is financed, in equal proportion (18.5%), by private households and
complementary VHI.
The pharmacy reimbursement system for multi-source categories (i.e. where a generic
option is available) was changed to provide 2.5% margin on branded products and 10%
on generics. In March 2006, the substitution rate (i.e. the percentage of generic-eligible
prescriptions to be filled with generics) was 66.4% up from 61.6% in December 2005.
The average price for a generic prescription in 2005 was $4.78, which is 35% lower than
the European average of $7.3. Financial sustainability, the ageing population, increasing
health care expenditure, the need for rationing and a decreasing supply of doctors are
some challenges that need to be addressed.
69
9.8. Bibliography
o World Health Organization (2004) Health systems in transition 2004 [Internet],
WHO Regional Office for Europe on behalf of the European Observatory on
Health Systems and Policies. Available from:
<http://www.euro.who.int/document/e83126.pdf> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=fra&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=fra&indicators=healthpersonnel> [Accessed October 2007].
o OECD data (2007) OECD Health data 2007 [Internet].
Available from: <
http://www.oecd.org/dataoecd/45/20/38980771.pdf> [Accessed October 2007].
o VOI Consulting (2006) PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o Embassy of France in the United States (2005) [Internet], Available from:
<http://www.info-france-usa.org/atoz/health.asp> [Accessed October 2007].
o Datamonitor (2004), Exploiting technology opportunities in European healthcare,
2004, DMTC1017.
70
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL PHYSICIANS
TOTAL
MALE
%
FEMALE
%
198,215
122,557
62
75,658
38
Anatomy and Cytopathology
1,463
578
40
885
60
Anesthesiology
9,577
6,266
65
3,311
35
Cardiology
5,952
4,879
82
1,073
18
Child and Adolescent Psychiatry
1,232
597
48
635
52
Dermatology and Venereology
3,821
1,401
37
2,420
63
642
570
89
72
11
Endocrinology and Metabolism
1,483
447
30
1,036
70
Gastroenterology
3,266
2,515
77
751
23
General Medicine1
96,717
59,765
145
36,952
55
3,699
3,398
92
301
8
341
158
46
183
54
Gynecology and Obstetrics (Surgery)
3,120
2,145
69
975
31
Gynecology and Obstetrics2
2,119
2,099
2,112
2,118
2,182
Digestive Surgery
General Surgery
Geriatrics
Hematological Oncology
Hematology
Internal Medicine
Maxillofacial surgery
14
9
64
5
36
235
114
49
121
51
2,373
1,683
71
690
29
63
46
73
17
27
Medical Biology
2,587
1,300
50
1,287
50
Medical Genetics
182
58
32
124
68
Medical Oncology
587
331
56
256
44
Medical Rehabilitation
54
48
89
6
11
Medical Research
14
8
57
6
43
Nephrology
1,186
802
68
384
32
Neurology
1,799
1,091
61
708
39
Neurosurgery
382
343
90
39
10
Nuclear Medicine
521
349
67
172
33
Occupational Medicine
6,049
1,803
30
4,246
70
Ophthalmology
5,374
3,099
58
2,275
42
71
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
TOTAL
MALE
%
FEMALE
%
Orthopedic Surgery
2,483
2,400
97
83
3
Otolaryngology
2,861
2,383
83
478
17
211
142
67
69
33
Pediatrics
6,441
2,555
40
3,886
60
Physical Medicine and Rehabilitation
1,761
1,027
58
734
42
688
556
81
132
19
Pneumology
2,556
1,727
68
829
32
Psychiatry3
11,658
6,571
131
5,087
69
Public Health
1,556
653
42
903
58
Radiology and Medical Imaging
7,142
5,091
71
2,051
29
Radiology, Medical Imaging and Radiotherapy
142
129
91
13
9
Radiotherapy
648
413
64
235
36
Rheumatology
2,503
1,574
63
929
37
Stomatology
1,204
1,015
84
189
16
2
2
100
0
0
Thoracic and Cardiovascular Surgery
250
240
96
10
4
Urologic Surgery
814
790
97
24
3
Vascular Surgery
443
1 General Medicine+General Medicine (Specialists) (General Medicine as a specialty was started in 2004)
2 Gynecology and Obstetrics+Medical Gynecology
3 Psychiatry+Neuropsychiatry
420
95
23
5
Pediatric Surgery
Plastic, Cosmetic and Reconstructive Surgery
Surgery of the Face and the Neck
Note: Data includes physicians in France and its overseas territories of Départements d'outre-mer (DOM) & Territoires d'outre mer (TOM)
Source: Conseil National de l'Ordre des Médecins (2007) L’ATLAS DE LA DÉMOGRAPHIE MEDICALE EN France [internet], Conseil National de l'Ordre des Médecins. Available from:
<http://www.web.ordre.medecin.fr/demographie/introatlas2007.pdf> [Accessed September 2007]
72
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL PHYSICIANS
TOTAL
<40
40-44
45-49
50-54
55-59
60-64
65 AND
OVER
5,207
199,490
30,861
26,436
38,807
42,283
39,684
16,212
1,471
250
247
249
357
226
113
29
10,235
758
939
2,264
2,244
1,408
953
1,669
Cardiology
5,966
1,066
858
1,129
1,135
1,059
565
154
Child and Adolescent Psychiatry
1,235
10
9
156
450
440
149
21
Dermatology and Venereology
3,825
449
464
781
928
792
337
74
644
111
207
164
57
66
34
5
1,487
418
296
274
262
173
49
15
Anatomy and Cytopathology
Anesthesiology
Digestive Surgery
Endocrinology and Metabolism
Gastroenterology
3,269
631
528
723
587
529
224
47
General Medicine1
97,012
14,696
13,510
20,110
20,425
19,892
6,939
1,440
3,719
790
227
440
699
866
565
132
341
45
70
83
70
53
16
4
Gynecology and Obstetrics (Surgery)
3,132
751
483
618
522
436
271
51
Gynecology and Obstetrics2
2,122
7
28
399
720
676
239
53
10
3
3
3
0
1
0
0
235
130
91
12
1
1
0
0
2,391
436
286
270
408
569
330
92
64
48
14
2
0
0
0
0
Medical Biology
2,595
604
702
634
269
229
103
54
Medical Genetics
183
46
30
38
32
25
8
4
Medical Oncology
592
173
133
89
73
80
34
10
Medical Rehabilitation
54
17
15
13
5
2
1
1
Medical Research
15
0
2
13
0
0
0
0
Nephrology
1,190
298
200
207
187
201
83
14
Neurology
General Surgery
Geriatrics
Hematological Oncology
Hematology
Internal Medicine
Maxillofacial surgery
1,811
510
353
326
289
240
83
10
Neurosurgery
384
95
62
70
47
52
45
13
Nuclear Medicine
521
122
70
91
80
89
48
21
6,052
617
516
828
1,834
1,816
375
66
Occupational Medicine
73
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
Ophthalmology
5,383
608
477
1,064
1,458
1,130
505
65 AND
OVER
141
Orthopedic Surgery
2,493
458
500
603
406
327
156
43
Otolaryngology
2,864
357
349
527
698
584
292
57
211
54
48
34
35
24
13
3
Pediatrics
6,464
1,283
725
1,060
1,242
1,301
679
174
Physical Medicine and Rehabilitation
1,765
239
180
279
457
431
151
28
690
130
160
148
101
72
65
14
Pneumology
2,560
516
381
472
566
431
165
29
Psychiatry3
11,737
1,771
1,387
1,685
2,477
2,637
1,333
447
SPECIALTY
Pediatric Surgery
Plastic, Cosmetic and Reconstructive Surgery
TOTAL
<40
40-44
45-49
50-54
55-59
60-64
Public Health
1,582
320
125
328
375
338
91
5
Radiology and Medical Imaging
7,162
1,198
957
1,466
1,465
1,365
633
78
142
0
0
4
4
8
42
84
Radiology, Medical Imaging and Radiotherapy
Radiotherapy
650
140
85
107
139
119
50
10
Rheumatology
2,508
355
330
511
522
506
235
49
Stomatology
1,208
32
52
233
421
280
137
53
2
2
Surgery of the Face and the Neck
Thoracic and Cardiovascular Surgery
253
55
86
69
20
17
6
0
Urologic Surgery
815
198
187
157
113
97
56
7
Vascular Surgery
446
64
64
1 General medicine+General Medicine (Specialists) (General Medicine as a specialty was started in 2004)
2 Gynecology and Obstetrics+Medical Gynecology
3 Psychiatry+Neuropsychiatry
74
103
96
39
6
Note:
1)
2)
Data also includes overseas French physicians and who are not practicing in France. So the total number of physicians does not match with that of in table 1 & table 3.
Data includes physicians in France and its overseas territories of Départements d'outre-mer (DOM) & Territoires d'outre mer (TOM)
Source: Conseil National de l'Ordre des Médecins (2007) L’ATLAS DE LA DÉMOGRAPHIE MEDICALE EN France [internet], Conseil National de l'Ordre des Médecins. Available from:
<http://www.web.ordre.medecin.fr/demographie/introatlas2007.pdf> [Accessed September 2007]
74
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006
Table No 3. Total Physicians by specialty and Major Professional Activity
MAJOR PROFESSIONAL ACTIVITY
PATIENT CARE
SPECIALTY
TOTAL
INCOME
198,215
TOTAL
PATIENT
CARE
198,215
123,612
72,855
1,748
108,947
Anatomy and Cytopathology
1,463
1,463
616
839
8
704
759
Anesthesiology
9,577
9,577
3,076
6,485
16
3,201
6,376
Cardiology
5,952
5,952
2,784
3,132
36
3,591
2,361
Child and Adolescent Psychiatry
1,232
1,232
555
673
4
440
792
Dermatology and Venereology
3,821
3,821
2,654
1,140
27
2,975
846
642
642
252
390
0
293
349
Endocrinology and Metabolism
1,483
1,483
544
922
17
707
776
Gastroenterology
3,266
3,266
1,365
1,890
11
1,783
1,483
General Medicine1
96,717
96,717
75,322
20,068
1,327
62,735
33,982
3,699
3,699
1,226
2,465
8
1,444
2,255
341
341
64
277
0
19
322
Gynecology and Obstetrics (Surgery)
3,120
3,120
1,092
2,028
0
1,362
1,758
Gynecology and Obstetrics2
2,119
2,119
1,265
850
4
1,556
563
TOTAL PHYSICIANS
Digestive Surgery
General Surgery
Geriatrics
Hematological Oncology
OFFICE
BASED
HOSPITAL
BASED
MIXED/
OTHERS
FEES
SALARIED
89,268
14
14
2
12
0
1
13
235
235
13
219
3
14
221
2,373
2,373
285
2,065
23
341
2,032
63
63
34
29
0
40
23
Medical Biology
2,587
2,587
1,428
1,116
43
1,090
1,497
Medical Genetics
182
182
17
163
2
8
174
Medical Oncology
Hematology
Internal Medicine
Maxillofacial surgery
587
587
116
466
5
134
453
Medical Rehabilitation
54
54
1
53
0
1
53
Medical Research
14
14
4
7
3
3
11
Nephrology
1,186
1,186
285
896
5
267
919
Neurology
1,799
1,799
483
1,306
10
694
1,105
382
382
79
302
1
94
288
Neurosurgery
75
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN FRANCE 2006
Table No 3. Total Physicians by specialty and Major Professional Activity (Cont…)
SPECIALTY
TOTAL
MAJOR PROFESSIONAL ACTIVITY
PATIENT CARE
HOSPITAL
MIXED/
OFFICE BASED
BASED
OTHERS
161
358
2
521
TOTAL
PATIENT CARE
521
Occupational Medicine
6,049
6,049
5,648
392
Ophthalmology
5,374
5,374
3,535
1,826
Orthopedic Surgery
2,483
2,483
1,168
1,312
Otolaryngology
2,861
2,861
1,544
211
211
Pediatrics
6,441
Physical Medicine and Rehabilitation
Nuclear Medicine
INCOME
FEES
SALARIED
154
367
9
46
6,003
13
4,308
1,066
3
1,381
1,102
1,309
8
1,996
865
23
188
0
29
182
6,441
2,712
3,691
38
2,299
4,142
1,761
1,761
794
959
8
497
1,264
688
688
441
247
0
569
119
Pneumology
2,556
2,556
797
1,742
17
964
1,592
Psychiatry3
Pediatric Surgery
Plastic, Cosmetic and Reconstructive Surgery
11,658
11,658
4,839
6,790
29
4,647
7,011
Public Health
1,556
1,556
1,000
520
36
59
1,497
Radiology and Medical Imaging
7,142
7,142
4,124
3,011
7
4,626
2,516
142
142
94
46
2
104
38
Radiology, Medical Imaging and Radiotherapy
Radiotherapy
648
648
236
412
0
280
368
Rheumatology
2,503
2,503
1,402
1,080
21
1,632
871
Stomatology
1,204
1,204
797
405
2
979
225
Surgery of the Face and the Neck
2
2
0
2
0
0
2
Thoracic and Cardiovascular Surgery
250
250
71
179
0
89
161
Urologic Surgery
814
814
442
372
0
530
284
Vascular Surgery
443
443
222
1 General Medicine+General Medicine (Specialists) (General Medicine as a specialty was started in 2004)
2 Gynecology and Obstetrics+Medical Gynecology
3 Psychiatry+Neuropsychiatry
221
0
261
182
Note: Data includes physicians in France and its overseas territories of Départements d'outre-mer (DOM) & Territoires d'outre mer (TOM)
Source: Conseil National de l'Ordre des Médecins (2007) L’ATLAS DE LA DÉMOGRAPHIE MEDICALE EN France [internet], Conseil National de l'Ordre des Médecins. Available from:
<http://www.web.ordre.medecin.fr/demographie/introatlas2007.pdf> [Accessed September 2007]
76
10. GERMANY
77
10.1. Introduction to Germany
With over 82 million inhabitants, Germany is the most populous country in the European
Union. However, its fertility rate of 1.39 children per mother is one of the lowest in the
world, and the federal statistics office estimates the population will shrink to between 69
and 74 million by 2050 (69 million assuming a net migration of +100,000 per year; 74
million assuming a net migration of +200,000 per year). Germany has a number of larger
cities, the most populous being Berlin, Hamburg, Munich, Cologne, Frankfurt and
Stuttgart.
As of December 2004, about seven million foreign citizens were registered in Germany,
and 19% of the country's residents were of foreign or partially foreign descent. The
largest group (2.3 million) is from Turkey, and a majority of the rest are from European
states such as Italy, Serbia, Greece, Poland, and Croatia. In its State of World Population
2006 report, the United Nations Population Fund lists Germany as hosting the thirdhighest percentage of international migrants worldwide, about 5% or 10 million of all 191
million migrants. As a consequence of restrictions of Germany's formerly rather
unrestricted laws on asylum and immigration, the number of immigrants seeking asylum
or claiming German ethnicity (mostly from the former Soviet Union) has been declining
steadily since 2000. Immigrants to Germany often face integration issues among other
difficulties.
Germany has the second largest population in Europe (after European Russia) and is
seventh largest in area. The territory of Germany covers 357,021 km² (137,847 square
miles), consisting of 349,223 km² (134,836 square miles) of land and 7,798 km² (3,011
square miles) of water. Elevation ranges from the mountains of the Alps (highest point:
the Zugspitze at 2,962 metres (9,718 ft)) in the south to the shores of the North Sea
(Nordsee) in the north-west and the Baltic Sea (Ostsee) in the north-east. Between lie the
forested uplands of central Germany and the low-lying lands of northern Germany
(lowest point: Wilstermarsch at 3.54 metres (11.6 ft) below sea level), traversed by some
of Europe's major rivers such as the Rhine, Danube and Elbe. Because of its central
78
location, Germany shares borders with more European countries than any other country
on the continent. Its neighbors are Denmark in the north, Poland and the Czech Republic
in the east, Austria and Switzerland in the south, France and Luxembourg in the southwest and Belgium and the Netherlands in the north-west. Germany is divided into sixteen
states (Länder, singular Land; commonly Bundesländer, singular Bundesland). It is
further subdivided into 439 districts (keise, singular Kreis) and cities (kreisfreie Städte)
(Figure 5).
Figure 5:
Map of Germany showing states and key cities
Source: www.wikipedia.org
DATAMONITOR
79
10.2. Germany’s healthcare system
Under the German constitution (Basic Law), the Federal Ministry of Health and the 16
Länder governments share decision-making responsibilities for healthcare provision,
while non-government, non-profit-making bodies play a vital role in financing and
delivering healthcare. Germany’s healthcare system traces its roots back to 1876 with the
establishment of the Health Office and subsequent setting up of the Statutory Health
Insurance (SHI) scheme by Chancellor Bismark in 1883. The minimum benefits covered
by the SHI defined by Bismark have expanded over the last century to represent a
comprehensive system of healthcare provision. A top-line structure of the German
healthcare system is given in Figure 6.
Figure 6:
Structure of the German healthcare system
Source: internal secondary research
DATAMONITOR
The system is based on the principle of solidarity among the insured population who pay
contributions to sickness funds which are unrelated to the insured risks and who are
provided healthcare benefits that are not dependent on the amount of contributions. Some
80
89% of Germany’s 82.5 million population are covered by the statutory health insurance
scheme, according to the European Observatory on Health Care Systems. Around 9% are
covered by private health insurance, 2% of the population are entitled to free government
healthcare (including police officers, soldiers and those doing an alternative to military
service, and individuals receiving social welfare). Less than 0.2% are uninsured.
10.3. Healthcare insurance
In the private sector, research has shown that some 7.7 million people were fully covered
by private health insurance in 2002, with a further 7.6 million people having
supplementary private cover, according to the association of private health insurers, PKV.
The 9.3% of the population who have full-cover private insurance include high-earning
employees who can opt out of the SHI, the self-employed and civil servants. Since the
government reimburses 50-80% of civil servants’ healthcare costs directly, private
insurance is often used to cover the portion not paid for by the government.
The 7.6 million SHI-insured people who take out private health insurance in general seek
to augment their state benefits, such as receiving treatment in single bed hospital rooms.
Unlike the system in France, where complementary insurance is taken out to cover copayments, German private insurance is regarded as a luxury choice.
Some private
insurers have, however, begun to offer plans which cover SHI co-payments. According to
the German Federal Statistical Office, households with private insurance spend some 2.5
times more on out-of-pocket payments than those covered by the SHI. Policies and
premiums vary widely among private insurers. Since separate premiums are required for
dependants (unlike the SHI), private insurance tends to be favored among single people
or working couples. Group insurance is not a feature of the private market. The following
figure (Figure 7) shows the coverage of the patient population by insurance type in 2003.
81
Figure 7:
German healthcare insurance coverage by type, 2003
Source: Datamonitor
DATAMONITOR
10.4. Service delivery
Public health is mainly the competence of the Länder. However, 14 out of 16 Länder
have devolved public health functions to municipalities. Public health offices are
responsible for surveillance and health reporting, for the supervision of environmental
and infectious hygiene of health care personnel and institutions in inpatient and outpatient
care. They are restricted to delivering a limited scope of preventive services, since most
preventive services, e.g. immunization, are provided by ambulatory physicians.
In terms of the Statutory Health Insurance System, the Social Code Book requires all
employees and certain defined groups (pensioners, students, artists and the disabled) to be
insured under the Statutory Health Insurance Scheme (Gesetzliche Krankenversicherung
– GKV). Membership of a statutory health insurance fund/sickness fund (Krankenkasse)
is compulsory for employees, except those whose income exceeds a specific level and
those who belong to a specific statutory scheme, such as civil servants. Contributions are
shared equally between employers and employees.
82
Some 75% of the population have compulsory SHI cover, while a further 14% are
covered voluntarily, according to Berlin-based healthcare expert Professor Dr Reinhard
Busse. Insured individuals are free to join any sickness fund and are also free to choose
their healthcare provider. The system is self-regulating, with the Social Code Book
providing the regulatory framework. The sickness funds and providers have delegated
regulatory powers and through their respective federal and regional associations
(corporatist bodies) exert legal power over their membership. While these bodies are not
private enterprises, they combine private status with public functions. Supervisory
oversight of the self-regulatory bodies is provided at federal and state levels.
The functions of payers and providers are separated, with sickness funds (payers)
negotiating healthcare services with providers on behalf of their members. Services
covered by contracts with providers are accessible to members without prior permission.
Insured patients make a contribution to the cost of healthcare services they receive
generally through a system of co-payments.
The sickness funds are responsible for collecting contributions from members and
determining premiums, within the limitations of the law. Since benefits provided by
sickness funds are essentially identical in terms of obligatory treatment, funds compete on
contribution rates to attract members. Expenditure has traditionally exceeded income,
prompting sick funds to implement cost-containment measures with the drug bill a target
for generating savings.
The providers are represented by the doctors’ and dentists’ associations who contract
with sickness funds to deliver healthcare services defined by law. Benefits covered by the
SHI are defined in general terms in the SHI benefits catalogue, which serves as the feeschedule for office-based physicians. Decisions on which benefits to exclude are made by
the Federal Committee of Physicians and Sickness Funds. Items which have been
excluded include technologies of limited medical benefit such as osteodensitometry for
asymptomatic patients, certain dental services, some medical aid devices, medicines for
83
minor illnesses such as the common cold and for travel-related diseases, and
pharmaceuticals which are of unproven medical benefit.
Negotiations between sickness funds and provider associations determine the financing
mechanisms and details of ambulatory care. The introduction of competition among
funds in 1996 saw a shift in negotiating contracts from a group or collective basis to
selective purchasing. Patients receive care free at the point of delivery as sick funds pay
providers for care delivered. An exception to this is the option of cost-reimbursement for
patients who are voluntarily insured under SHI. Healthcare provision is segregated
between ambulatory care, which is a powerful and growing sector, and hospitals, which
concentrate on inpatient care.
10.4.1. Ambulatory care
Office-based physicians provide virtually all ambulatory care, including primary and
outpatient secondary care. Since there is no gate keeping system patients are free to
choose a family practitioner affiliated to their sickness fund, although they cannot switch
doctors more frequently than quarterly. The large proportion of office-based specialists
also means that patients frequently seek specialist care in the ambulatory sector.
Ambulatory care physicians are legally responsible for providing preventive services,
including screening and check-ups, whereas immunization programs are negotiated with
sickness funds, hence the relatively low rates compared with international coverage. The
payment of office-based physicians for services they provide per patient encourages them
to see as many patients as possible.
The majority of office-based physicians refer their patients to hospital physicians for
inpatient treatment but carry out follow-up procedures themselves. Thus, patients
commonly receive post-surgical care from their primary care physician rather than the
hospital surgeon. In addition to office-based physicians, some 11,000 physicians
(generally heads of hospital departments) are accredited to treat ambulatory patients: they
84
are permitted to offer certain services and treat patients when physicians’ offices are
closed.
10.4.2. Hospital care
Due to a significant proportion of outpatient care provided by office-based physicians,
hospital care in Germany has focused on inpatient care. Formal outpatient facilities have
until recently been confined to university hospitals, although the growth in day surgery
and provision of specialized care, such as chemotherapy, on an outpatient basis has
changed the traditional basis of the sector. By the end of the 1990s, over half of German
hospitals offered ambulatory care.
A small percentage of office-based physicians (5%, according to the European
Observatory) are permitted to treat patients in the hospital setting. This usually applies to
less common surgical specialties where there is insufficient demand for a full-time
hospital specialist. Hospitals contract on an individual basis with sickness funds although
the services offered and remuneration rates are valid for all sickness funds. In general,
sickness funds with at least 5% market share in a particular hospital tend to negotiate the
contract with that hospital.
Referral from an ambulatory physician is required for access to German hospitals, with
the exception of emergency patients. Hospitals are required to accept all urgent cases
(which in Germany tends to cover a wide definition), regardless of occupancy rates.
Although patients are free to choose their hospital, the referring physician plays an
influencing role. The hospital’s ownership status is not relevant for insured patients.
Generally hospital admissions occur on the same day as the referral: waiting lists are not
an issue in Germany.
The German healthcare system is highly decentralized, although there are movements
towards adopting a more centralized approach by increasing the level of national
involvement. Sickness funds are the key stakeholder in terms of healthcare provision,
85
however other bodies and associations impact healthcare provision, as detailed in the
following figure (Figure 8).
Figure 8:
A number of governmental bodies, physician and pharmacist associations,
and industry associations impact healthcare provision in Germany
Source: internal secondary research
10.5. Healthcare financing and expenditure
Total health spending accounted for 10.7% of GDP in Germany in 2005. Germany ranks
only 10th among OECD countries in health spending per capita, with spending of $3,287
per person in 2005 (adjusted for purchasing power parity). Health spending per capita in
Germany increased, in real terms, by 1.3% per year on average between 2000 and 2005.
The relatively slow growth in health spending in Germany is partly due to costcontainment measures that have been introduced in the context of health reforms.
Spending on pharmaceuticals in Germany has increased over the past decade and
accounted for 15.2% of total health expenditure in 2005. In 2005, 76.9% of health
spending in Germany was funded by public sources. The following table (Table 11)
shows the recent key health expenditure indicators.
86
Table 11:
German healthcare spending statistics
Value
Indicator
Total expenditure on health as percentage of gross domestic product
Public expenditure on health as percentage of total expenditure on health
Private expenditure on health as percentage of total expenditure on health
Out-of-pocket expenditure as percentage of private expenditure on health
Private prepaid plans as percentage of private expenditure on health
Per capita total expenditure on health (adjusted for purchasing power parity)
10.7% (2005)
76.9% (2005)
23.1% (2005)
57.5% (2004)
39.1% (2004)
%3,287 (2005)
Source: WHO sources World Health Statistics, various years were used (see
DATAMONITOR
above)
Of the total expenditure, 57% of the funds came from statutory health insurance, 7% from
statutory long-term care insurance, 4% from other statutory insurance schemes and 8%
from government sources (World Health Organisation Regional Office for Europe, 2004).
Private health insurers financed 8%, employers 4% and non-profit organizations and
households 12% (World Health Organisation Regional Office for Europe, 2004). German
statutory insurance does not provide universal coverage – those with incomes above a
certain limit can choose to opt out in favor of private insurance. Approximately 9% of
Germany’s total healthcare expenditure comes from private insurance, while 10% comes
from out-of-pocket payments. Most out-of-pocket payments went to purchase over-thecounter drugs and to co-payments for prescribed drugs. Co-payments were introduced in
2004, for outpatient visits and were raised for virtually all other benefits.
10.6. Resources
There are 4.2 million working in the German health sector, which accounted for 10.6% of
total employment at the end of 2002. There are more than 1 million employees working
in the German hospital sector. Since the early 1990s the total number of employees has
dropped by about 3.6% (Liberalisation, privatization and regulation in the German
healthcare sector/hospitals, 2006, Pique report).
87
Germany has more physicians and nurses than the average across OECD countries. In
2005, Germany had 3.4 practicing physicians per 1 000 population. Germany has 9.7
nurses per 1,000 population. The number of acute care hospital beds in Germany stood at
6.4 per 1,000 population in 2005. Although the number of hospital beds per capita and
average length of stay in acute hospitals in Germany has fallen over time, it still ranks
high on these indicators among the OECD countries. The following table (Table 12)
gives the total number of physicians and nurses as well as density per 1,000 population in
the recent years.
Table 12:
German physician and nurse numbers
Resource indicator
Physicians (number)
Physicians (density per 1,000 population)
Nurses (number)
Nurses (density per 1,000 population)
Source: OECD Healthcare Statistics, various years are indicated
Value (year)
277, 885 (2003)
3.4 (2005)
801, 677 (2003)
9.7 (2005)
DATAMONITOR
For a complete review of the most up to date physician statistics, please refer to the
German physician statistics section of this report. There were 2,166 hospitals with more
than 530, 000 beds in 2004. Since the 1990s the hospital capacities in Germany have
shown a continuous decline. Between 1991 and 2004, the total numbers of hospitals fell
by about 10% while the number of beds decreased by about 20%. The table below (Table
13) shows a comparison of German hospital key figures between 1991 and 2004
(Liberalisation, privatization and regulation in the German healthcare sector/hospitals,
2006, Pique report).
88
Table 13:
The German Hospital sector – Key figures 1991 and 2004
Number of hospitals
Number of beds
Beds per 1,000 inhabitants
Number of employees
Total
Full-time equivalents
Hospital cases
Average length of stay
Average occupancy rate
Occupancy and billing days
1991
2004
Changes
1991/2004
2, 411
665, 565
8.3
2, 166
531, 333
6.4
-10.2%
-20.2%
-22.9%
1, 119, 791
875, 816
14, 577, 000
14.0 days
84.10%
204, 204, 000
1, 079, 831
805, 988
16, 801, 000
8.7 days
75.70%
146, 746, 000
-3.6%
-8.0%
15.3%
-37.9%
-10.0%
-28.2%
Source: Liberalisation, privatization and regulation in the German healthcare
DATAMONITOR
sector/hospitals, 2006, Pique report
10.7. The German pharmaceuticals market
The pharmaceutical industry in Germany is among the most powerful in developed
countries and contributes significantly to the export market. There were about 1,100
pharmaceutical companies with 114,800 workers operating in Germany in 2002. Of the
pharmaceutical industry's total turnover of $34.6 billion in 2002, $17.0 billion was gained
in the domestic market and $17.6 billion from exports (especially the other European
Union countries, Japan, Switzerland and the United States).
Of the $54.6 billion spent on drugs in 2002, $46.8 billion was spent on pharmacies in
ambulatory care while $4.4 billion was spent on acute hospital care. Of the $49.6 billion
spent on drugs in pharmacies in 2002, $43.2 billion was spent on prescription drugs and
$6.2 billion on over-the-counter (OTC) medication. Expenditure on OTC drugs increased
until 1997 and has decreased since, while prescription drug costs rose continuously.
Private households spent about 25% of their out-of-pocket payments on drugs in 2001.
89
Of the total pharmaceutical expenditure in 2002, 70% was spent by statutory health
insurance, 6% by private health insurance, 18% by private households (and not-for profit
organizations), and the remaining 5% by other sources. Most pharmaceutical
expenditures were in ambulatory care. As a result of cost-sharing measures, private
household expenditures on pharmaceuticals increased throughout the 1990s, accounting
for up to 26% of pharmaceutical expenditures in 1998 but decreased again to 18% in
2002.
High R&D expenditures over the past few years made it possible to launch 23 new
molecular entities (NMEs) in the German market in 2005, most of which focused on
innovative therapeutic drugs for cancer. According to a Verband Forschender
Arzneimittelhersteller (VFA) report, Germany's share in the world market has decreased
from 5.2% in 1998 to 3.2%in 2005 (at a constant exchange rate). In Germany, innovative
pharmaceuticals are still prescribed less frequently than in other European countries, percapita sales are in the middle range in Europe, and the pharmaceutical market exhibits
only below-average growth in an international comparison. With a volume of about $26
billion in 2005, Germany is the third largest market for pharmaceuticals and yet, it is one
of the markets exhibiting below-average growth because of the high regulatory density.
From 1998 to 2005, sales in the German pharmacy market increased by about 40%.
In 2005, German pharmaceutical companies provided pharmaceuticals worth USD 32.6
billion (at manufacturers' prices) via pharmacies for outpatient treatment. A total of 15%
of this amount was for self-medication with over-the-counter (OTC) drugs, about 12% for
private prescriptions outside of statutory health insurance, and 73% for SHI prescriptions.
The latter category was financed through co-payments by insured patients, manufacturers'
and trade discounts and expenditures of the health insurance funds (86%).
In 2005, the gross sales volume in the German pharmacy market was USD 32.6 billion at
manufacturers' prices. Taking into account the rebates the manufacturers had to grant to
statutory health insurance (2004: USD 2.4 billion, 2005: USD 0.82 billion), these sales
decreased to USD 31.7 billion. About 81% of sales were made in prescription drugs. The
90
number of packages sold in 2005 was 1.62 billion, up 1.4% compared to the previous
year but down 4.9% compared to 2003.
In Germany, 75% of SHI prescriptions and at 49% almost half of all sales in the entire
market are generated in this so-called generics-eligible market. During the past 12 years,
Germany has evolved into the world's most generics-friendly country. Frequently, after
their patents expire, the original products lose almost their entire market share to generic
drugs within a few months. On average, 74% of all prescriptions and 70% of sales in the
generics-eligible market were generated by generics in 2004.
Much change has occurred in the German pharmaceutical market in recent years, with
sweeping healthcare reforms playing a critical role in pharmaceutical sales and research
and development. The leading reform principles after reunification have been to reduce
structural east-west differences and to contain costs through expenditure control,
prospective provider payment and regulated competition among sickness funds, while
securing quality and avoiding adverse effects on equity. Rationalization was given
priority over rationing. While cost-sharing was enhanced, few benefits were excluded
until 2004. At the same time, new benefits and separate mandatory long-term care
insurance were introduced to meet the changing needs of the population more
appropriately. In recent years, reorganization of the pharmaceutical market and the
bridging sectoral boundaries have gained importance. Currently, the revenue side of
statutory health and long-term care insurance are under discussion. The following table
(Table 21) shows the reforms that have shaped the German healthcare system since 2000.
91
Table 14:
Year
2000
2002
2003
Pharmaceutical reforms in Germany, 2000-2006
Law
Main cost reduction provision
Statutory Health Insurance
Reform Act of 1999
Medication Expenditure
Restriction Act
•
Increasing focus on prevention, self-help, patient
rights, and quality control
•
Aut Idem pharmacy substitution introduced
Increase of mandatory pharmacy rebates to 6%
(from 5%)
New mandatory rebates for pharmaceutical
industry (6%) and wholesalers (3%)
Price-variant pharmacy rebates (6-10%)
New co-payments on physician visits (€10 per
quarter, except for prevention and referrals)
OTC products (i.e. non-prescription) excluded
from coverage (with exception of certain
indications and children under 13 years of age)
Higher co-payments on medication (10%,
minimum €5, maximum €10)
Mail-order pharmacies and individual ownership
of up to four (regional) pharmacies allowed
Reduction of pharmacy rebates to €2; 5% on
prescribed OTC and not pre-packaged products
Exclusion of non-sickness-related expenditures
(e.g. contraception) from coverage
Mandates price freezes for two years
Further decreases in reference prices
10% mandatory rebates for generics
A redefinition of how innovative drugs are
categorized
Financial reward/punishment system for
prescribers
Premiums
•
•
2004
Contributions Security Act and
the SHI Modernization Act
•
•
•
•
•
•
•
2006
AVWG (Law for the Economic
Supply with Drugs)
•
•
•
•
•
Source: Adapted from Farrag & Riemer-Hommel, 2006; Walenta, Visiongain,
DATAMONITOR
May 2006
92
10.8. Bibliography
o World Health Organization (2007), World health statistics [Internet], Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=deu&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=deu&indicators=healthpersonnel> [Accessed October 2007].
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o Datamonitor (2004), Exploiting technology opportunities in European healthcare,
2004, DMTC1017.
o World Health Organization (2004), Health systems in transition 2004 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health
Systems
and
Policies.
Available
from:
<http://www.euro.who.int/Document/E85472.pdf> [Accessed October 2007].
o OECD data (2007), OECD Germany Health data 2007 [Internet] Available from:
< http://www.oecd.org/dataoecd/45/55/38979836.pdf> [Accessed October 2007].
o Pharmaexecutive
Europe,
[Internet].
Available
from:<http://www.pharmexeceurope.com/europharmexec/article/articleDetail.jsp?
id=405242&pageID=1&sk=&date=> [Accessed October 2007].
o PIQUE report (2006), Liberalisation, privatization and regulation in the German
healthcare sector/hospitals, 2006, Wirtschafts- und Sozialwissenschaftliches
Institut.
[Internet].
Available
http://www.boeckler.de/pdf/wsi_pj_piq_sekkrankh.pdf>
from:<
[Accessed
October
2007].
93
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL PHYSICIANS
Anatomy
Anesthesiology
TOTAL
MALE
%
FEMALE
%
311,230
118
17,418
186,876
94
10,510
60
80
60
124,354
24
6,908
40
20
40
Biochemistry
Child and Youth Medicine
Child and Youth Psychiatry - Psychotherapy
Dermatology & Venereology
61
11,640
1,354
5,071
47
5,738
612
2,644
77
49
45
52
14
5,902
742
2,427
23
51
55
48
Human Genetics
Hygiene and Environmental Medicine
Internal Medicine and General Medicine
Laboratory Medicine
227
212
82,593
942
94
114
54,826
664
41
54
66
70
133
98
27,767
278
59
46
34
30
Legal Medicine
Maxillofacial Surgery
211
1,357
162
1,235
77
91
49
122
23
9
Microbiology, Virology & Infection Epidemiology
Neurology1
645
7,793
402
5,125
62
132
243
2,668
38
68
Neurosurgery
Nuclear Medicine
Occupational Medicine
Ophthalmology
1,379
955
2,703
6,544
1,197
691
1,555
3,804
87
72
58
58
182
264
1,148
2,740
13
28
42
42
Otolaryngology
Pathology
Pharmacology
Physical and Rehabilitative Medicine
5,527
1,400
481
1,680
3,838
1,019
382
1,066
69
73
79
63
1,689
381
99
614
31
27
21
37
Physiology
Psychiatry and Psychotherapy
108
7,148
87
3,884
81
54
21
3,264
19
46
Psychosomatic Medicine and Psychotherapy
Public Health Service
3,861
961
1,968
560
51
58
1,893
401
49
42
Radiology
Radiotherapy
6,456
844
4,543
482
70
57
1,913
362
30
43
94
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
Surgery
TOTAL
MALE
%
FEMALE
%
28,414
24,367
86
4,047
14
Transfusional Medicine
Urology
512
4,883
279
4,379
54
90
233
504
46
10
Women’s Health
Without any Specialty
Other Specialties
15,811
91,724
197
7,708
42,706
94
49
47
48
8,103
49,018
103
51
53
52
1 Neurology+Nerve Medicine
Source: Bundesärztekammer (2007) Results of the physician statistics to 31 December 2006 [internet], Bundesärztekammer. Available from:
<http://www.bundesaerztekammer.de/downloads/Aerztestatistik2006.pdf> [Accessed September 2007].
95
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL PHYSICIANS
Anatomy
Anesthesiology
Biochemistry
Child and Youth Medicine
TOTAL
UNDER 35
35-39
40-49
50-59
60-65
65 AND OVER
311,230
49,449
42,061
104,962
79,308
27,745
118
0
7
52
30
18
7,705
11
17,418
511
2,557
7,978
5,056
1,199
117
61
0
1
17
29
12
2
11,640
362
1,478
4,464
3,497
1,496
343
Child and Youth Psychiatry - Psychotherapy
1,354
25
170
612
393
123
31
Dermatology & Venereology
5,071
277
727
2,050
1,354
512
151
Human Genetics
227
7
35
90
66
20
9
Hygiene and Environmental Medicine
212
5
15
87
71
26
8
82,593
1,441
9,418
30,552
27,467
10,516
3,199
942
6
98
388
272
135
43
Internal Medicine and General Medicine
Laboratory Medicine
Legal Medicine
211
4
26
84
56
31
10
1,357
20
212
606
370
122
27
645
15
68
289
172
74
27
7,793
175
1,026
2,694
2,455
1,065
378
1,379
43
269
632
312
96
27
Nuclear medicine
Occupational Medicine
Ophthalmology
955
2,703
6,544
31
25
240
130
207
842
430
1,011
2,428
215
1,027
1,904
107
344
835
42
89
295
Otolaryngology
5,527
210
808
2,129
1,542
646
192
Pathology
1,400
16
133
598
407
192
54
481
6
47
186
138
88
16
1,680
9
74
638
698
220
41
108
0
5
38
34
24
7
Psychiatry and Psychotherapy
7,148
83
877
3,895
1,869
348
76
Psychosomatic Medicine and Psychotherapy
3,861
4
92
904
1,853
718
290
Maxillofacial Surgery
Microbiology, Virology & Infection
Epidemiology
Neurology1
Neurosurgery
Pharmacology
Physical and Rehabilitative Medicine
Physiology
Public health service
Radiology
Radiotherapy
961
1
13
261
526
143
17
6,456
133
759
2,860
1,919
659
126
844
17
163
456
172
29
7
96
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
Surgery
Transfusional Medicine
Urology
UNDER 35
35-39
40-49
50-59
60-65
65 AND OVER
28,414
604
4,331
11,750
8,383
2,722
512
8
52
266
143
38
624
5
4,883
130
749
2,004
1,336
550
114
Women’s Health
15,811
496
1,884
6,005
4,806
2,089
531
Without any Specialty
91,724
44,545
14,786
18,458
10,649
2,502
784
197
0
2
50
87
46
12
Other Specialties
1 Neurology+Nerve Medicine
Source: Bundesärztekammer (2007) Results of the physician statistics to 31 December 2006 [internet], Bundesärztekammer. Available from:
<http://www.bundesaerztekammer.de/downloads/Aerztestatistik2006.pdf> [Accessed September 2007].
97
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006
Table No 3. Total Physicians by Specialty and Major Professional Activity
MAJOR PROFESSIONAL ACTIVITY
PATIENT CARE
SPECIALTY
TOTAL PHYSICIANS
Anatomy
Anesthesiology
Biochemistry
Child and Youth Medicine
406,974
284,427
136,105
148,322
OTHER ACTIVITIES
PUBLIC
OFFICER/
OTHER
CORPORATE
BODY
2,003
26,803
177
101
13
88
28
59
21,001
18,660
5,191
13,469
775
3,583
106
5,553
5,521
32
23
45
5,231
TOTAL
TOTAL
PATIENT
CARE
OFFICE
BASED
HOSPITAL
BASED
91
NO MEDICAL
ACTIVITY
95,744
16,871
10,641
6,431
4,210
999
Child and Youth Psychiatry - Psychotherapy
1,659
1,277
649
628
77
305
Dermatology & Venereology
6,785
4,767
3,848
919
32
304
1,714
Human Genetics
258
195
81
114
32
31
Hygiene and Environmental Medicine
438
86
12
74
6
126
226
Internal Medicine and General Medicine
107,037
76,809
57,079
19,730
565
5,784
24,444
Laboratory Medicine
1,351
829
516
313
11
113
409
Maxillofacial Surgery
1,656
1,325
961
364
10
32
299
941
494
173
321
11
151
296
10,396
7,218
3,541
3,677
19
575
2,603
Neurosurgery
1,561
1,340
362
978
9
39
182
Nuclear Medicine
1,229
905
559
346
4
50
274
Occupational Medicine
4,013
266
2
264
19
2,174
1,310
Ophthalmology
8,749
1,084
265
819
25
204
2,205
Otolaryngology
7,325
5,353
4,162
1,191
32
174
1,798
Pathology
1,967
1,292
597
695
6
108
567
749
201
16
185
280
268
2,083
1,529
535
994
151
403
171
69
5
64
12
39
63
7,907
6,560
2,554
4,006
6
588
759
Microbiology, Virology & Infection Epidemiology
Neurology1
Pharmacology
Physical and Rehabilitative Medicine
Physiology
Psychiatry and Psychotherapy
98
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN GERMANY 2006
Table No 3. Total Physicians by Specialty and Major Professional Activity (Cont…)
MAJOR PROFESSIONAL ACTIVITY
PATIENT CARE
SPECIALTY
TOTAL
TOTAL
PATIENT
CARE
OFFICE
BASED
HOSPITAL
BASED
OTHER ACTIVITIES
PUBLIC
OFFICER/
OTHER
CORPORATE
BODY
NO MEDICAL
ACTIVITY
Psychosomatic Medicine and Psychotherapy
4,264
3,790
2,996
794
Public Health Service
1,561
50
21
29
9
911
600
Radiology
8,634
6,141
2,817
3,324
3
315
2,178
963
821
210
611
23
119
310
131
10
121
1
80
99
35,681
16,697
6
16,691
100
1,542
7,267
Radiotherapy
Right Medicine
Surgery
Transfusional Medicine
Urology
Women’s Health
Without any Specialty
Other Specialties
71
403
655
386
51
335
4
126
143
6,156
4,735
2,821
1,914
15
148
1,273
20,933
15,234
10,586
4,648
2
577
5,122
122,799
66,332
2
66,330
987
10,073
31,075
588
86
42
44
2
111
391
1 Neurology+Nerve Medicine
Source: Bundesärztekammer (2007) Results of the physician statistics to 31 December 2006 [internet], Bundesärztekammer. Available from:
<http://www.bundesaerztekammer.de/downloads/Aerztestatistik2006.pdf> [Accessed September 2007].
99
11. Italy
100
11.1. Introduction to Italy
Italy is located on the Italian Peninsula in Southern Europe, and on the two largest islands
in the Mediterranean Sea, Sicily and Sardinia. Italy shares its northern Alpine boundary
with France, Switzerland, Austria and Slovenia. The independent states of San Marino
and the Vatican City are enclaves within the Italian Peninsula, while Campione d'Italia is
an Italian exclave in Switzerland.
Today, Italy is a democratic republic, and a developed country with the 7th-highest GDP
(nominal) and the 20th-highest Human Development Index rating in the world. It is a
founding member of what is now the European Union (having signed the Treaty of Rome
in 1957), and also a member of the G8, the Council of Europe, the Western European
Union, and the Central European Initiative. Beginning January 1, 2007, Italy became a
non-permanent member of the United Nations Security Council. Italy is subdivided into
20 regions (regioni, singular regione). Five of these regions enjoy a special autonomous
status that enables them to enact legislation on some of their specific local matters, such
as Sardinia and Sicily. Italy is further divided into 109 provinces (province) and 8,101
municipalities (comuni) (Figure 9).
The latest population estimate from ISTAT (Italian Statistics Office) shows 59,206,382
inhabitants
in
Italy
in
February
2007
-
(source:
http://demo.istat.it/bilmens2007gen/index.html), an increase of 49,084 people from a
month earlier. Italy has the fourth largest population in the European Union (after
Germany, France and the United Kingdom), and the 22nd in the world. Gradual increase
of population is mainly supplemented by immigrants and an increase in life expectancy of
79.81 years. Despite population growth, Italy is rapidly aging. Though the Italian fertility
rate is climbing gradually, it sits at 1.35 children per woman, almost one in five Italian
inhabitants is a pensioner; if this aging trend continues, the Italian population could
shrink by a quarter by 2050.
Italy has the fifth highest population density in Europe with 196 persons per square
kilometer. The highest density is in Northwestern Italy, as two regions out of twenty
101
(Lombardy and Piedmont) combined, contain one quarter of the Italian population, where
an estimated 7.4 million people live in the metropolitan Milan area. The literacy rate in
Italy is 98% overall, and school is mandatory for children aged 6 to 18. Approximately
two thirds of the population live in urban areas, which is much lower than other Western
European nations.
Figure 9:
Map of Italy showing key cities and regions
Source: www.wikipedia.org
DATAMONITOR
102
11.2. Italian healthcare system
The National Health Service (NHS) financed by general taxation, aims at granting
universal access to a uniform level of care throughout the country. Universal coverage
has been achieved, although regions widely differ in terms of health care and health
expenditure, with a distinct north-south divide.
Italy has a highly decentralized healthcare system, based on national, regional and local
levels of healthcare provision. The state has exclusive power to define the basic benefit
package (LEA; livelli essenziali di assistenza), which must be uniformly provided
throughout the country, and the 20 regions have responsibility for organizing and
administering the health care system. Local health units (public health enterprises legally
independent from the region) have responsibility for delivering health care services at the
local level, serving geographical areas with average populations of about 300,000. The
following figure gives an overview of the healthcare system in Italy (Figure 10).
Figure 10:
Organizational structure of the Italian healthcare system
Source: internal secondary research
DATAMONITOR
103
11.3. Healthcare insurance
Italian healthcare is primarily provided by a public system, although the Italian National
Health Service (SSN; Servizio Sanitario Nationale) finances a relatively low level of
overall healthcare expenditure. Approximately one third of the Italian population has
private healthcare cover, which, because of the relatively poor standard of public
healthcare, tends to replace and duplicate SSN services. The use of private healthcare in
Italy therefore differs from countries such as France, where private healthcare is used to
supplement public healthcare and cover patient co-payments. For this reason, private
insurance primarily covers ambulatory specialist care and private hospital care for minor
surgery.
11.4. Service delivery
Primary care is delivered by self-employed GPs and physicians, who are independent
contractors of the NHS. They act as gatekeepers to secondary care. Physicians work
under government contract and are paid through capitation fees. Secondary care is
provided by local health units, public hospital trusts and private accredited hospitals.
Local health units are in charge of protecting and promoting public health mainly through
disease prevention (especially immunization), health promotion and food control.
Specialized services are provided either directly by local health units or through
contracted-out public (61%) and private (mainly not-for-profit) facilities accredited by
local health units.
11.5. Healthcare financing and expenditure
Total health spending accounted for 8.4% of GDP in 2004. Italy ranks below the OECD
average in terms of health spending per capita, with spending of about 2392 USD in 2004
(adjusted for purchasing power parity). Between 1999 and 2004, health spending per
capita in Italy increased in real terms by 3.5% per year on average.
104
According to OECD health data (2006), the share of public spending in Italy was 76.4%
in 2004. Private healthcare is available to those who can afford private insurance or direct
payment. About 15% of the population has complementary private health insurance either
individually subscribed or offered by employers (internal secondary research). Use of
private services is encouraged through the tax system; patient expenditures on private
healthcare are eligible for tax deductions and credits.
The rise in pharmaceutical spending has been one of the factors behind the rise in total
health spending in Italy. In 2004, spending on pharmaceuticals accounted for 21.4% of
total health spending in Italy. For 2003, expenditure can be split into: the hospital sector
(48%), drug spending (15%), outpatient specialist care (12%) and other (25%) (France et
al., 2005). The following table (Table 15) shows the key health expenditure indicators in
2004.
Table 15:
Italian healthcare spending statistics
Indicator
Total expenditure on health as percentage of gross domestic product
Public expenditure on health as percentage of total expenditure on health
Private expenditure on health as percentage of total expenditure on health
Out-of-pocket expenditure as percentage of private expenditure on health
Private prepaid plans as percentage of private expenditure on health
Per capita total expenditure on health (adjusted for purchasing power parity)
Source: WHO sources World Health Statistics 2007
Value
8.4% (2004)
76.4% (2004)
23.6% (2004)
84.4% (2004)
3.6% (2004)
$2,392 (2004)
DATAMONITOR
The Italian healthcare system is based on a National Health Service (NHS) model.
Citizens and their employers make compulsory social contributions to the central
government, which in turn finances the National Health Fund (NHF). Money from this
fund is allocated to the regional authorities, who are responsible for funding the local
health units. The local health units directly fund the providers, paying out capitations for
GPs, salaries for public hospitals and per diems for hospitals under contract with the
105
NHF. This complicated method of funding has resulted in deep regional inequalities in
healthcare expenditures.
11.6. Resources
According to the OECD data (2006), Italy had 4.2 practicing physicians per 1,000
population in 2004 and 5.4 qualified nurses per 1,000 population in 2003. The number of
acute care hospital beds was 3.7 per 1,000 population in 2003. As in most OECD
countries, the number of hospital beds per capita in Italy has fallen over time. This
decline has coincided with a reduction of average length of stays in hospitals and an
increase in the number of surgical procedures performed on a same-day (or ambulatory)
basis. The following table (Table 16) gives the absolute number and density of physicians
and nurses in the recent years. For a complete review of the most up to date physician
statistics, please refer to the Italian physician statistics section of this report.
Table 16:
Italian physician and nurse numbers
Resource Indicator
Physicians (number)
Physicians (density per 1,000 population)
Nurses (number)
Nurses (density per 1,000 population)
Source: OECD Healthcare Statistics, 2007
Value (year)
241,000 (2004)
4.2 (2004)
312,377 (2003)
5.4 (2003)
DATAMONITOR
11.7. Italian pharmaceutical market
Italy is the fourth largest market in Europe and the sixth largest in the world. It is the third
largest producer of pharmaceuticals in Europe and the fifth largest in the world. There
were 240 pharmaceutical companies in Italy with 74,000 employees in 2004. Menarini,
the largest Italian pharmaceutical company had 2004 sales of USD 2.8 billion. Other
106
major companies include Sigma-Tau, Recordati, Chiesi and Zambon. The following table
(Table 17) shows retail sales by therapeutic category during 2005.
Table 17:
Italian retail sales by therapeutic category, 2005
Category
Cardiovascular
Central Nervous System
Alimentary/ Met.
Respiratory
Anti-infectives
Musculoskeletal
Genitourinary
Cytostatics
Blood Agents
Dermatologicals
Sensory Organs
Diagnostic Agents
Systemic Hormones
Miscellaneous
Hospital Solutions
Parasitology
Total
$m
% change
3,718
1,939
2,131
1,277
1,237
834
896
535
552
451
329
318
198
38
41
8
-2%
1%
2%
6%
-1%
-9%
2%
-7%
-3%
2%
1%
12%
-2%
-8%
-14%
9%
14.502
4%
Source: internal secondary research
DATAMONITOR
The SSN has attempted a variety of measures to control rising costs and has focused on
its prescription drug funding as one of the most readily managed segments of its budget.
The abolition of co-payments of prescription drugs resulted in a 25% decline in the
amount of total drug payments from private sources. The following table (Table 18) lists
the measures taken to reduce pharmaceutical spending since 2000.
107
Table 18:
Pharmaceutical reforms in Italy, 2001-2006
Year
Measure
2000
2001
• Nation wide elimination of patient co-payments
• Prescribing restrictions lifted for statins.Cox-2 inhibitors. other popular
2002
therapeutic categories
• Reinstatement of co-payments at regional discretion.
2003
2004
• 5% across-the-board price cuts
• Italy becomes the first major European market to implement reference
pricing at the pharmacological category rather than active ingredient level
• 7% across-the-board price cuts
• Elimination of Class B (Partially reimbursed) categories
• 5% tax on promotional spending
• Passage of Decree 156, which mandates that drug spending not exceed 13%
of the total health bill (or 16% when hospital drugs are included).
• Pharmaceutical manufacturers pay 60% of overspending, with the regions
paying the remainder
• Overspending of the target results in 6.8% across-the-board price cuts
2005
2006
introduced in June 2004 and ran through October 2005
• Selective reductions of up to 10% on drugs that grew faster than the market
in 2004 (56 active ingredients included).
• New drugs must negotiate price-volume agreements as condition of
admission to reimbursement lists.
• Revisions to reimbursement lists.
• Measures result in total savings of € 870 million during the year
• Products with selective reductions restored to December 2004 prices
• 2005 Expenditures totaled 17.8% of health budget versus 16% target; leading
to a 4.4% across-the-board price cut for reimbursed products.
• Mandatory discount of 1% (ex-factory) for reimbursed products sold in the
retail channel.
• 20% reductions (at pharmacy) of Class C (non0reimbursed) drugs.
Source: Datamonitor research
DATAMONITOR
According to secondary research, generics grew to 10.1% of market value and 21.7% of
prescription volume by early 2005 – however, about 81% was captured by branded
generics. Sales of true generics totaled only $522 million in 2005. This represented 2.4%
of the retail value and approximately 5% of retail volume. Sales in the true generic sector
were up by 49% in 2005. Despite growth of the generic sector, Italy is likely to remain a
brand-oriented market for some years.
Pharmacists are now legally obligated to switch branded prescriptions to generics, if the
option exists and if the physician has not marked “do not substitute”. Physicians are also
108
required to inform patients of the existence of generics and low cost prescribing is
reinforced using computerized tracking systems.
According to secondary research, sales of Class A (reimbursable) generics in 2005 were
dominated by gabapentin (Neurontin), which generated 46% of total reimbursable generic
sales. Class C (non-reimbursable) is dominated by lorazepam (Xanax), which had 32% of
sales. There were 2,273 total generic drugs with 139 different active ingredients in 2006.
This translates to 16.3 versions for each active ingredient. The median and average retail
prices were $9.4 and $13.6, respectively.
Pharmaceutical research spending totaled $1,252m in 2004, up from $1214m in 2003 and
$1,090 million in 2002 (secondary research). This represents 7% of total sales. Italian
companies have traditionally focused on generic rather than original drug development. A
new committee (CRS) within the AIFA (Italian Medicines Agency) was established in
the first quarter of 2005 to promote the domestic pharmaceutical research sector. A
National Monitoring Centre for Clinical Trials (Osservatorio Nazionale per le
sperimentazione cliniche) was established as a division of the AIFA to modernize and
support the clinical research industry in Italy. Guaranteeing a basic benefit package free
of user charges as well as uniform levels and quality of healthcare across the regions are
the current challenges of the Italian healthcare system.
109
11.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=ita&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007) World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=ita&indicators=healthpersonnel> [Accessed October 2007].
o World Health Organisation (2001), Health systems in transition 2001 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health
Systems
and
Policies.
Available
from:
<http://www.euro.who.int/document/e73096.pdf > [Accessed October 2007].
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o OECD data (2007), OECD Italy Health data 2007 [Internet] Available from: <
http://www.oecd.org/dataoecd/45/52/38979929.pdf> [Accessed October 2007].
o World Health Organisation Regional Office for Europe, Highlights on health
(2004),
[Internet].
Available
from:
<http://www.euro.who.int/document/E88550.pdf> [Accessed October 2007].
o Datamonitor (2006), Pricing & Reimbursement in Europe: Can the drive for cost
effectiveness overcome cost containment?, September 2006, DMHC2238.
110
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ITALY 2006
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
Total
TOTAL
MALE
%
FEMALE
%
293,933
216,547
74
77,386
26
Allergy / Immunology
1,673
1,034
62
639
38
Anatomic / Clinical Pathology
1,250
804
64
446
36
Anesthesiology
10,070
7,182
71
2,888
29
Cardiology
13,974
11,681
84
2,293
16
Cardiovascular Surgery
549
523
95
26
5
Clinical Biochemistry
367
200
54
167
46
2,419
1,558
64
861
36
15
15
100
0
0
Dermatology and Venereology
4,664
3,058
66
1,606
34
Endocrinology
6,174
3,982
64
2,192
36
Gastroenterology
6,242
4,941
79
1,301
21
Gastrointestinal Surgery
2,091
1,835
88
256
12
General Physicians
57,554
40,288
70
17,266
30
General Surgery
13,314
12,071
91
1,243
9
4,266
2,989
70
1,277
30
12,804
8,224
64
4,580
36
4,152
2,737
66
1,415
34
11,411
8,101
71
3,310
29
Infantile Neuropsychiatry
2,372
983
41
1,389
59
Infectious Disease
2,710
1,923
71
787
29
Internal Medicine
8,910
6,902
77
2,008
23
Legal Medicine
626
514
82
112
18
Maxillofacial Surgery
679
634
93
45
7
Medical Genetics
193
99
51
94
49
Medical Toxicology
856
648
76
208
24
Microbiology and Virology
653
413
63
240
37
Nephrology
2,869
1,975
69
894
31
Neurology
6,518
4,364
67
2,154
33
Clinical Pathology
Community Medicine
Geriatric Medicine
Gynecology and Obstetrics
Hematology
Hygiene / Preventive Medicine
111
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ITALY 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
TOTAL
Neurosurgery
MALE
%
FEMALE
%
766
709
93
57
7
Nuclear Medicine
1,021
778
76
243
24
Nutrition
1,679
1,012
60
667
40
Occupational Medicine
6,449
5,083
79
1,366
21
20,793
17,232
83
3,561
17
Oncology
3,764
2,673
71
1,091
29
Ophthalmology
6,038
4,376
72
1,662
28
Orthopedic Surgery and Traumatology
7,230
6,862
95
368
5
Otolaryngology
5,938
4,986
84
952
16
724
586
81
138
19
18,902
9,853
52
9,049
48
616
447
73
169
27
Physical Medicine and Rehabilitation
4,783
3,478
73
1,305
27
Psychiatry
7,418
4,754
64
2,664
36
Pulmonology
6,548
5,277
81
1,271
19
280
192
69
88
31
Radiodiagnostics
7,197
5,912
82
1,285
18
Reconstructive Plastic Surgery
1,214
1,046
86
168
14
Rheumatology
1,837
1,243
68
594
32
Sports Medicine
4,156
3,631
87
525
13
Thoracic Surgery
1,176
1,108
94
68
6
347
284
82
63
18
Urology
3,829
3,670
96
159
4
Vascular Surgery
1,853
1,677
91
176
9
Odontostomatology
Pediatric Surgery
Pediatrics
Pharmacology
Radiation Oncology
Tropical Medicine
Source: International Department, Italian Medical Council (FNOMCEO), 2006, [Accessed October 2007].
112
12. Japan
113
12.1. Introduction to Japan
Japan is an island country in East Asia. Located in the Pacific Ocean, it lies to the east of
China, Korea and Russia, stretching from the Sea of Okhotsk in the north to the East
China Sea in the south. The characters that make up Japan's name mean "sun-origin",
which is why Japan is sometimes identified as the "Land of the Rising Sun". A major
economic power, Japan has the world's second largest economy by nominal GDP. It is a
member of the United Nations, G8, G4 and APEC, with the world's fifth largest defense
budget. It is also the world's fourth largest exporter and sixth largest importer and a world
leader in technology and machinery.
While there exists eight commonly defined regions of Japan, administratively Japan
consists of forty-seven prefectures, each overseen by an elected governor, legislature and
administrative bureaucracy. The city of Tokyo, which with just over 8 million
inhabitants, has the highest number of inhabitants of all cities in Japan, is further divided
into twenty-three special wards, each with the same powers as cities. The nation is
currently undergoing administrative reorganization by merging many of the cities, towns
and villages with each other. This process will reduce the number of sub-prefecture
administrative regions and is expected to cut administrative costs. A map of Japan, along
with the names of the 47 prefectures, is shown in the following figure (Figure 11).
114
Figure 11:
Geographical map of Japan with location and names of prefectures
Source: www.servas-japan.org
DATAMONITOR
Japan's population is estimated at around 127.4 million. For the most part, Japanese
society is linguistically and culturally homogeneous with small populations of foreign
workers, Zainichi Koreans, Japanese Chinese, Japanese Filipinos, Japanese Brazilians
and others. The most dominant native ethnic group is the Yamato people; the primary
minority groups include the indigenous Ainu and Ryukyuans, as well as social minority
groups like the burakumin. Japan has one of the highest life expectancy rates in the
world, at 81.25 years of age as of 2006. However, the Japanese population is rapidly
aging, the effect of a post-war baby boom followed by a decrease in births in the latter
115
part of the twentieth century. In 2004, about 19.5% of the population was over the age of
65.
12.2. Japan’s healthcare system
Healthcare provision (including inpatient, outpatient and tertiary care) in Japan is covered
by public universal insurance funded by contributions from employees, employers and
the government. The system has been in place since 1961, when every patient was made
to join employee insurance programs or the National Health Insurance (NHI) system.
Approximately 80% of Japan’s healthcare spending is funded by public sources, which is
considerably higher than the US, where 45% of healthcare is funded by public sources.
However, it is similar to other major markets in Europe, which have healthcare systems
dominated by government-led public healthcare provision.
12.3. Public healthcare insurance in Japan
People are assigned an insurance scheme based on their employment or residence. These
insurance schemes, which are not-for-profit, are regulated and in some cases managed by
the government, and provision is thought of as egalitarian, with patients historically
shouldering a minimal burden of healthcare costs. Company employees are covered by
the Social Insurance System (SIS), representing approximately 63% of the population.
These are delivered through approximately 1,800 entities nationwide, which are known as
Health Insurance Societies. Premiums are based on the employees’ incomes and represent
approximately 8.5% of their salaries. The remaining 37% of the population are covered
by NHI, which is provided through approximately 3,400 regional plans. The wide range
of insurance schemes vary in terms of contribution, national subsidies and benefits levels,
although the reimbursement system is the same. Public insurance bodies cannot compete
for members because patients are not allowed to choose their fund, nor can they tailor
their product offering, choose which patients to cover, or negotiate with providers.
Therefore, they have limited scope for containing costs.
116
Additionally, patients are also covered by long-term care insurance (Kaigo Hoken),
which was initiated in April 2000 to cover the elderly population. This insurance is
designed to increase the percentage of elderly patients who can live on their own by
providing them with home-care services. The premiums for this insurance are shared
equally between the government and the population aged over 40. To qualify for this type
of insurance, patients must be older than 65, or 40–64 and suffering from one of 15
conditions (e.g. pre-senile dementia). This has been a key strategy designed to tackle the
ageing population and its creation highlights the fact that the government realizes it has to
take significant steps to cope with this problem. This sector of the market is set to
experience significant growth given the ageing population, with Japan’s largest life
insurance company Nippon Life estimating that the market will be worth ¥9 trillion in the
short term (Economist Intelligence Unit, 2005).
12.4. Hospitals remain the first port-of-call
Japan has a much stronger in-patient culture than European countries, with 43% of the
total pharmaceutical spending generated by the hospital sector. In contrast, 27% of drug
spending was generated by the primary care setting (Scrip #3112, December 2005). This
can be compared to European markets such as France, where drugs prescribed in
hospitals represent only 17% of total pharmaceutical spending, compared to retail
pharmacies in the outpatient setting, which account for 77% (Chicoye, 2003). Despite
this, healthcare provision is increasingly weighted towards outpatient care, since Japan
has the highest rate of physician visits and the lowest rate of hospital admissions. This
apparent contradiction can be explained by three factors:
o most patients choose hospitals as their first port-of-call when they have a medical
problem. This is partly because hospitals have evolved to offer primary care in an
outpatient setting as part of the blurring between primary and secondary care in
Japan. It also relates to the fact that patients believe specialists at large hospitals
provide the best medical advice;
117
o when patients get into hospital, they stay longer: Japan has the longest average
length of stay (ALOS) per patient in the major markets (Scrip #3134, February
2006);
o most institutional care for the elderly is provided by hospitals (often as part of
shakaiteki nyuin: the process of social admissions), rather than tertiary care
common in Europe. These long-term inpatients remain in hospital because of a
lack of in-home care services, a fear of disease and the lower co-payment burden.
If these long-term inpatients were taken out of total healthcare expenditure, the
total healthcare spending for the elderly would be cut by 25% (Fukawa &
Izumida, 2004).
Additionally, patients are also covered by long-term care insurance (Kaigo Hoken),
which was initiated in April 2000 to cover the elderly population. The premiums for this
insurance are shared equally between the government and the population aged over 40.
This sector of the market is set to experience significant growth given the ageing
population, with Japan’s largest life insurance company Nippon Life estimating that the
market will be worth ¥9 trillion in the short term (Datamonitor DMHC2265). There is a
wide range of bodies and groups representing a number of different healthcare providers
and users that affect healthcare provision in Japan, as detailed in the following figure
(Figure 12).
118
Figure 12:
Stakeholders impacting healthcare provision in Japan
Source: internal secondary research
DATAMONITOR
12.5. Service delivery
Patients are able to seek care at hospitals of their choice. By law, hospitals and clinics are
owned by physicians and may not be operated for profit. Despite pressure from trading
partners and the possibility of reducing costs, the legalization of the for-profit sector was
denied in 2001 and will probably not be authorized on a broad scale in the near future.
There are, however, 59, investor owned hospitals that existed prior to passage of the 1948
law. A July 2003 law allowed for profit hospitals in designated “deregulation zones,” but
these are completely excluded from the reimbursement system (internal secondary
research).
The lack of a referral system, where GPs act as a gatekeeper to secondary and tertiary
hospital care, has resulted in a blurring of functions. Primary care is delivered by hospital
outpatient departments as well as GP clinics and inpatient care is offered by clinics as
well as hospitals. The government is attempting to reform and rationalize the system to
119
restrict inpatient care to hospitals and outpatient care to GP clinics and its efforts have
had some effect.
12.6. Healthcare financing and expenditure
Total health spending accounted for 8.0% of GDP in Japan in 2004. Japan’s health
spending per capita, amounted to 2358 USD in 2004 (adjusted for purchasing power
parity). Health spending per capita in Japan rose, in real terms, by 2.1% between 2000
and 2004. In Japan, 81.7% of health spending is funded by public sources, well above the
average of 72.5% in OECD countries. The following table (Table 19) shows the key
health expenditure indicators in 2004.
Table 19:
Key Japanese health expenditure indicators, 2004
Indicator
Total expenditure on health as percentage of gross domestic
product
Public expenditure on health as percentage of total
expenditure on health
Private expenditure on health as percentage of total
expenditure on health
General government expenditure on health as percentage of
total government expenditure
Out-of-pocket expenditure as percentage of private
expenditure on health
Per capita total expenditure on health (adjusted for purchasing
power parity)
Source: OECD Health data, 2007
Value (year)
8% (2004)
81.7% (2004)
18.3% (2004)
17.2% (2004)
94.9% (2004)
$2,358 (2004)
DATAMONITOR
Over the last several years, the government has made a number of moves to shift the
burden of payment to patients: in 2002, elderly patients were required to contribute 10%
co-payments, in April 2003, the co-payment for rest of the population was raised to 30%
from 20%, and the out-of-pocket ceiling for expensive operations was raised over a three
year period ending in 2003. These cost-sharing initiatives are continuing, with the most
prominent example being a new health insurance plan for people 75 years or older. This
plan will commence in 2008 and will require participants to bear a higher proportion of
120
the cost for their care. As the first step, wealthier patients over 70 will have to meet the
30% co-payment level starting in October 2006 (internal secondary research).
12.7. Resources
According to OECD Health data (2007), Japan had 2 practicing physicians per 1,000
population in 2004. On the other hand, Japan had 9 nurses per 1,000 population in 2004.
Japan had the highest number of acute care hospital beds of all OECD countries, with 8.2
beds per 1,000 population in 2005. The Japanese healthcare system has several distinctive
features compared with the US and Europe. It has a high number of hospital beds per
person (about 16 per 1,000) and long hospital stays (around 30 days on average), while
the relatively low number of doctors per person and the lack of an appointment system
results in overcrowding and long waits for outpatients (Macro environmental healthcare
issues in Japan, 2004). The following table (Table 20) gives the absolute number and
density of physicians and nurses in the recent years.
Table 20:
Physicians and Nurses
Resource indicator
Physicians (number)
Physicians (density per 1,000 population)
Nurses (number)
Nurses (density per 1,000 population)
Source: OECD Health Data, 2007
Value (year)
251,889 (2002)
2.0 (2004)
993,628 (2002)
9.0 (2004)
DATAMONITOR
According to the Pharma Handbook (2006), Japan has over 9,000 hospitals with over 1.6
million beds. About 8,000 hospitals are privately owned, approximately 1,000 are owned
by local government authorities and about 300 are owned by the national government or
by national government agencies. Over half of the beds are acute, while long-term care
and psychiatric care beds both number approximately 350,000. Of the approximately 1.9
million beds in the healthcare system, according to the October 2001 census, around 11%
were in GP clinics (internal secondary research). For a complete review of the most up to
121
date physician statistics, please refer to the Japanese physician statistics section of this
report.
Table 21:
The number of hospitals, GP clinics, dental clinics, plus beds, in Japan in
2001
Institution
No. of institutions
No. of beds
9,239
94,019
64,297
1,646,797
209,544
153
Hospitals
GP clinics
Dental clinics
Source: Ministry of Health, Labor and Welfare
DATAMONITOR
12.8. Japanese pharmaceutical market
Japan accounts for 10% of global pharmaceutical sales, making it the world’s second
largest market. IMS reports that total market value reached $60.3 billion in 2005, an
increase of 7% over 2004 (internal secondary research). Per capita consumption in 2005
was $411. The following table (Table 22) shows the sales by therapeutic category in
2005.
122
Table 22:
Japanese pharmaceutical sales by therapeutic category, 2005
Sales $m
2005
Growth on
Previous
year %
Cardiovascular
Central Nervous System
Alimentary/ Metabolic
Respiratory
Antiinfectives
Musculoskeletal
Genitourinary
Cytostatics
Blood Agents
Dermatologists
Sensory Organs
Diagnostic Agents
Systemic Hormones
Miscellaneous
Hospital Solutions
Parasitology
12,049
4,942
8,474
4,357
6,304
3,856
1,335
5,288
3,801
1,295
1,859
2,215
1,129
1,568
1,795
4
6%
8%
4%
15%
8%
5%
7%
13%
5%
-3%
8%
8%
2%
5%
0%
-10%
Total
60,271
7%
Category
Source: internal secondary research
DATAMONITOR
Generic products have a very low penetration in the Japanese market: 11% of market
volume and 6% of market value in 2005 (internal secondary research). Brands in Japan
tend to lose 5% to 10% of market share annually after generic entry.
Members of the Japanese Pharmaceutical Manufacturers Association spent an average of
13.7% of sales on research and development in the first half of 2005. This compares to
13% in the same period of 2004 and suggests a long-term growth in R&D spending. It is
estimated that the cost of enrollment in Japanese clinical trials amounts to $50,000 per
patient - much higher than most markets. Additionally, the clinical trials system has been
liberalized in recent years with greater recognition of foreign-generated data and easier
procedures for patient enrollment.
123
Until the late 1990s, the government required extensive domestic testing as a condition
for approval. High costs and the ability to use outside data have severely restricted
clinical trial activity: total trials fell to 361 in 2003 from 1,200 in 1993. As part of a
collaborative industry-government plan to promote the clinical trials industry, the
National Center for Highly Specialized Medical Treatment has been working to create a
large scale-network of numerous medical institutions that will conduct both physician-led
and company-sponsored trials. Until 2003, data generated in university-led trials could
not be used for drug approval purposes. Additionally, schools are now allowed to set up
separate entities (independent administrative institutions or IAI) for commercialization
purposes. As a result of the regulatory changes, academic researchers are becoming
increasingly involved in the drug development process. There are 32 contract research
firms in Japan.
The Japanese industry has seen considerable consolidation in recent years. In large part,
this is due to the scale required to compete on a global basis, but changes in corporate law
and the reduction of barriers to foreign companies in Japan have also contributed. A 2006
law allowing foreign companies to purchase Japanese firms via share swaps should
accelerate the acquisition process. In addition to M&A activity, globalization was also
evidenced by a 26% increase in partnership arrangements in 2005 over the previous year.
The Japanese biotech industry’s total market capitalization is approximately $5.1 billion
– making it the fourth largest in the world. Three companies (AnGes MG, Sosei, Takara
Bio) account for approximately 62% of this amount. Including these majors, there are 464
biotech companies employing some 4,200 people. Life science accounts for 12%, or $133
million, of Japanese venture capital investments.
124
12.9. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=jp&indicators=selected&language=en> [Accessed October 2007].
o OECD data (2007), OECD Japan Health data 2007 [Internet] Available from: <
http://www.oecd.org/dataoecd/45/51/38979974.pdf> [Accessed October 2007].
o Datamonitor (2006), Pricing and Reimbursement in Japan: Costly healthcare
system inefficiencies increase the focus on healthcare cost containment,
November 2006, DMHC2265.
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
o Datamonitor (2004), Macro-environmental healthcare issues in Japan.
125
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL PHYSICIANS
TOTAL
MALE
%
FEMALE
%
256,668
214,628
84
42,040
16
207
167
81
40
19
Anesthesiology
6,397
4,538
71
1,859
29
Cardiology
9,009
8,139
90
870
10
Cardiovascular Surgery
2,632
2,533
96
99
4
342
300
88
42
12
Allergy
Cosmetic Surgery
Dermatology
7,780
4,824
62
2,956
38
Gastroenterology
10,352
9,270
90
1,082
10
General Medicine
3,883
2,608
67
1,275
33
Gynecology
1,562
1,170
75
392
25
15
73,670
62,749
85
10,921
Lung Surgery
Internal Medicine
1,110
1,059
95
51
5
Neurology1
3,908
3,194
166
714
34
Neurosurgery
6,287
6,052
96
235
4
431
340
79
91
21
Obstetrics and Gynecology
10,163
7,951
78
2,212
22
Ophthalmology
12,452
7,867
63
4,585
37
Orthopedics
18,771
18,087
96
684
4
9,076
7,408
82
1,668
18
Obstetrics
Otolaryngology
Pediatric Surgery
Pediatrics
Plastic Surgery
682
577
85
105
15
14,677
10,105
69
4,572
31
1,765
1,402
79
363
21
Proctology
393
379
96
14
4
Psychiatry
12,151
9,906
82
2,245
18
752
591
79
161
21
Pulmonology
3,655
3,056
84
599
16
Radiology
4,780
3,899
82
881
18
Rehabilitation
1,696
1,402
83
294
17
Psychosomatic Medicine
126
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
Rheumatology
Surgery
Tracheoesophagology
Unknown
Urology
Venereology
Others2
1 Neurology+Nerve Internal Medicine
2 Others+Major Diagnosis and Treatment
TOTAL
MALE
%
FEMALE
%
640
516
81
124
19
23,240
22,160
95
1,080
5
40
38
95
2
5
264
197
75
67
25
6,032
5,838
97
194
3
22
21
95
1
5
7,847
6,285
165
1,562
35
Source: Statistics and Information Department, Minister's Secretariat, Ministry of Health, Labour and Welfare, Japan, [Accessed October 2007].
127
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL PHYSICIANS
TOTAL
UNDER 35
35-44
45-54
55-64
65 AND OVER
256,668
256,668
513,336
770,004
1,283,340
207
35
44
62
34
32
Anesthesiology
6,397
2274
2134
1419
459
111
Cardiology
9,009
2651
3197
2019
795
347
Cardiovascular Surgery
2,632
781
967
631
211
42
342
94
134
77
26
11
Allergy
Cosmetic Surgery
Dermatology
3,080,016
7,780
1708
2022
1902
1040
1108
Gastroenterology
10,352
2503
3195
2463
1287
904
General Medicine
3,883
3678
119
31
16
39
Gynecology
1,562
118
259
330
236
619
17385
Internal Medicine
73,670
11224
15330
18252
11479
Lung Surgery
1,110
310
429
276
84
11
Neurology1
3,908
1,123
1,285
942
365
193
Neurosurgery
6,287
1414
2056
1701
800
316
431
100
112
109
74
36
Obstetrics and Gynecology
10,163
1976
2314
2170
1592
2111
Ophthalmology
12,452
2771
3724
2861
1232
1864
Orthopedics
18,771
3870
5606
4511
2469
2315
9,076
1712
2358
2101
1034
1871
682
208
203
150
97
24
14,677
3330
3239
3819
2171
2118
Obstetrics
Otolaryngology
Pediatric Surgery
Pediatrics
Plastic Surgery
1,765
695
587
337
102
44
Proctology
393
16
92
123
92
70
Psychiatry
12,151
2455
3395
2911
1586
1804
752
105
218
253
94
82
Pulmonology
3,655
1194
1229
826
254
152
Radiology
4,780
1396
1758
1138
341
147
Rehabilitation
1,696
285
514
425
210
262
Psychosomatic Medicine
128
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN JAPAN 2004
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
Rheumatology
Surgery
Tracheoesophagology
Unknown
Urology
Venereology
Others2
1 Neurology+Nerve Internal Medicine
2 Others+Major Diagnosis and Treatment
UNDER 35
35-44
45-54
55-64
65 AND OVER
640
179
210
138
73
40
23,240
5057
6309
5027
3190
3657
40
5
20
10
2
3
264
105
45
20
26
68
6,032
1410
1888
1555
775
404
22
1
3
4
3
11
7,847
2,861
1,711
1,413
842
1,020
Source: Statistics and Information Department, Minister's Secretariat, Ministry of Health, Labour and Welfare, Japan, [Accessed October 2007]..
129
13. Spain
130
13.1. Introduction to Spain
Spain is a Western European country. The country consists of Peninsular Spain which is
located between the Mediterranean Sea and the Atlantic Ocean, two archipelagos, one in
each sea, and two autonomous cities in North Africa.
The Spanish mainland is bordered by the Mediterranean Sea to the south and east, by the
Cantabric Sea that includes the Bay of Biscay to the north, and by the Atlantic Ocean and
Portugal to the west. Spanish territory also includes the Balearic Islands in the
Mediterranean and the Canary Islands off the African coast. It shares land borders with
Portugal, France, Andorra, the British overseas territory of Gibraltar, and Morocco. It is
the largest of the three sovereign states that make up the Iberian Peninsula — the others
being Portugal and Andorra. With an area of 504,030 km², Spain is the second largest
country in Western Europe (behind France). Spain is a constitutional monarchy organized
as a parliamentary democracy, and has been a member of the European Union since
1986. It is a developed country with the ninth largest economy in the world and fifth
largest in the EU, based on nominal GDP.
Spain is divided into 17 autonomous communities (comunidades autónomas) and 2
autonomous cities (ciudades autónomas) - Ceuta and Melilla. These autonomous
communities are subdivided into 50 provinces (provincias). Historically, some provinces
are also divided into comarcas (roughly equivalent to a US "county" or an English
district). The lowest administrative division of Spain is the municipality (municipio)
(Figure 13).
131
Figure 13:
Map of Spain
Source: www.paradoxplace.com
DATAMONITOR
In 2007 Spain officially reached 45 million people registered at the Padrón municipal, an
official record analogous to the British Register office. Spain's population density, at
87.8/km² (220/mile2), is lower than that of most Western European countries and its
distribution along the country is very unequal. With the exception of the region
surrounding the capital, Madrid, the most populated areas lie around the coast.
The population of Spain doubled during the twentieth century, due to the spectacular
demographic boom by the 60's and early 70's. The pattern of growth was extremely
uneven due to large-scale internal migration from the rural interior to the industrial cities
during the 60's and 70's. No fewer than eleven of Spain's fifty provinces saw an absolute
132
decline in population over the century. Then, after the birth rate plunged in the 80's and
Spain's population became stalled, a new population increase started based initially in the
return of many Spanish who emigrated to other European countries during the 70's and,
more recently, it has been boosted by the large figures of foreign immigrants, mostly
from Latin America (38.75%), Eastern Europe (16.33%), North Africa (14.99%) and
Sub-Saharan Africa (4.08%).
In 2005, Spain instituted a 3-month amnesty program through which certain hitherto
undocumented aliens were granted legal residency. Also some important pockets of
population coming from other countries in the European Union are found (20.77% of the
foreign residents) , specially along the Mediterranean costas and Balearic islands, where
many choose to live their retirement or even telework. These are mostly English, French,
German, and Dutch from fellow EU countries and, from outside the EU, Norwegian. The
demographic distribution of Spain’s population in 2005 is given in the following figure
(Figure 14).
Figure 14:
Demographic distribution of Spain’s population, 2005
Source: given in figure above
DATAMONITOR
133
13.2. Spanish healthcare system
The 1986 General Health Care Act outlines the main principles of the Spanish National
Healthcare System (NHS). This system, created from the social security health services,
provides universal coverage with free access to healthcare, is publicly funded, mainly
through taxation, and has a regional organizational structure.
Public healthcare provision is coordinated by the Ministry of Health (MoH; Ministero de
Sanidad y Consumo). However, over the last 25 years, the Spanish healthcare system has
become increasingly devolved, with the 17 Autonomous Communities (ACs)
increasingly dominating healthcare provision. Regional healthcare funds are allocated
budgets following discussion between central and regional finance ministers. The
Ministry of Health has continued to govern the public healthcare service, although it is
relatively weak compared to other European central governance bodies. The
Interterritorial Council of the NHS (Consejo Interterritorial del Sistema Nacional de
Salud), composed of representatives of the autonomous communities and the State,
promotes the cohesion of the system (Health systems in transition, 2006). Given the wide
variation between the different regions of Spain, there is now considerable variation in
health policies from one region to another.
A key trend in the Spanish healthcare system is its decentralization, which was largely
completed in 2002, with the result that healthcare provision is now the primary
responsibility of Spanish ACs. The following figure (Figure 15) gives an overview of the
healthcare system in Spain (internal secondary research).
134
Figure 15:
The Spanish healthcare system
Source: Lopez-Casasnovas et al., 2005
DATAMONITOR
Access to healthcare is available for everyone, primarily via public health insurance, to a
lesser extent via private insurance or, in certain cases, through national healthcare
charities. The public compulsory healthcare insurance scheme covers 98% of the Spanish
population, which is part of the Social Security (Seguridad Social) system. The public
health insurance scheme covers all employees, the self-employed and their dependents,
the unemployed and pensioners. As in many other public healthcare systems, however,
patient waiting times can be quite long. As such, many Spaniards are willing to make outof-pocket payments or pay for private insurance to access services more quickly.
Approximately 15% of Spaniards have private health insurance, while a further 10% buy
supplemental coverage from private health provider. Under the public health insurance
system, patients are not required to make any payment towards the cost of medical care
and are reimbursed for a percentage of the cost of pharmaceuticals if they are prescribed
135
by a doctor working in the public sector. Patients must pay for drugs prescribed by a
private doctor, although private insurance may cover drug costs.
13.3. Healthcare insurance
Access to healthcare is available for everyone, primarily via public health insurance, to a
lesser extent via private insurance or, in certain cases, through national healthcare
charities. The public compulsory healthcare insurance scheme covers 98% of the Spanish
population, which is part of the Social Security (Seguridad Social) system. The public
health insurance scheme covers all employees, the self-employed and their dependents,
the unemployed and pensioners. As in many other public healthcare systems, however,
patient waiting times can be quite long. As such, many Spaniards are willing to make outof-pocket payments or pay for private insurance to access services more quickly.
Approximately 15% of Spaniards have private health insurance, while a further 10% buy
supplemental coverage from private health provider (Datamonitor DMHC2216, 2006).
Under the public health insurance system, patients are not required to make any payment
towards the cost of medical care and are reimbursed for a percentage of the cost of
pharmaceuticals if they are prescribed by a doctor working in the public sector. Patients
must pay for drugs prescribed by a private doctor, although private insurance may cover
drug costs.
13.4. Service delivery
Healthcare provision is managed within each region by the autonomous regional
governments’ relevant regional healthcare organization, such as the Catalan Health
Service (Servei Catala de la Salut – Catsalud) and the Andalucia Health Service (Servicio
Andaluz de Salud). It includes the provision of hospitals (public or private), including
university hospitals, private clinics, primary healthcare centers and outpatient centers,
office-based specialists, GPs, community nurses, ambulance services and dentists.
Benefits covered by the NHS include primary health care, which covers medical and
136
pediatric health care, prevention of disease, health promotion and rehabilitation;
specialized health care in the form of outpatient and inpatient care, which covers all
medical and surgical specialties in acute care; and pharmaceutical benefits and
complementary benefits such as prostheses or orthopedic products. Dental care is heavily
underprovided in Spain.
In Italy, about 70% of hospitals are in the public sector and 30% in the private sector,
although this split can vary from region to region, with the percentage of private beds
being higher in prosperous regions such as Catalonia and lower in poorer regions such as
Andalucia and Extremadura. The majority of Spanish healthcare is delivered by public
healthcare providers. Almost 100% of primary care and the majority of hospitals are
owned and managed by the public sector.
Pursuant to the General Health Care Act (1986), primary health care (PHC) was given an
independent, reinforced status. The first contact point of the population with the health
system is the general practitioner, who acts as a gatekeeper. PHC coverage is rising with
the reformed network and, by 2001, was well above 90% in most autonomous
communities (WHO Regional Office for Europe, 2004).
Despite the political focus on PHC, the health system is still centered around hospitals.
Alongside the hospital system, there is an extensive network of outpatient ambulatory
centers. In the reformed model of provision, members of the specialist teams in clinical
departments rotate to cover outpatient care in ambulatory centers. Although waiting times
have decreased, they are still considerable in public health care provision.
13.5. Healthcare financing and expenditure
Total healthcare expenditure in Italy accounted for 8.2% of GDP in 2005. Spain is low in
terms of health spending per capita, with spending of $2,255 in 2005 (adjusted for
purchasing power parity) compared to other OECD countries. In 2005, 71.4% of health
spending was funded by public sources. The government expenditure on health accounted
137
for 14.7% of the total government expenditure in 2004 and the per capita government
expenditure on health amounted to $1,397.
The rise in pharmaceutical spending has been one of the factors behind the rise in total
health spending in Spain. In 2005, spending on pharmaceuticals accounted for 22.9% of
total health spending, up from 19.2% in 1995. But the one factor boosting cost
effectiveness is the relatively low price of drugs in Spain, compared to the rest of Europe,
and recent growth in pharmaceutical expenditure has been attributed to an increase in
prescription volume, rather than an increase in price per prescription (internal secondary
research). The following table (Table 26) shows the recent key health expenditure
indicators in the recent years.
Table 23:
Spanish healthcare spending statistics
Value
Indicator
Total expenditure on health as percentage of gross domestic product
Public expenditure on health as percentage of total expenditure on health
Private expenditure on health as percentage of total expenditure on health
Out-of-pocket expenditure as percentage of private expenditure on health
Private prepaid plans as percentage of private expenditure on health
Per capita total expenditure on health (adjusted for purchasing power parity)
Source: OECH Health Data, 2007
8.2% (2005)
71.4% (2005)
28.6% (2005)
81% (2004)
16.2% (2004)
$2,255 (2005)
DATAMONITOR
The health care system is financed out of general taxation such as value-added tax,
income tax and regionally raised taxes. Two autonomous communities, País Vasco and
Navarra, have gained relatively great fiscal autonomy. Private health care financing
complements public financing with out-of-pocket payments to the public system (such as
co-payments for pharmaceuticals) as well as the private sector (such as private outpatient
care) and contributions to voluntary insurance. Hospital payment mechanisms vary
among
autonomous
communities.
Traditionally
hospital
expenditures
were
retrospectively reimbursed, with no prior negotiation and no formal evaluation. During
the past two decades, the use of contract programs with prospective financing of target
138
activities increased, especially for private hospitals. Most physicians are employed by the
public sector and receive fixed salaries.
13.6. Resources
According to OECD Health data (2007), Spain had 3.8 practicing physicians per 1,000
population in 2005, above the OECD average of 3.0, despite the relatively low level of
health expenditure. On the other hand, there were 7.4 qualified nurses per 1,000
population in the same year.
There are approximately 800 hospitals in Spain. The number of acute care hospital beds
in Spain was 2.6 per 1,000 population in 2004. The number of hospital beds per capita in
Spain has fallen over time. This reduction has coincided with a reduction of average
length of stays in hospitals and an increase in the number of surgical procedures
performed on a same-day (or ambulatory) basis. The following table (Table 24) gives the
absolute number and density of physicians and nurses in the recent years. For a complete
review of the most up to date physician statistics, please refer to the Spanish physician
statistics section of this report.
Table 24:
Spanish physician and nurse numbers
Resource Indicator
Physicians (number)
Physicians (density per 1,000 population)
Nurses (number)
Nurses (density per 1,000 population)
Source: OECD Healthcare Statistics, 2007
Value (year)
135,300 (2003)
3.8 (2005)
315,200 (2003)
7.4 (2005)
DATAMONITOR
139
13.7. Spanish pharmaceutical market
The Spanish pharmaceutical market is the seventh largest in the world, valued at $21
billion in 2006 (The pharmaceutical market: Spain, 2006, Espicom report). There are
currently around 270 pharmaceutical companies with production activity and
approximately 375 laboratories in Spain. Spanish pharmaceutical companies employ
about 39,000 people, which represents about 7% of the total European pharmaceutical
industry workforce (Outlook for pharmaceutical market in Spain looks strong, 2004,
Chiltern International report).
Spain’s pharmaceutical manufacturing sector is fragmented but advanced. It is almost
entirely concentrated in Barcelona and Madrid. Almirall Prodesfarma and Esteve are the
leading domestic producers, with sales valued at $1.2 billion and $1 billion, respectively,
in 2005 (The pharmaceutical market: Spain, 2006, Espicom report). It is estimated that
foreign companies now represent 75% of pharmaceutical producers in Spain. In 2002,
eight multinational companies featured among the top ten leading companies in Spain
and accounted for over 50% of the national market. The majority of sales of new
medicines in Spain have been in the oncology, cardiovascular and central nervous system
(CNS) categories.
The IMS Health market data reveal that between 2001 and 2002, the Spanish
pharmaceutical market grew by over 10% (Business briefing: Pharma outsourcing report,
Spain and the pharmaceutical industry, 2004). Although Spain has been considered as
one of the lower-priced European countries for pharmaceuticals, prices for innovative
new products are rapidly converging with those of neighboring countries. Industry figures
show that in 2002, a total of 185 new pharmaceutical products were launched in Spain, of
which generics represented 55% (Outlook for pharmaceutical market in Spain looks
strong, 2004, Chiltern International report). The average price of innovative therapeutic
products was $20, which was considerably higher than the average price for existing
medicines ($9.5) (Outlook for pharmaceutical market in Spain looks strong, 2004,
Chiltern International report).
140
Spain has one of the lowest generic use rates in the EU, with generics only accounting for
8.1% of the 5EU pharmaceutical markets in terms of volume. The generics market
accounted for 5.1% of 5EU pharmaceutical sales in 2004, resulting in a total value of
$715 million (The pharmaceutical market: Spain, 2006, Espicom report). Growth in the
generic sector has been impressive in recent years, although it still only accounts for
5.4% of the market by value and 9.4% by volume in 2005 (Spain and the pharmaceutical
industry, 2004, Business briefing: Pharma outsourcing report). There has been an
increase in the number of generic medicines available in Spanish hospitals with new data
showing that they accounted for 17.7% of all treatments authorized for use in hospitals in
October 2005 (The pharmaceutical market: Spain, 2006, Espicom report). Between 1999
and 2002, there was a 31.5% increase in research & development (R&D) activity for the
Spanish pharmaceutical industry. The following figure (Figure 16) shows the distribution
of funds for pharmaceuticals R&D in 2000.
Figure 16:
Allocation of pharmaceutical R&D funds, 2000
Source: Business briefing: Pharma outsourcing report, Spain and the
DATAMONITOR
pharmaceutical industry, 2004
Low prices make Spain a major source of parallel-trade drugs in the European Union.
Spain exported $3.6 billion of finished drugs in 2004, of which over 35% went to the UK
and Germany (The pharmaceutical market: Spain, 2006, Espicom report). The extension
of the public network, the transition from a social security system to a tax-funded system
141
and decentralization to the autonomous communities has reaped particularly favorable
results. The formal goal of shifting the focus of the health care system towards PHC has
not been accomplished yet. Challenges to be addressed include long waiting times,
information development, managerial autonomy and the expansion of social and
community care.
142
13.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=esp&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007), World health statistics [Internet]. Available
from:<http://www.who.int/whosis/database/core/core_select_process.cfm?country
=esp&indicators=healthpersonnel> [Accessed October 2007].
o World Health Organization (2006), Health systems in transition 2006 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health
Systems
and
Policies.
Available
from:
<http://www.euro.who.int/Document/E89491.pdf> [Accessed October 2007].
o OECD data (2007), OECD Spain Health data 2007 [Internet] Available from:
<http://www.oecd.org/dataoecd/46/7/38980294.pdf> [Accessed October 2007].
o Chiltern International report (2004), Outlook for pharmaceutical market in Spain
looks
strong
[Internet].
Available
<http://www.medicalnewstoday.com/articles/6800.php>
[Accessed
from:
October
2007].
o Datamonitor (2006), Pricing & Reimbursement in Europe: Can the drive for cost
effectiveness overcome cost containment?, September 2006, DMHC2238.
o Datamonitor (2006), Global Generics Guide: Part 2 - Benchmarking country
markets and strategic issues, June 2006, DMHC 2216.
o World Health Organization Regional Office for Europe, Highlights on health
(2004),
[Internet].
Available
from:
<http://www.euro.who.int/eprise/main/who/progs/chhspa/system/20050131_1>
[Accessed October 2007].
o Espicom report (2006), Spain generics market report, [Internet] Available from:
<https://www.espicom.com/Prodcat.nsf/Search/00000097?OpenDocument>
[Accessed October 2007].
143
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL PHYSICIANS
TOTAL
MALE
%
FEMALE
%
149,942
82,702
55
67,240
45
Allergy / Immunology1
1,063
527
50
536
50
Anesthesiology / Intensive Care Medicine2
6,128
3,160
52
2,968
48
Cardiovascular Diseases
2,133
1,578
74
555
26
765
606
79
159
21
1,304
587
45
717
55
899
450
50
450
50
1,812
1,160
64
652
36
76,180
39,880
52
36,300
48
3,797
2,848
75
949
25
737
339
46
398
54
Hematology
1,341
617
46
724
54
Internal Medicine
5,289
3,173
60
2,116
40
803
337
42
466
58
Nephrology
1,135
658
58
477
42
Neurology4
2,190
1,253
57
937
43
Neurosurgery
475
375
79
100
21
Nuclear Medicine
455
228
50
228
50
Obstetrics and Gynecology
5,098
2,651
52
2,447
48
Ophthalmology
3,032
1,819
60
1,213
40
418
322
77
96
23
4,292
3,648
85
644
15
Cardiovascular Surgery and Angiology3
Dermatology
Endocrinology and Diabetes
Gastroenterology
General Physicians / General Practitioners / Family Doctors
General Surgery
Geriatric Medicine
Medical Oncology
Oral and Maxillofacial Surgery
Orthopedic Surgery and Traumatology
Otolaryngology
1,779
1,210
68
569
32
Pathology5
4,582
1,982
43
2,600
57
Pediatrics
8,145
3,584
44
4,561
56
308
219
71
89
29
1,313
591
45
722
55
682
512
75
171
25
3,563
1,924
54
1,639
46
Pediatric Surgery
Physical Medicine & Rehabilitation
Plastic Surgery
Psychiatry
144
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
TOTAL
MALE
%
FEMALE
%
Public Health / Preventive Medicine / Occupational Medicine
1,562
890
57
672
43
Pulmonology
1,937
1,182
61
755
39
452
226
50
226
50
Radiation Oncology
Radiology
2,941
1,647
56
1,294
44
Rheumatology
966
551
57
415
43
Thoracic Surgery
178
141
79
37
21
1,895
1,706
90
190
10
293
123
42
170
58
Urology
Other specialties
1 Allergy + Immunology
2 Anesthesiology + Intensive Medicine
3 Cardiovascular surgery + Angiology and Surgery
4 Neurology + Clinical Neurophysiology
5 Anatomical Pathology + Clinical Analysis + Clinical Biochemistry + Microbiology
Note: General Practitioners statistics is of the year 2004
Source:
1)
2)
CESM (2005) Physicians Demography [internet], CESM. Available from: <http://www.cesm.org/nueva/fundaciondemogr/Publicaciones/AbstractPhysicDemogr.htm> [Accessed October 2007]
MSC (2007) OFERTA Y NECESIDAD DE MEDICOS ESPECIALISTAS EN ESPANA [internet], MSC. Available from: <http://www.msc.es/novedades/docs/necesidadesEspeciales06_30.pdf>
[Accessed October 2007]
145
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL PHYSICIANS
TOTAL
UNDER 36
36-45
46-55
56-65
65 AND OVER
149,942
37,962
71,641
30,263
7,673
Allergy / Immunology1
1,063
478
466
90
27
2
Anesthesiology / Intensive Care Medicine2
6,128
2,023
1,774
1,815
430
85
Cardiovascular Diseases
2,133
691
473
676
227
66
765
287
201
191
65
20
Cardiovascular Surgery and Angiology3
Dermatology
2,403
1,304
431
478
305
72
18
899
259
322
208
87
23
1,812
653
454
512
148
45
76,180
14,687
48,240
10,519
1,896
840
3,797
923
1,170
1,297
306
101
737
458
189
62
14
14
Hematology
1,341
473
340
419
101
8
Internal Medicine
5,289
1,263
1,454
1,859
577
136
0
Endocrinology and Diabetes
Gastroenterology
General Physicians / General Practitioners / Family
Doctors
General Surgery
Geriatric Medicine
Medical Oncology
803
516
205
72
9
Nephrology
1,135
371
367
369
28
0
Neurology4
2,190
999
616
432
114
29
15
Neurosurgery
475
127
80
215
38
Nuclear Medicine
455
200
185
62
7
0
Obstetrics and Gynecology
5,098
1,646
1,377
1,409
542
123
Ophthalmology
3,032
938
1,122
747
172
53
418
222
125
46
22
2
4,292
1,397
1,086
1,356
369
85
24
Oral and Maxillofacial Surgery
Orthopedic Surgery and Traumatology
Otolaryngology
1,779
530
627
470
129
Pathology5
4,582
1,177
1,905
1,107
334
59
Pediatrics
8,145
2,272
2,149
2,242
1,054
428
308
51
89
132
30
6
1,313
417
501
323
66
5
682
253
213
167
46
2
3,563
1,196
1,150
915
264
38
Pediatric Surgery
Physical Medicine & Rehabilitation
Plastic Surgery
Psychiatry
146
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
Public Health / Preventive Medicine / Occupational
1,562
Medicine
Pulmonology
1,937
UNDER 36
36-45
46-55
56-65
65 AND OVER
349
976
171
42
24
51
655
640
449
142
452
226
166
50
9
2
2,941
943
1,171
673
129
26
Rheumatology
966
277
401
228
49
11
Thoracic Surgery
178
50
56
56
11
5
1,895
496
676
569
102
52
28
197
50
14
4
Radiation Oncology
Radiology
Urology
Other Specialties
293
1 Allergy + Immunology
2 Anesthesiology + Intensive Medicine
3 Cardiovascular surgery + Angiology and Surgery
4 Neurology + Clinical Neurophysiology
5 Anatomical Pathology + Clinical Analysis + Clinical Biochemistry + Microbiology
Note:
1)
2)
Source:
1)
2)
General Practitioners statistics is of the year 2004.
It was assumed that the age break up within the specialties to remain similar to that of the earlier available statistics (year 1999).
CESM (2005) Physicians Demography [internet], CESM. Available from: <http://www.cesm.org/nueva/fundaciondemogr/Publicaciones/AbstractPhysicDemogr.htm> [Accessed October 2007]
MSC (2007) OFERTA Y NECESIDAD DE MEDICOS ESPECIALISTAS EN ESPANA [internet], MSC. Available from: <http://www.msc.es/novedades/docs/necesidadesEspeciales06_30.pdf>
[Accessed October 2007]
147
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SPAIN 2006
Table No.3a Total Physicians by Gender and Major Professional Activity, 1999
PROFESSIONAL ACTIVITY
Total
Total Private Sector
General Consultation in Public Sector
Specialist Consultation in Public Sector
Other Activities in Public Sector
Residence (in training)
No Medical Activities / Unemployed Physicians
TOTAL
MALE
%
FEMALE
%
130,204
15,774
33,034
70,128
9,766
19,996
53.9
61.9
60.5
60,076
6,008
13,038
46
38
40
24,944
13,228
19,128
24,096
16,722
6,848
7,366
9,430
67
51.8
38.5
39.1
8,222
6,380
11,762
14,666
33
48
62
60
Table No.3b Total Physicians by Age and Major Professional Activity, 1999
PROFESSIONAL ACTIVITY
TOTAL
<36
36-45
46-55
56-65
>65
Total
Total Private Sector
130,204
15,774
43,389
1,490
60,779
11,220
19,757
2,419
4,720
498
1,559
147
General Consultation in Public Sector
Specialist Consultation in Public Sector
33,034
24,944
2,618
1,243
21,788
11,856
6,472
8,852
1,351
2,493
805
500
Other Activities in Public Sector
Residence (in training)
No Medical Activities / Unemployed Physicians
13,228
19,128
24,096
5,602
17,587
14,849
6,534
1,541
7,840
906
0
1,108
156
0
222
30
0
77
Source: Doctor Universe Statistics in Major Markets, December 2003
148
14. UK
149
14.1. Introduction to the UK
The United Kingdom (UK) of Great Britain and Northern Ireland is in Western Europe. It
comprises the island of Great Britain (most of England, Scotland and Wales) and the
north-eastern one-sixth of the island of Ireland (Northern Ireland) , together with many
smaller islands. The UK has a total area of approximately 245,000 square kilometers
(94,600 square miles). The UK lies between the North Atlantic Ocean and the North Sea,
and comes within 35 kilometers (22 miles) of the north-west coast of France, from which
it is separated by the English Channel. Northern Ireland shares a 360 kilometers (224
miles) land boundary with the Republic of Ireland (Figure 17).
Figure 17:
Map of the UK
Source: www.kmike.com
DATAMONITOR
150
At the April 2001 UK census, the UK’s population was 58.8 million, the third largest in
the European Union (behind Germany and France), the fifth largest in the
Commonwealth and the twenty-first largest in the world. In August 2006 it was
confirmed that the UK's population had reached 60 million, then rapidly increased to 60.2
million, largely from net immigration, but also because of a rising birth rate and
increasing life expectancy.
The UK's overall population density is one of the highest in the world. About a quarter of
the population lives in England's prosperous south-east and is predominantly urban and
suburban, with an estimated 7.5 million in the capital of London. In 2006 the UK's total
fertility rate (TFR) was 1.86 children per woman, below the replacement rate of 2.1. In
2001, the TFR was at a record low of 1.63, but it has increased each year since, and will
continue to do so as the share of births from immigrant mothers continues to prod the
fertility rate. The TFR was considerably higher during the 1960s 'baby boom', peaking at
2.95 children per woman in 1964.
14.2. The UK healthcare system
The UK has devolved responsibility for healthcare to its constituent countries. They
mainly fund health care through national taxation, deliver services through public
providers and have devolved purchasing responsibilities to local bodies: primary care
trusts (PCTs) in England, primary care partnerships in Northern Ireland, health boards in
Scotland and local health boards (LHBs) in Wales.
Coverage is available to 100% of the population. All legal residents of the UK, residents
of the European Economic Area and citizens of other countries with which the UK has
reciprocal agreements are covered under the United Kingdom National Health Service
(NHS). Therefore, the uptake of private medical insurance is quite low at 11.5% of the
population in 2001.
151
The organizational structures for health service administration and delivery vary between
United Kingdom countries. In England, for example, personnel with public health
functions can be found in the central and regional departments of Health, the strategic
health authorities and the PCTs. In Wales, a national public health service has been
established to provide services and support to the LHBs, other NHS organizations and
local authorities.
There are considerable differences in health system across the United Kingdom. In
Scotland, major differences include the funding of personal as well as nursing care for
people in long-term care, and the decision not only to reject foundation trusts but also to
abolish hospital trusts, reorganize primary care and develop community health
partnerships. Northern Ireland, in contrast to the rest of the United Kingdom, has always
had integrated health and social care services.
In Wales, the Welsh Assembly Government has reformed the NHS by setting up LHBs to
plan and commission services to meet most health needs, while an all-Wales body
commissions specialist hospital services. Developments include adjusting the way
resources are allocated to the NHS to take account of the needs of disadvantaged areas,
and to address inequities in access to health services. The Assembly Government has also
announced the phased elimination of co-payments for prescriptions for all, regardless of
income, over a five-year period beginning in 2004. The figure below (Figure 18) gives an
overview of the healthcare system in the UK (internal secondary research).
152
Figure 18:
Structure of the UK health service
Source: www.bized.co.uk
DATAMONITOR
14.3. Healthcare insurance
The vast majority of healthcare in the UK is not only paid for by general taxation, but
also delivered by a government-owned system. The UK healthcare system is primarily a
public system, of which four-fifths of the funding comes from taxation, 12% is funded
with national insurance, with patient co-payments funding the remaining 8% (internal
secondary research). Coverage is universal and services are free at the point of delivery.
Private healthcare is entirely separate from the state system, paid for separately and using
different facilities, although senior specialist physicians can work in both sectors.
Private healthcare is restricted to a relatively low percentage of UK citizens who can
afford it. The percentage of the UK population covered by private healthcare has risen
over the last 20 years, from 5% of the population in 1980 to 12.7% by 2003. Despite the
153
relatively low private insurance coverage compared to countries such as the US (where
private healthcare covers approximately two-thirds of the population), there is an
increasing role for private healthcare in the UK, in the form of healthcare financing and
delivery. Private contractors have been used to provide hospital care in both the UK and
in Europe to cut waiting list time. The exchange between private and public healthcare
goes both ways, as private healthcare plans also pay to use NHS hospitals.
14.4. Service delivery
The UK healthcare system is relatively complex, with a range of different trusts and
authorities delivering and impacting on healthcare provision. In the United Kingdom,
GPs in group practices (with an average of three per practice) provide primary care. In
England in 2002, a GP served about 1800 members of the local community. There are
also a small number of NHS walk-in clinics. GPs act as gatekeepers in the system, and a
referral is required to gain access to specialist services. In 2004, 209 NHS trusts provided
secondary care in the English NHS, and 23 mental health trusts provided specialist
mental health services in hospitals and the community. There are about 240 private acute
hospitals, accounting for less than 5% of total beds.
Improving the efficiency, responsiveness and equity of the system has recently become
an important issue. Measures have been introduced to reach particular aims, including
reducing waiting lists, improving the quality of care provision, increasing funding and
staff numbers, encouraging innovation and extending patient choice.
14.5. Healthcare financing and expenditure
Total health spending accounted for 8.3% of GDP in the UK in 2005. Per capita spending
on health in the United Kingdom was 2724 USD in 2005 (adjusted for purchasing power
parity). Health spending per capita in the United Kingdom remains much lower. The
share of public funding of total expenditure was 86.3% in 2004, reflecting the UK
government’s commitment to increase public spending on health. Private share of total
154
healthcare expenditure is relatively low, at 13.7%. Table 26 shows the key health
expenditure indicators in the recent years.
Table 25:
Key health expenditure indicators
Indicator
Total expenditure on health as percentage of gross domestic product
Public expenditure on health as percentage of total expenditure on health
Private expenditure on health as percentage of total expenditure on health
Out-of-pocket expenditure as percentage of private expenditure on health
Private prepaid plans as percentage of private expenditure on health
Per capita total expenditure on health (adjusted for purchasing power parity)
Source: OECD Health Data, 2007
Value (year)
8.%3 (2005)
86.3% (2004)
13.7% (2004)
91.8% (2004)
8.2% (2004)
$2,724 (2005)
DATAMONITOR
The NHS is mainly funded through general taxation: direct taxes, value-added tax and
employee income contributions. Local taxation provides further funding for social
services. Private funding can be broken down into out-of-pocket payments for
prescription drugs, ophthalmic and dental services and private medical insurance
premiums. Services are mostly free at the point of use.
In England, budgets for health care are set every three years through negotiations
between the Chancellor of the Exchequer and Department of Health. In the rest of the
United Kingdom, the devolved administrations set budgets separately. LHBs and PCTs,
covering populations of 50, 000–250, 000, are the main purchasers of health services. The
central Government uses a weighted capitation formula to allocate funding to them.
General practitioners (GPs) are self employed. On 1 April 2004, remuneration of their
services moved from a system mainly based on capitation and fixed allowances to one
that combines capitation and quality points. With most of the population concentrated in
urban areas, there are problems with access to and sustainability of services in remote and
rural areas. Hospitals receive activity-based and contract financing. Hospital staffs are
mainly salaried, but consultants are also permitted to earn money in the private sector.
155
14.6. Resources
Following a perceived shortage of health professionals in the UK, there has, over recent
years, been a determined and active campaign to increase numbers. Latest figures show
that in 2005, the UK had 2.4 practicing physicians per 1,000 population, up from 1.9
doctors per 1,000 population in 1998. Similarly, there has been a notable increase in the
number of nurses in the UK in recent years, after a period of relative stability. In 2005,
there were 9.1 nurses per 1,000 population in the UK, compared with 8.0 in 1998.
The number of acute care hospital beds in the UK was 3.1 per 1 000 population in 2005.
In line with many OECD countries, the number of hospital beds per capita in the UK has
fallen gradually over the past decade. This decline has coincided with a reduction of
average length of stays in hospitals and an increase in the number of surgical procedures
performed on a same-day (or ambulatory) basis. The following table (Table 26) shows
the absolute and density of physicians and nurses in the recent years.
Table 26:
UK physicians and nurses, 2005
Resource Indicator
Physicians (number)
Physicians (density per 1 000 population)
Nurses (number)
Nurses (density per 1 000 population)
Value (year)
n/a
2.4 (2005)
n/a
1.9 (2005)
n/a – not available
Source: OECD Health Data, 2007
DATAMONITOR
14.7. The UK pharmaceutical market
The UK is the world’s fifth largest pharmaceutical market and the third largest in the
European Union. Sales declined by 2% in 2005 to reach $22.1 billion, or $384 per person,
($19.5 billion / $328) (internal secondary research). Two major factors contributed to the
decline: first, manufacturers were required to reduce prices by 7% as a result of the
pricing agreement signed in 2005; second, several major products lost patent protection
156
and were quickly exposed to generic penetration. With 89% of direct payments and a
further 6% derived from co-payments, the NHS is very nearly the sole purchaser of
prescription pharmaceuticals in the UK. Only 5% of industry turnover is generated by
private, non-NHS purchases. The following table (Table 27) shows the retail sales by
therapeutic category in 2005.
Table 27:
UK retail sales by therapeutic category, 2005
Category
Cardiovascular
Central Nervous System
Alimentary/ Met.
Respiratory
Anti- Infectives
Musculoskeletal
Genitourinary
Cytostatics
Blood Agents
Dermatologicals
Sensory Organs
Diagnostic Agents
Systemic Hormones
Miscellaneous
Hospital Solutions
Parasitology
Total
Source: internal secondary research
Sales $m 2005
% Change
3,308
3,213
2,335
1,754
488
830
760
435
497
535
270
276
181
26
15
62
-16%
4%
3%
-1%
-5%
-14%
0%
-11%
17%
1%
4%
8%
9%
9%
4%
14%
14,985
-3%
DATAMONITOR
The UK has an extremely high prevalence of generics in the market. As shown in table
34, over half of prescriptions are dispensed for generics. By value, branded products
represented 79.9% of the market in 2004, a decline from 83% in 2003. The following
table (Table 28) shows the trend in market value for branded and generic drugs.
157
Table 28:
Evolution of generic / brand share of market value in the UK, 2000-2004
Generics
Brands
2000
2001
2002
2003
2004
13.8%
86.2%
11.1%
88.9%
13.3%
86.7%
17%
83%
20.1%
79.9%
Source: internal secondary research
DATAMONITOR
The British pharmaceutical industry spent 24% of sales, or $6.6 billion, on R&D in 2004.
This is essentially unchanged from $6.7 billion in 2003. As a high price EU market, the
UK is a major destination for parallel imports. However, the growth rates of parallel
imports fell during 2004 to 11%, down from 44% in 2001. Pharmaceuticals are one of
Britain’s leading manufacturing sectors, bringing in a trade surplus of $7 billion in 2004.
And the industry is a major employer, with around 73, 000 people employed directly
(http://www.abpi.org.uk/). The value of UK pharmaceutical exports in 2005 was $252.6
billion, more than $343,704 per employee.
Prescription medicines are the subject of Government controls and intensive competition.
Research and development lies at the heart of the pharmaceutical industry. It invests 30
per cent of its sales in research, and a quarter of the entire research expenditure by the
UK manufacturing sector is funded or carried out by the pharmaceutical sector. Research
and development expenditure by the pharmaceutical industry in Britain amounts to more
than $6.2 billion, or around $18.6 million a day.
Of the major medicines sold in the UK, around half were developed in British
laboratories. More than 825 million prescriptions are dispensed every year, at an average
cost of around $22.7 each. The UK is one of the most developed generics markets in
Europe. According to the European Generics Association (EGA), generics accounted for
21% of the total UK pharmaceutical market in terms of value and 49% of volume in
2004.
158
14.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:
<http://www.who.int/whosis/database/core/core_select_process.cfm?country=gbr
&indicators=selected&language=en> [Accessed October 2007].
o Datamonitor (2006), Global Generics Guide: Part 2 - Benchmarking country
markets and strategic issues, June 2006, DMHC 2216.
o OECD data (2007), OECD United Kingdom Health data 2007 [Internet] Available
from: < http://www.oecd.org/dataoecd/46/4/38980557.pdf> [Accessed October
2007].
o World Health Organization (1999), Health systems in transition 1999 [Internet].
WHO Regional Office for Europe on behalf of the European Observatory on
Health
Systems
and
Policies,
2004.
Available
from:
<http://www.euro.who.int/document/e68283.pdf> [Accessed October 2007].
o VOI Consulting (2006), PharmaHandbook: A Guide to the International
Pharmaceutical Industry 2006.
159
ENGLAND
160
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL
MALE
%
FEMALE
%
TOTAL PHYSICIANS
93,320
57,608
62
35,712
Accident & Emergency
4,714
2,950
63
1,764
37
10,281
6,780
66
3,501
34
Anesthesiology
38
Clinical oncology
1,052
536
51
516
49
Dental group
2,380
1,480
62
900
38
10
5
50
5
50
1,143
779
68
364
32
Oral Surgery
147
79
54
68
46
Orthodontics
544
303
56
241
44
Pediatric Dentistry
81
34
42
47
58
Periodontics
20
13
65
7
35
Prosthodontics
14
11
79
3
21
223
142
64
81
36
11
7
64
4
36
187
107
57
80
43
General Medical Practitioners (excluding GP registrars and retainers)
33,091
19,541
59
13,550
41
General medicine group
23,399
14,043
60
9,356
40
24
14
58
10
42
Endodontics
Oral & Maxillofacial Surgery
Restorative Dentistry
Surgical Dentistry
Additional Dental Medicine Specialties
Allergy
Audiological Medicine
72
35
49
37
51
2,056
1,626
79
430
21
Clinical Genetics
211
65
31
146
69
Clinical Neurophysiology
102
79
77
23
23
Clinical Pharmacology and Therapeutics
188
124
66
64
34
Dermatology
1,129
508
45
621
55
Endocrinology and Diabetes Mellitus
1,223
799
65
424
35
Gastroenterology
1,538
1,150
75
388
25
General (Internal) Medicine
5,767
3,125
54
2,642
46
969
408
42
561
58
Cardiology
Genito-urinary Medicine
161
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
TOTAL
MALE
%
FEMALE
%
Geriatric Medicine
2,956
1,772
60
1,184
40
Infectious Diseases
298
189
63
109
37
Medical Oncology
601
329
55
272
45
Medical Ophthalmology
25
18
72
7
28
1,012
738
73
274
27
Occupational Health
202
125
62
77
38
Palliative Medicine
389
108
28
281
72
Rehabilitation Medicine
227
156
69
71
31
Renal Medicine
927
608
66
319
34
1,451
957
66
494
34
992
612
62
380
38
9
4
44
5
56
Other
1,031
494
48
537
52
Obstetrics & Gynecology
4,958
2,296
46
2,662
54
Pediatric Group
7,039
3,171
45
3,868
55
124
83
67
41
33
Pediatrics
6,915
3,088
45
3,827
55
Pathology Group
3,956
2,182
55
1,774
45
251
165
66
86
34
24
10
42
14
58
Hematology
1,308
707
54
601
46
Histopathology
1,643
903
55
740
45
103
65
63
38
37
Neurology
Respiratory Medicine
Rheumatology
Sports and Exercise Medicine
Pediatric Cardiology
Chemical Pathology
Clinical Cytogenetics and Molecular Genetics
Immunology
Medical Microbiology & Virology
627
332
53
295
47
PHM & CHS Group
3,283
1,248
38
2,035
62
Dental Public Health
1,529
527
34
1,002
66
Public Health Medicine
1,754
721
41
1,033
59
162
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
TOTAL
MALE
%
FEMALE
%
Psychiatry Group
9,629
5,590
58
4,039
42
Child and Adolescent Psychiatry
1,060
455
43
605
57
Forensic Psychiatry
519
342
66
177
34
General Psychiatry
6,090
3,654
60
2,436
40
531
330
62
201
38
1,271
721
57
550
43
158
88
56
70
44
Radiology Group
3,204
2,084
65
1,120
35
Clinical Radiology
3,129
2,034
65
1,095
35
75
50
67
25
33
19,425
15,248
78
4,177
22
717
632
88
85
12
6,591
4,752
72
1,839
28
553
481
87
72
13
Ophthalmology
2,293
1,576
69
717
31
Otolaryngology
1,614
1,308
81
306
19
304
183
60
121
40
Learning Disabilities
Old age Psychiatry
Psychotherapy
Nuclear Medicine
Surgical Group
Cardiothoracic Surgery
General Surgery
Neurosurgery
Pediatric Surgery
Plastic Surgery
780
621
80
159
20
Trauma and Orthopedic Surgery
5,163
4,533
88
630
12
Urology
1,410
1,162
82
248
18
Source: IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from:
<http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
163
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 2. Total Physicians by Specialty and Age
UNDER
SPECIALTY
TOTAL
30
TOTAL PHYSICIANS
93,320
21,450
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70 AND
OVER
134
17,265
14,131
12,378
10,067
7,849
6,247
3,138
661
4,714
1,948
997
648
423
255
183
156
85
19
-
10,281
1,473
2,143
1,799
1,625
1,251
901
694
336
55
4
Clinical Oncology
1,052
176
238
205
135
104
75
80
32
5
2
Dental Group
2,380
524
372
361
309
288
222
179
98
24
3
10
-
4
3
3
-
-
-
-
-
-
1,143
301
163
180
149
115
94
86
50
5
-
147
42
21
23
18
16
15
7
5
-
-
Accident & Emergency
Anesthesiology
Endodontics
Oral & Maxillofacial
Surgery
Oral Surgery
544
57
112
72
86
83
60
44
22
6
2
Pediatric Dentistry
Orthodontics
81
13
16
14
13
7
6
6
4
2
-
Periodontics
20
1
3
4
2
1
2
5
1
1
-
Prosthodontics
14
1
2
1
3
4
1
1
-
1
-
223
50
26
34
20
39
32
11
7
4
-
11
1
3
1
1
3
1
-
1
-
-
187
58
22
29
14
20
11
19
8
5
1
33,091
527
3,569
4,529
5,979
6,303
5,124
4,148
1,972
719
220
47
Restorative Dentistry
Surgical Dentistry
Additional Dental
Medicine Specialties
General Medical
practitioners (excluding
GP registrars and
retainers)
General medicine group
23,399
7,382
3,953
3,253
2,735
2,030
1,665
1,443
726
165
Allergy
24
2
2
5
4
1
3
2
2
2
1
Audiological Medicine
72
3
8
9
15
6
8
14
8
-
1
Cardiology
2,056
447
413
366
321
198
143
100
52
12
4
Clinical Genetics
211
6
30
46
39
39
28
16
6
-
1
Clinical Neurophysiology
Clinical Pharmacology and
Therapeutics
102
-
6
12
20
13
22
18
6
4
1
188
71
32
28
13
12
8
14
6
3
1
UN
KNOWN
-
1
164
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
UNDER
SPECIALTY
TOTAL
30-34
30
Dermatology
1,129
70
189
Endocrinology and
1,223
219
190
Diabetes Mellitus
Gastroenterology
1,538
330
293
202
182
160
133
121
52
15
70 AND
OVER
5
247
182
116
99
105
53
7
5
35-39
40-44
45-49
50-54
55-59
60-64
65-69
274
253
145
91
90
52
9
1
969
103
143
128
158
143
121
90
58
20
5
Geriatric Medicine
2,956
958
462
387
283
258
277
204
105
21
1
Infectious Diseases
298
73
62
46
37
35
26
9
8
1
1
Medical Oncology
601
113
135
120
77
51
39
43
20
2
1
25
1
2
5
3
4
2
5
2
-
1
5
Genito-urinary Medicine
Medical Ophthalmology
Neurology
1,012
173
144
208
152
118
83
88
31
10
Occupational Health
202
6
17
22
47
32
35
20
22
1
-
Palliative Medicine
389
48
94
47
72
48
48
19
10
3
-
Rehabilitation Medicine
227
31
22
35
34
27
31
30
14
2
1
Renal Medicine
927
253
187
146
133
91
56
33
25
2
1
1,451
362
303
241
166
121
99
107
46
4
2
992
128
148
172
157
122
91
107
49
14
4
Respiratory Medicine
Rheumatology
Sports and Exercise
Medicine
Other
9
2
1
1
1
-
-
2
2
-
-
6,798
3,983
1,070
506
386
290
222
206
97
33
5
Obstetrics & Gynecology
4,958
1,005
914
838
754
582
395
296
152
20
2
Pediatric Group
7,039
1,665
1,556
1,062
862
683
532
442
198
36
3
124
19
28
17
16
21
9
7
3
3
1
Pediatrics
6,915
1,646
1,528
1,045
846
662
523
435
195
33
2
Pathology Group
3,956
371
650
591
574
598
551
386
179
50
6
251
25
29
25
31
35
49
38
15
4
-
Pediatric Cardiology
Chemical Pathology
Clinical Cytogenetics and
Molecular Genetics
Hematology
24
1
6
2
4
5
3
2
1
-
-
1,308
180
227
184
161
168
166
142
61
17
2
Histopathology
1,643
121
289
275
250
260
223
124
75
23
3
UN
KNOWN
165
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
UNDER
SPECIALTY
TOTAL
30-34
30
Immunology
103
2
19
Medical Microbiology &
627
42
80
Virology
PHM & CHS Group
3,283
256
326
35-39
40-44
45-49
50-54
55-59
60-64
70 AND
OVER
65-69
UN
KNOWN
17
18
18
11
9
8
1
-
88
110
112
99
71
19
5
1
14
366
476
627
543
406
225
44
Dental Public Health
1,529
158
201
173
215
276
239
168
81
14
4
Public Health Medicine
1,754
98
125
193
261
351
304
238
144
30
10
Psychiatry Group
Child and Adolescent
Psychiatry
Forensic Psychiatry
9,629
1,364
1,909
1,583
1,426
1,203
925
716
375
100
28
1,060
90
171
178
190
156
130
87
46
11
1
519
62
103
107
100
64
38
28
15
1
1
General Psychiatry
6,090
1,019
1,321
973
843
704
526
411
219
54
20
Learning Disabilities
Old age Psychiatry
Psychotherapy
531
44
76
79
74
79
67
61
36
12
3
1,271
143
221
220
197
181
135
107
45
20
2
158
6
17
26
22
19
29
22
14
2
1
Radiology Group
3,204
196
720
560
468
455
375
262
125
40
3
Clinical Radiology
3,129
189
711
548
458
442
367
254
121
36
3
75
7
9
12
10
13
8
8
4
4
-
19,425
5,090
3,487
2,865
2,591
1,991
1,482
1,187
607
103
22
Nuclear Medicine
Surgical Group
Cardiothoracic Surgery
General Surgery
Neurosurgery
717
137
129
140
116
74
55
46
14
5
1
6,591
2,527
953
792
772
571
432
351
161
28
4
553
124
132
100
76
54
27
21
14
4
1
Ophthalmology
2,293
232
395
387
390
307
261
197
98
20
6
Otolaryngology
1,614
312
281
230
224
180
151
124
88
20
4
Pediatric Surgery
304
79
58
48
41
23
29
15
8
3
-
Plastic Surgery
Trauma and Orthopedic
Surgery
Urology
780
159
189
123
129
85
45
35
13
1
1
5,163
1,192
1,115
833
662
522
345
307
164
18
5
1,410
328
235
212
181
175
137
91
47
4
-
Note: 1) ' - ' denotes zero; 2) ' 0 ' denotes less than one, more than zero
Source: The information centre, National Health Service, Department of Health, 2006 [Accessed October 2007].
166
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 3. Medical Staff by specialty and Grade
CONSULTANT
(INCLUDING
ASSOCIATE
SPECIALTY
TOTAL
DIRECTOR
SPECIALIST
OF PUBLIC
HEALTH)
TOTAL
93,320
32,874
2,830
PHYSICIANS
Accident &
4,714
725
110
Emergency
Anesthesiology
10,281
4,698
275
STAFF
GRADE
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICER
FOUNDATION
YEAR 2
HOUSE
OFFICER &
FOUNDATION
PROGRAM
YEAR 1
HOSPITAL
PRACTITIONER/
CLINICAL
ASSISTANT
OTHER
STAFF
5,937
18,808
18,863
3,693
4,905
3,522
1,888
536
802
1,607
714
96
123
1
10
782
2,283
1,927
103
121
82
Clinical Oncology
1,052
482
17
43
302
142
27
15
24
-
Dental Group
2,380
692
115
217
345
486
3
26
442
54
Endodontics
Oral &
Maxillofacial
Surgery
Oral Surgery
10
1
-
-
1
-
-
-
4
4
1,143
306
54
164
118
370
3
1
121
6
147
28
8
18
13
42
-
-
35
3
Orthodontics
544
189
21
12
139
9
-
1
162
11
Pediatric Dentistry
81
31
3
3
18
6
-
-
15
5
Periodontics
20
8
1
-
1
2
-
-
2
6
Prosthodontics
Restorative
Dentistry
Surgical Dentistry
Additional Dental
Medicine
Specialties
General medicine
Group
Allergy
Audiological
Medicine
Cardiology
14
2
-
2
1
-
-
-
8
1
223
82
6
7
37
35
-
1
52
3
11
-
3
2
1
-
-
1
2
2
187
45
19
9
16
22
-
22
41
13
23,399
7,277
453
908
4,454
4,728
1,470
2,358
1,724
27
24
9
-
2
5
-
1
-
7
-
72
40
7
2
19
3
1
-
-
-
Clinical Genetics
2,056
752
34
89
591
307
64
96
123
-
211
132
13
5
56
1
-
-
4
-
167
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 3. Medical Staff by specialty and Grade (Cont…)
CONSULTANT
(INCLUDING
ASSOCIATE
SPECIALTY
TOTAL
DIRECTOR
SPECIALIST
OF PUBLIC
HEALTH)
Clinical
102
81
Neurophysiology
Clinical
188
54
3
Pharmacology and
Therapeutics
Dermatology
1,129
454
67
Endocrinology and
1,223
506
19
Diabetes Mellitus
Gastroenterology
1,538
639
22
General (Internal)
5,767
521
56
Medicine
Genito-urinary
969
348
59
Medicine
Geriatric Medicine
2,956
909
52
Infectious
298
116
Diseases
Medical Oncology
601
233
9
Medical
25
13
2
Ophthalmology
Neurology
1,012
506
16
Occupational
202
95
8
Health
Palliative
389
185
8
Medicine
Rehabilitation
227
106
7
Medicine
Renal Medicine
927
347
17
Respiratory
1,451
583
12
Medicine
Rheumatology
992
511
15
STAFF
GRADE
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICER
FOUNDATION
YEAR 2
HOUSE
OFFICER &
FOUNDATION
PROGRAM
YEAR 1
HOSPITAL
PRACTITIONER/
CLINICAL
ASSISTANT
OTHER
STAFF
1
17
1
-
-
2
-
2
54
33
14
23
5
-
46
188
56
9
4
305
-
25
343
117
32
69
112
-
26
457
163
44
108
79
-
207
285
2,228
642
1,484
336
8
97
133
87
25
4
211
5
178
501
711
165
270
169
1
6
86
62
14
9
5
-
28
184
93
16
15
23
-
1
4
4
-
-
1
-
20
231
163
28
8
40
-
3
48
5
-
1
31
11
28
83
28
19
3
33
2
20
45
28
8
8
5
-
17
291
182
20
46
7
-
15
467
174
35
127
38
-
26
219
75
8
28
110
-
168
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 3. Medical Staff by specialty and Grade (Cont…)
CONSULTANT
(INCLUDING
ASSOCIATE
SPECIALTY
TOTAL
DIRECTOR
SPECIALIST
OF PUBLIC
HEALTH)
Sports and
9
4
1
Exercise Medicine
Other
1,031
133
26
Obstetrics &
4,958
1,506
125
Gynecology
Pediatric Group
7,039
2,154
287
Pediatric
124
63
Cardiology
Pediatrics
6,915
2,091
287
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICER
FOUNDATION
YEAR 2
HOUSE
OFFICER &
FOUNDATION
PROGRAM
YEAR 1
HOSPITAL
PRACTITIONER/
CLINICAL
ASSISTANT
OTHER
STAFF
-
2
-
-
2
-
-
64
145
207
325
53
78
-
280
1,328
1,318
184
58
142
17
530
1,736
1,935
204
129
47
17
-
36
25
-
-
-
-
530
1,700
1,910
204
129
47
17
3,956
2,416
79
77
1,022
221
65
18
57
1
251
159
4
3
63
9
11
-
2
-
24
16
1
-
7
-
-
-
-
-
60
321
133
21
14
48
1
12
441
64
17
3
3
-
1
34
-
-
1
4
-
10
1
156
15
16
-
-
-
885
143
183
179
40
71
-
49
1,733
1,529
69
3
1
14
1
-
-
3
1,438
1,754
816
140
182
165
39
71
-
46
295
Pathology Group
Chemical
Pathology
Clinical
Cytogenetics and
Molecular
Genetics
Hematology
1,308
663
47
Histopathology
1,643
1,087
16
103
62
1
627
429
3,283
Immunology
Medical
Microbiology &
Virology
PHM & CHS
Group
Dental public
health
Public Health
Medicine
STAFF
GRADE
169
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN ENGLAND 2006
Table No 3. Medical Staff by specialty and Grade (Cont…)
CONSULTANT
(INCLUDING
ASSOCIATE
SPECIALTY
TOTAL
DIRECTOR
SPECIALIST
OF PUBLIC
HEALTH)
Psychiatry Group
Child and
Adolescent
Psychiatry
Forensic
Psychiatry
General Psychiatry
Learning
Disabilities
Old age Psychiatry
Psychotherapy
STAFF
GRADE
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICER
FOUNDATION
YEAR 2
HOUSE
OFFICER &
FOUNDATION
PROGRAM
YEAR 1
HOSPITAL
PRACTITIONER/
CLINICAL
ASSISTANT
OTHER
STAFF
9,629
3,805
473
1,236
1,022
2,554
88
50
377
24
1,060
615
33
79
164
151
-
4
11
3
519
239
26
66
82
101
-
-
5
-
6,090
2,107
316
823
585
1,921
74
39
208
17
531
216
18
72
46
84
-
3
89
3
1,271
521
77
192
124
284
12
1
59
1
158
107
3
4
21
13
2
3
5
-
Radiology Group
3,204
2,105
27
31
1,004
8
10
2
17
-
Clinical Radiology
3,129
2,061
25
30
981
7
8
2
15
-
75
44
2
1
23
1
2
-
2
-
19,425
6,129
726
1,114
4,331
3,897
754
2,032
438
4
717
240
4
15
251
166
26
11
4
-
6,591
1,756
151
272
1,302
1,100
268
1,598
144
-
553
187
3
5
208
121
20
9
-
-
Ophthalmology
2,293
816
194
287
434
391
36
7
124
4
Otolaryngology
Nuclear Medicine
Surgical Group
Cardiothoracic
Surgery
General Surgery
Neurosurgery
1,614
552
89
127
310
374
72
24
66
-
Pediatric Surgery
304
104
1
5
95
81
10
8
-
-
Plastic Surgery
Trauma and
Orthopedic
Surgery
Urology
780
254
23
20
244
210
16
7
6
-
5,163
1,710
201
295
1,193
1,210
264
220
70
-
1,410
510
60
88
294
244
42
148
24
-
Source: IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from:
<http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
170
NORTHERN IRELAND
171
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL PHYSICIANS
TOTAL
MALE
%
FEMALE
%
4,798
2,814
59
1,984
41
364
246
68
118
32
Cardiothoracic Surgery
27
24
89
3
11
Cardiovascular Diseases
104
72
69
32
31
Anesthesiology
Dermatology
42
13
31
29
69
191
126
66
65
34
1,110
703
63
407
37
General Surgery / Vascular Surgery
317
231
73
86
27
Internal Medicine
812
455
56
357
44
6
5
78
1
22
Neurology
18
13
72
5
28
Neurosurgery
18
15
83
3
17
233
102
44
131
56
70
37
53
33
47
118
98
83
20
17
Otolaryngology
74
53
72
21
28
Pathology
84
52
62
32
38
Emergency Medicine
General Physicians / General Practitioners / Family Doctors
Medical Oncology
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery and Traumatology
Pediatric & Pediatric Surgery
228
102
45
126
55
Physical Medicine, Rehabilitation and Rheumatology
37
14
38
23
62
Plastic Surgery
25
19
76
6
24
Psychiatry
323
145
45
178
55
Public Health / Community Medicine / Occupational Medicine
157
50
32
107
68
Radiology
188
127
68
61
32
30
23
77
7
23
49
30
61
19
39
173
59
34
114
66
Urology / Renal Failure Surgery
Other Specialties
Dental Group
Source: Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007 [Accessed October 2007].
172
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL
UNDER 35
35-44
45-54
65 AND
OVER
55-64
TOTAL PHYSICIANS
Anesthesiology
Cardiovascular Diseases
Dermatology
4,653
364
104
42
1,710
128
51
11
1,417
116
27
15
1,070
81
13
13
428
36
14
4
28
2
0
0
Emergency Medicine
General Physicians / General Practitioners / Family Doctors
General Surgery / Vascular Surgery
Internal Medicine
191
1,110
317
812
103
137
183
507
61
428
69
146
21
401
42
111
6
132
23
45
0
11
1
3
6
18
2
7
2
8
3
3
0
0
0
0
Neurosurgery
Obstetrics and Gynecology
18
233
6
102
8
70
2
32
2
25
0
4
Ophthalmology
Orthopedic Surgery and Traumatology
Otolaryngology
Pathology
70
118
74
84
23
59
30
28
28
35
21
26
10
15
15
22
9
9
8
7
0
0
0
1
Pediatric Surgery
Physical Medicine, Rehabilitation and Rheumatology
Plastic Surgery
Psychiatry
228
37
25
323
119
28
8
141
66
3
11
90
28
5
3
73
15
1
3
18
0
0
0
1
Public Health / Community Medicine / Occupational Medicine
Radiology
157
188
13
89
49
49
67
30
28
20
0
0
Thoracic Surgery
Urology / Renal Failure Surgery
27
30
10
12
9
10
5
5
2
2
0
1
Other Specialties
49
5
19
13
11
1
Medical Oncology
Neurology
Assumptions: It was assumed that distribution of physicians in each specialty by age group would remain similar in 2007 to that of in 2002
Source: Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007, [Accessed October 2007].
173
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007
Table No 3. Medical Staff by Specialty and Grade
SPECIALTY
TOTAL
PHYSICIANS
Anesthesiology
Cardiovascular
Diseases
Dermatology
Emergency
Medicine
General Physicians
/ General
Practitioners /
Family Doctors
General Surgery /
Vascular Surgery
Internal Medicine
CONSULT
ANT
TOTAL
STAFF
GRADE
ASSOCIATE
SPECIALIST
SPECIALIST
REGISTRAR
SENIOR
HOUSE
OFFICER
MEDICAL
OFFICER
HOSPITAL
PRACTITI
ONER
GENERAL/
MEDICAL
PRACTITI
ONER
OTHER
STAFF
3,515
1,143
187
56
614
1,237
78
73
102
25
364
206
16
4
63
74
0
0
1
0
104
32
6
3
25
32
0
4
0
1
42
13
0
3
7
2
0
6
11
1
191
31
34
6
12
84
0
12
11
0
0
0
0
0
0
0
0
0
0
0
317
85
10
1
51
164
1
2
1
1
812
184
37
10
97
411
6
34
30
4
6
5
0
2
0
0
0
0
0
0
Neurology
18
8
0
0
7
3
0
0
0
0
Neurosurgery
Obstetrics and
Gynecology
Ophthalmology
Orthopedic Surgery
and Traumatology
Otolaryngology
18
8
0
0
8
2
0
0
0
0
233
73
2
4
59
92
2
1
0
0
70
25
6
5
15
11
4
1
0
1
118
43
7
1
28
37
0
1
0
0
74
28
5
0
14
21
0
1
5
0
84
44
2
1
24
8
0
0
5
1
Medical Oncology
Pathology
174
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN NORTHERN IRELAND 2007
Table No 3. Medical Staff by Specialty and Grade (Cont…)
SPECIALTY
Pediatric &
Pediatric Surgery
Physical Medicine,
Rehabilitation and
Rheumatology
Plastic Surgery
Psychiatry
Public Health /
Community
Medicine /
Occupational
Medicine
Radiology
Thoracic Surgery
Urology / Renal
Failure Surgery
Other Specialties
CONSULT
ANT
TOTAL
STAFF
GRADE
ASSOCIATE
SPECIALIST
SPECIALIST
REGISTRAR
SENIOR
HOUSE
OFFICER
MEDICAL
OFFICER
HOSPITAL
PRACTITI
ONER
GENERAL/
MEDICAL
PRACTITI
ONER
OTHER
STAFF
228
60
25
1
42
92
2
1
5
0
37
9
0
0
15
13
0
0
0
0
25
10
0
0
10
6
0
0
0
0
323
125
18
9
38
123
2
4
4
1
157
33
18
6
9
2
55
4
23
8
188
69
0
0
69
49
0
0
0
0
27
15
1
0
8
2
0
0
0
0
30
12
0
0
11
7
0
0
0
0
49
25
0
1
3
0
5
1
8
6
Assumptions: It was assumed that distribution of physicians in each specialty by grade would remain similar in 2007 to that of in 2002
Source: Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007. [Accessed October 2007]
175
SCOTLAND
176
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL
MALE
%
FEMALE
%
TOTAL PHYSICIANS
11,203
6,292
56
4,911
44
All Medical Specialties
10,500
5,972
57
4,528
43
Hospital Medical Specialties
9,952
5,780
58
4,172
42
Anesthesiology
1,065
672
63
393
37
Emergency Medicine
494
288
58
206
42
Clinical Laboratory Specialties
Chemical Pathology
555
40
292
30
53
75
263
10
47
25
Clinical Genetics
24
9
38
15
63
Hematology
182
90
49
92
51
Histopathology
212
111
52
101
48
Immunology
Medical Microbiology & Virology
Medical Specialties
Audiological Medicine
Dermatology
General Medicine (group)
Cardiology
Clinical Neuro-Physiology
6
4
67
2
33
91
48
53
43
47
3,570
1,918
54
1,652
46
2
1
50
1
50
158
63
40
95
60
1,871
1,071
57
800
43
185
134
72
51
28
5
3
60
2
40
115
63
55
52
45
27
21
78
6
22
Endocrinology & Diabetes
136
85
63
51
38
Gastroenterology
137
105
77
32
23
General (acute) Medicine
970
462
48
508
52
Clinical Oncology
Clinical Pharmacology & Therapeutics
Genito - Urinary Medicine
51
21
41
30
59
534
297
56
237
44
Homoeopathy
17
9
53
8
47
Infectious Diseases
53
30
57
23
43
Intensive Care Medicine
17
11
65
6
35
Medical Oncology
62
21
34
41
66
Geriatrics
177
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
Medical Ophthalmology
TOTAL
MALE
%
FEMALE
%
3
2
67
1
33
87
57
66
30
34
568
226
40
342
60
Occupational Medicine
54
29
54
25
46
Pediatric Cardiology
12
8
67
4
33
536
243
45
293
55
Palliative Medicine
69
27
39
42
61
Rehabilitation Medicine
52
33
63
19
37
Renal Medicine
120
73
61
47
39
Respiratory Medicine
150
110
73
40
27
Neurology
Obstetrics & Gynecology
Pediatrics
Rheumatology
83
44
53
39
47
1,152
568
49
584
51
105
26
25
79
75
Forensic Psychiatry
49
26
53
23
47
General Psychiatry
744
393
53
351
47
Old age Psychiatry
150
79
53
71
47
87
39
45
48
55
Psychiatric Specialties
Child & Adolescent Psychiatry
Psychiatry of Learning Disability
Psychotherapy
21
7
33
14
67
Radiology
344
231
67
113
33
Clinical Radiology
337
225
67
112
33
7
6
86
1
14
2,177
1,573
72
604
28
79
67
85
12
15
ENT Surgery
165
121
73
44
27
General Surgery
874
566
65
308
35
58
47
81
11
19
232
154
66
78
34
Oral & Maxillofacial Surgery
32
31
97
1
3
Pediatric Surgery
62
38
61
24
39
Nuclear Medicine
Surgical Specialties
Cardiothoracic Surgery
Neurosurgery
Ophthalmology
178
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
Plastic Surgery
TOTAL
MALE
%
FEMALE
%
84
58
69
26
31
Trauma & Orthopedic surgery
471
390
83
81
17
Urology
121
102
84
19
16
Public Health Medicine
171
87
51
84
49
Community Medical Specialties
399
112
28
287
72
Breast Screening Service
20
3
15
17
85
Community Child Health
135
15
11
120
89
8
6
75
2
25
Family Planning
87
10
11
77
89
General Practice
145
78
54
67
46
Community Psychiatry
Women’s Health Service
5
-
0
5
100
All Dental Specialties
703
320
46
383
54
Hospital Dental Specialties
308
181
59
127
41
Dental & Maxillofacial Radiology
6
2
33
4
67
Fixed & Removable Prosthodontics
1
-
0
1
100
14
9
64
5
36
4
3
75
1
25
Oral Medicine
Oral Microbiology
Oral Pathology
1
1
100
-
0
Oral Surgery
103
60
58
43
42
Orthodontics
70
39
56
31
44
Pediatric Dentistry
26
6
23
20
77
Restorative Dentistry
84
61
73
23
27
-
-
Community Dental Specialties
401
141
35
260
65
Community Dentistry
378
127
34
251
66
Dental Public Health
23
14
61
9
39
General Practitioners
4,637
2,439
53
2198
47
Surgical Dentistry
-
Note: The statistics includes employees working in more than one Board / Region / Specialty or Grade and is presented under each group but counted once in the total.
Source: ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B5: HCHS staff by gender, contract type, specialty, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB05_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007].
179
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL
UNDER 35
35-44
45-54
55-59
60 AND OVER
TOTAL PHYSICIANS
11,203
4,811
2,920
2,286
785
401
All Medical Specialties
10,500
4,591
2,718
2,101
728
362
Hospital Medical Specialties
9,952
4,485
2,570
1,901
667
329
Anesthesiology
30
1,065
350
354
246
85
Emergency Medicine
494
330
91
55
13
5
Clinical Laboratory Specialties
Chemical Pathology
555
40
138
5
152
16
169
11
65
5
31
3
0
Clinical Genetics
24
1
7
12
4
Hematology
182
59
46
47
21
9
Histopathology
212
56
52
64
25
15
1
Immunology
Medical Microbiology & Virology
Medical Specialties
Audiological medicine
Dermatology
General medicine (group)
Cardiology
Clinical Neuro-Physiology
6
0
1
3
1
91
17
30
32
9
3
3,570
1,824
794
604
237
111
0
2
0
0
2
0
158
47
47
48
13
3
1,871
1,095
358
263
108
47
185
69
50
40
19
7
5
0
2
1
2
0
115
45
38
17
8
7
27
8
9
6
2
2
Endocrinology & Diabetes
136
29
49
40
12
6
Gastroenterology
137
39
48
30
13
7
General (acute) Medicine
970
803
65
69
24
9
Clinical Oncology
Clinical Pharmacology & Therapeutics
Genito - Urinary Medicine
Geriatrics
51
13
15
11
7
5
534
241
112
115
47
19
Homoeopathy
17
1
0
11
3
2
Infectious Diseases
53
24
12
10
7
0
Intensive Care Medicine
17
14
3
0
0
0
Medical Oncology
62
27
20
11
1
3
180
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
Medical Ophthalmology
Neurology
Obstetrics & Gynecology
UNDER 35
35-44
45-54
55-59
60 AND OVER
3
2
1
0
0
0
87
26
36
15
8
2
568
257
149
102
36
24
Occupational Medicine
54
8
13
23
7
3
Palliative Medicine
69
20
18
21
10
0
Pediatric Cardiology
12
5
4
1
1
1
536
276
134
80
25
21
Pediatrics
Rehabilitation Medicine
52
17
11
16
6
2
Renal Medicine
120
36
46
24
9
5
Respiratory Medicine
150
53
48
26
16
7
Rheumatology
Psychiatric Specialties
Child & Adolescent Psychiatry
83
29
27
17
7
3
1,152
416
356
286
61
33
1
105
19
40
39
6
Forensic Psychiatry
49
12
22
11
3
1
General Psychiatry
744
327
213
156
30
18
Old age Psychiatry
150
33
59
38
10
10
87
25
15
33
11
3
Psychiatry of Learning Disability
Psychotherapy
21
0
9
9
3
0
Radiology
344
85
126
91
28
14
Clinical Radiology
337
85
122
89
27
14
7
0
4
2
1
0
2,177
1,077
536
339
143
82
79
34
20
18
5
2
Nuclear Medicine
Surgical Specialties
Cardiothoracic Surgery
ENT Surgery
165
66
41
35
12
11
General Surgery
874
528
153
117
49
27
58
30
16
6
5
1
232
68
84
45
21
14
Neurosurgery
Ophthalmology
Oral & Maxillofacial Surgery
32
0
15
10
5
2
Pediatric Surgery
62
39
11
6
4
2
181
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
Plastic Surgery
UNDER 35
35-44
45-54
55-59
60 AND OVER
84
37
33
7
7
0
Trauma & Orthopedic Surgery
471
234
119
71
26
21
Urology
121
41
45
24
9
2
Public Health Medicine
171
9
55
70
22
15
Community Medical Specialties
399
97
100
140
41
21
Breast Screening Service
20
2
5
11
1
1
Community Child Health
135
7
36
61
22
9
8
0
4
3
0
1
Family Planning
87
17
26
26
11
7
General Practice
145
70
28
38
6
3
Community Psychiatry
Women’s Health Service
5
1
1
2
1
0
All Dental Specialties
703
220
202
185
57
39
Hospital Dental Specialties
308
104
80
69
30
25
Dental & Maxillofacial Radiology
6
3
1
2
0
0
Fixed & Removable Prosthodontics
1
0
1
0
0
0
14
2
3
6
3
0
4
2
1
1
0
0
Oral Medicine
Oral Microbiology
Oral Pathology
1
0
0
0
0
1
Oral Surgery
103
53
23
13
7
7
Orthodontics
70
14
24
19
9
4
Pediatric Dentistry
26
12
6
7
0
1
Restorative Dentistry
84
18
21
21
12
12
0
0
0
0
0
0
Community Dental Specialties
401
117
126
116
27
15
Community Dentistry
378
115
123
107
23
10
Dental Public Health
23
2
3
9
4
5
General Practitioners
4,636
813
1,581
1,556
517
169
Surgical Dentistry
Note: The statistics includes employees working in more than one Board / Region / Specialty or Grade and is presented under each group but counted once in the total.
Source: ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B6: HCHS staff by specialty by age group, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB06_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007].
182
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 3. Medical Staff by Specialty and Grade
CONSULTANT
(INCLUDING
STAFF
SPECIALTY
TOTAL
DIRECTORS
GRADE
OF PUBLIC
HEALTH)
TOTAL
11,203
3,847
535
PHYSICIANS
All Medical
10,500
3,751
513
Specialties
Hospital
Medical
9,952
3,576
398
Specialties
Anesthesiology
1,065
560
45
Emergency
494
76
19
Medicine
Clinical
Laboratory
555
328
13
Specialties
Chemical
40
26
Pathology
Clinical
24
15
1
Genetics
Hematology
182
84
10
Histopathology
Immunology
Medical
Microbiology
& Virology
Medical
Specialties
Audiological
medicine
Dermatology
General
medicine
(group)
Cardiology
ASSOCIATE
SPECIALIST
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICERS /
FOUNDATION
YEAR 2
244
1,646
2,993
793
11
7
658
505
231
1,611
2,930
793
11
7
586
97
194
1,580
2,865
790
2
1
527
33
22
191
225
11
-
-
12
-
7
52
288
6
-
-
34
12
14
142
36
2
-
-
20
1
-
12
1
-
-
-
1
-
1
6
-
-
-
-
-
1
HOUSE
OFFICERS /
FOUNDATION
YEAR 1
SENIOR
CLINICAL
MEDICAL
OFFICER
CLINICAL
MEDICAL
OFFICER
GMP /
GDP
GRADES1
OTHER
7
42
23
2
-
-
15
-
212
140
1
5
56
7
-
-
-
3
-
6
6
-
-
-
-
-
-
-
-
-
91
57
1
1
26
5
-
-
-
1
-
3,570
981
130
70
511
1,129
424
1
1
314
13
2
1
-
1
-
-
-
-
-
-
-
158
55
6
5
26
25
-
-
-
40
1
1,871
464
47
33
242
572
388
-
1
114
11
185
78
9
1
47
32
9
-
-
8
1
183
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 3. Medical Staff by Specialty and Grade (Cont…)
CONSULTANT
(INCLUDING
STAFF
ASSOCIATE
SPECIALTY
TOTAL
DIRECTORS
GRADE SPECIALIST
OF PUBLIC
HEALTH)
Clinical Neuro5
5
Physiology
Clinical
115
55
5
Oncology
Clinical
Pharmacology &
27
13
1
Therapeutics
Endocrinology
136
70
2
& Diabetes
Gastroenterology
137
84
4
1
General (acute)
970
29
19
18
Medicine
Genito - Urinary
51
15
2
3
Medicine
Geriatrics
534
128
22
11
Homoeopathy
Infectious
Diseases
Intensive Care
Medicine
Medical
Oncology
Medical
Ophthalmology
Neurology
Obstetrics &
Gynecology
Occupational
Medicine
Pediatric
Cardiology
Pediatrics
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICERS /
FOUNDATION
YEAR 2
HOUSE
OFFICERS /
FOUNDATION
YEAR 1
SENIOR
CLINICAL
MEDICAL
OFFICER
CLINICAL
MEDICAL
OFFICER
GMP /
GDP
GRADES1
OTHER
-
-
-
-
-
-
-
36
18
-
-
-
1
-
11
1
-
-
-
1
-
27
11
-
-
1
25
-
32
13
2
-
-
-
1
20
435
367
-
-
75
8
5
7
-
-
-
19
-
51
188
25
-
-
109
-
17
2
-
6
1
1
-
-
-
7
-
53
19
4
1
11
16
2
-
-
-
-
17
1
-
-
3
13
-
-
-
-
-
62
20
5
1
24
10
2
-
-
-
-
3
1
-
-
1
1
-
-
-
-
-
87
48
1
1
20
13
3
-
-
2
-
568
171
22
13
86
240
4
1
-
28
4
54
22
-
1
13
1
-
-
-
16
1
12
5
-
-
4
3
-
-
-
-
-
536
141
30
8
84
256
5
1
-
11
-
184
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 3. Medical Staff by Specialty and Grade (Cont…)
CONSULTANT
(INCLUDING
STAFF
ASSOCIATE
SPECIALTY
TOTAL
DIRECTORS
GRADE SPECIALIST
OF PUBLIC
HEALTH)
Palliative
69
29
5
Medicine
Rehabilitation
52
18
7
2
Medicine
Renal Medicine
120
51
4
6
Respiratory
150
73
2
2
Medicine
Rheumatology
83
44
2
4
Psychiatric
1,152
488
109
23
Specialties
Child &
105
68
10
2
Adolescent
Psychiatry
Forensic
49
35
Psychiatry
General
744
264
75
13
Psychiatry
Old age
150
75
19
4
Psychiatry
Psychiatry of
87
29
6
3
Learning
Disability
Psychotherapy
21
17
1
1
Radiology
Clinical
Radiology
Nuclear
Medicine
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICERS /
FOUNDATION
YEAR 2
HOUSE
OFFICERS /
FOUNDATION
YEAR 1
SENIOR
CLINICAL
MEDICAL
OFFICER
CLINICAL
MEDICAL
OFFICER
GMP /
GDP
GRADES1
OTHER
15
11
1
-
-
7
1
4
14
-
-
-
7
-
31
25
2
-
-
1
-
39
25
6
-
-
2
1
20
11
-
-
-
2
-
107
333
2
-
-
90
1
16
8
-
-
-
1
-
10
4
-
-
-
-
-
56
289
2
-
-
45
-
16
16
-
-
-
20
-
8
16
-
-
-
24
1
1
-
-
-
-
1
-
344
234
-
3
106
1
-
-
-
-
-
337
228
-
3
105
1
-
-
-
-
-
7
6
-
-
1
-
-
-
-
-
-
185
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 3. Medical Staff by Specialty and Grade (Cont…)
CONSULTANT
(INCLUDING
STAFF
ASSOCIATE
SPECIALTY
TOTAL
DIRECTORS
GRADE SPECIALIST
OF PUBLIC
HEALTH)
Surgical
2,177
719
60
41
Specialties
Cardiothoracic
79
27
1
2
Surgery
ENT Surgery
165
66
8
4
General
874
234
19
8
Surgery
Neurosurgery
58
21
Ophthalmology
Oral &
Maxillofacial
Surgery
Pediatric
Surgery
Plastic Surgery
Trauma &
Orthopedic
surgery
Urology
Public Health
Medicine
Community
Medical
Specialties
Breast
Screening
Service
Community
Child Health
Community
Psychiatry
Family
Planning
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICERS /
FOUNDATION
YEAR 2
HOUSE
OFFICERS /
FOUNDATION
YEAR 1
SENIOR
CLINICAL
MEDICAL
OFFICER
CLINICAL
MEDICAL
OFFICER
GMP /
GDP
GRADES1
OTHER
372
612
341
-
-
31
1
17
28
3
-
-
-
1
34
51
1
-
-
1
-
102
218
280
-
-
13
-
11
24
2
-
-
-
-
232
89
15
15
52
47
5
-
-
9
-
32
24
-
-
8
-
-
-
-
-
-
62
15
1
-
10
17
19
-
-
-
-
84
26
-
1
20
33
2
-
-
2
-
471
163
12
10
90
168
23
-
-
5
-
121
54
5
1
28
26
6
-
-
1
-
171
117
3
1
29
-
-
1
3
4
14
399
60
113
37
2
65
3
8
3
61
50
20
8
4
-
-
-
2
-
-
5
1
135
37
62
22
-
4
-
4
-
6
-
8
2
1
-
-
-
-
-
-
5
-
87
11
45
15
2
-
-
4
1
11
-
186
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN SCOTLAND 2006
Table No 3. Medical Staff by Specialty and Grade (Cont…)
CONSULTANT
(INCLUDING
STAFF
ASSOCIATE
SPECIALTY
TOTAL
DIRECTORS
GRADE SPECIALIST
OF PUBLIC
HEALTH)
General
145
1
Practice
Women’s
5
2
Health Service
All Dental
703
96
22
13
Specialties
Hospital
Dental
308
86
22
13
Specialties
Dental &
Maxillofacial
6
2
Radiology
Fixed &
Removable
1
Prosthodontics
Oral Medicine
14
7
2
Oral
4
2
Microbiology
Oral Pathology
1
1
-
REGISTRAR
GROUP
SENIOR
HOUSE
OFFICERS /
FOUNDATION
YEAR 2
HOUSE
OFFICERS /
FOUNDATION
YEAR 1
SENIOR
CLINICAL
MEDICAL
OFFICER
CLINICAL
MEDICAL
OFFICER
GMP /
GDP
GRADES1
OTHER
-
61
1
-
-
33
49
-
-
-
-
2
1
-
35
63
-
-
-
72
408
33
63
-
-
-
71
20
1
3
-
-
-
-
-
1
-
-
-
-
-
-
1
-
-
-
-
3
1
-
2
-
-
-
-
-
-
-
-
-
-
-
-
Oral Surgery
103
7
14
9
3
41
-
-
-
17
12
Orthodontics
Pediatric
Dentistry
Restorative
Dentistry
Surgical
Dentistry
Community
Dental
Specialties
Community
Dentistry
Dental Public
Health
70
27
3
4
17
2
-
-
-
17
-
26
10
2
-
7
5
-
-
-
1
1
84
30
2
-
3
10
-
-
-
33
6
-
-
-
-
-
-
-
-
-
-
-
401
10
-
-
2
-
-
-
-
1
388
378
-
-
-
-
-
-
-
-
-
378
23
10
-
-
2
-
-
-
-
1
10
187
Source: ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B9: HCHS medical and dental staff by specialty, grade, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB09_HB_REG.xls> [Accessed September 2007].
188
WALES
189
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL
MALE
%
FEMALE
%
TOTAL PHYSICIANS
7,136
4,699
66
2,437
34
All Medical Specialties
5,045
3,357
67
1,688
33
209
140
67
69
33
Accident & Emergency
253
176
70
77
30
Anesthesiology
625
440
70
185
30
Audiological Medicine
3
1
33
2
67
Blood Transfusion
4
2
50
2
50
Cardiology
76
63
83
13
17
Cardio-thoracic Surgery
32
29
91
3
9
Chemical Pathology
21
13
62
8
38
Child & Adolescent Psychiatry
60
30
50
30
50
Clinical Genetics
21
6
29
15
71
Clinical Immunology and Allergy
1
1
100
-
0
Clinical Neuro Physiology
4
4
100
-
0
69
36
52
33
48
4
4
100
-
0
All Dental Specialties
Medical Specialties
Clinical Oncology
Clinical Pharmacology and Therapeutics
Clinical Radiology
157
103
66
54
34
Dermatology
72
46
64
26
36
Endocrinology & Diabetes Mellitus
40
30
75
10
25
Forensic Psychiatry
18
11
61
7
39
Gastroenterology
45
32
71
13
29
General Medicine
494
325
66
169
34
General Psychiatry
284
171
60
113
40
General Surgery
398
301
76
97
24
46
16
35
30
65
250
195
78
55
22
Hematology
78
50
64
28
36
Histopathology
71
52
73
19
27
Genito-urinary Medicine
Geriatric Medicine
190
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
Immunology
Infectious Diseases
TOTAL
MALE
3
%
FEMALE
2
67
%
1
33
2
2
100
-
0
Intensive Care Medicine
16
12
75
4
25
Medical Microbiology and Virology
45
25
56
20
44
Medical Oncology
13
6
46
7
54
Neurology
38
23
61
15
39
Neurosurgery
20
19
95
1
5
Nuclear Medicine
1
1
100
-
0
308
134
44
174
56
Occupational Medicine
15
12
80
3
20
Old age Psychiatry
83
46
55
37
45
Ophthalmology
140
103
74
37
26
Otolaryngology
117
97
83
20
17
5
5
100
-
0
Obstetrics & Gynecology
Pediatric Cardiology
Pediatric Neurology
3
1
33
2
67
10
9
90
1
10
432
207
48
225
52
Palliative Medicine
45
7
16
38
84
Plastic Surgery
36
30
83
6
17
Psychiatry of Learning Disability
40
26
65
14
35
5
3
60
2
40
Pediatric Surgery
Pediatrics
Psychotherapy
Rehabilitation Medicine
15
8
53
7
47
Renal Medicine
44
36
82
8
18
Respiratory Medicine
74
58
78
16
22
Rheumatology
49
31
63
18
37
269
244
91
25
9
Urology
79
68
86
11
14
Other
12
5
42
7
58
Traumatic & Orthopedic Surgery
191
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
Dental Specialties
Dental Medical Specialties
Oral and Maxillofacial Surgery
TOTAL
MALE
%
FEMALE
%
0
5
2
40
3
60
92
65
71
27
29
Oral Surgery
5
5
100
-
0
Orthodontics
40
26
65
14
35
Pediatric Dentistry
Restorative Dentistry
GP's
Source:
1)
2)
8
3
38
5
63
59
39
66
20
34
1,882
1,202
64
680
36
Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
Stats Wales (2007) GP Headcount (gender, age group) [internet], stats Wales. Available from: <http://www.statswales.wales.gov.uk/TableViewer/tableView.aspx?ReportId=1617> [Accessed October
2007]
192
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL
UNDER 35
35-44
45-54
55-64
65 AND OVER
TOTAL PHYSICIANS
5,254
1,927
1,529
1,134
614
50
All Medical Specialties
5,045
1,857
1,481
1,080
580
47
209
70
48
54
34
3
Accident & Emergency
253
125
64
43
20
1
Anesthesiology
625
193
227
128
72
5
Audiological Medicine
3
0
2
0
1
0
Blood Transfusion
4
0
0
2
1
1
Cardiology
76
32
25
17
2
0
Cardio-thoracic Surgery
32
10
13
7
2
0
Chemical Pathology
21
6
3
10
2
0
Child & Adolescent Psychiatry
60
13
18
23
4
2
Clinical Genetics
21
1
8
10
2
0
Clinical Immunology and Allergy
1
1
0
0
0
0
Clinical Neuro Physiology
4
1
0
2
0
1
69
24
18
15
12
0
4
0
1
1
2
0
All Dental Specialties
Medical Specialties
Clinical Oncology
Clinical Pharmacology and Therapeutics
Clinical Radiology
157
32
43
60
22
0
Dermatology
72
13
30
16
12
1
Endocrinology & Diabetes Mellitus
40
19
15
3
3
0
Forensic Psychiatry
18
6
7
5
0
0
Gastroenterology
45
21
18
5
1
0
General Medicine
494
304
69
67
47
7
General Psychiatry
284
88
90
67
34
5
General Surgery
398
193
94
66
42
3
46
5
15
18
6
2
250
82
69
58
36
5
Hematology
78
18
22
22
16
0
Histopathology
71
17
9
34
11
0
Genito-urinary Medicine
Geriatric Medicine
193
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
UNDER 35
35-44
45-54
55-64
65 AND OVER
Immunology
3
1
1
1
0
0
Infectious Diseases
2
2
0
0
0
0
Intensive Care Medicine
16
4
11
1
0
0
Medical Microbiology and Virology
45
6
15
15
8
1
Medical Oncology
13
4
5
4
0
0
Neurology
38
17
12
6
2
1
Neurosurgery
20
6
5
6
3
0
1
0
1
0
0
0
308
99
102
60
43
4
15
2
3
7
3
0
Nuclear Medicine
Obstetrics & Gynecology
Occupational Medicine
Old age Psychiatry
83
18
25
26
13
1
Ophthalmology
140
34
45
38
21
2
Otolaryngology
117
43
30
27
17
0
Pediatric Cardiology
5
1
2
1
1
0
Pediatric Neurology
3
0
2
1
0
0
10
3
2
4
1
0
432
168
134
85
43
2
Palliative Medicine
45
18
12
9
6
0
Plastic Surgery
36
16
14
4
2
0
Psychiatry of Learning Disability
40
9
15
14
2
0
5
3
0
1
1
0
Rehabilitation Medicine
15
3
6
3
3
0
Renal Medicine
44
20
13
8
2
1
Respiratory Medicine
74
31
29
7
7
0
Rheumatology
49
12
18
8
10
1
269
101
91
46
31
0
Urology
79
30
26
15
8
0
Other
12
2
2
4
3
1
Pediatric Surgery
Pediatrics
Psychotherapy
Traumatic & Orthopedic Surgery
194
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
Dental Specialties
Dental Medical Specialties
Oral and Maxillofacial Surgery
UNDER 35
35-44
45-54
55-64
65 AND OVER
5
0
3
2
0
0
92
36
20
19
15
2
Oral Surgery
5
1
1
2
1
0
Orthodontics
40
12
9
9
9
1
8
3
0
4
1
0
59
18
15
18
8
0
1,882
193
597
719
338
35
Pediatric Dentistry
Restorative Dentistry
GP's
Source: Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
195
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 3. Medical Staff by Specialty and Grade
SPECIALTY
TOTAL
PHYSICIANS
All Medical
Specialties
All Dental Specialties
Medical Specialties
Accident &
Emergency
Anesthesiology
SPECIALIST
REGISTRAR
SENIOR
HOUSE
OFFICER
HOUSE
OFFICER
HOSPITAL
PRACTITIONER
CLINICAL
ASSISTANT
483
850
1,269
257
56
307
57
158
461
826
1,232
257
55
253
57
16
22
24
37
0
1
54
0
0
0
CONSULTANT
ASSOCIATE
SPECIALIST
5,254
1,801
174
5,045
1,746
209
55
TOTAL
STAFF
GRADE
OTHER
STAFF
0
253
34
10
44
23
98
9
2
28
5
625
275
18
43
126
146
7
4
6
0
Audiological Medicine
3
1
0
0
2
0
0
0
0
0
Blood Transfusion
4
1
2
0
0
0
0
0
1
0
76
26
1
2
29
10
2
4
2
0
32
12
0
2
8
8
0
0
0
2
21
12
0
0
7
1
0
0
1
0
60
30
3
8
7
11
0
0
1
0
21
11
4
2
4
0
0
0
0
0
1
0
0
0
1
0
0
0
0
0
4
3
0
0
1
0
0
0
0
0
69
31
0
4
22
9
0
1
2
0
4
3
0
0
1
0
0
0
0
0
157
115
0
1
36
4
0
0
1
0
72
21
2
3
12
5
0
7
22
0
40
9
0
0
21
5
0
0
4
1
Cardiology
Cardio-thoracic
Surgery
Chemical Pathology
Child & Adolescent
Psychiatry
Clinical Genetics
Clinical Immunology
and Allergy
Clinical Neuro
Physiology
Clinical Oncology
Clinical Pharmacology
and Therapeutics
Clinical Radiology
Dermatology
Endocrinology &
Diabetes Mellitus
196
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 3. Medical Staff by Specialty and Grade (Cont…)
Forensic Psychiatry
18
7
1
2
1
SENIOR
HOUSE
OFFICER
7
0
0
0
Gastroenterology
45
12
1
0
28
3
1
0
0
0
General Medicine
494
107
9
40
1
204
97
3
23
10
General Psychiatry
284
97
11
46
20
85
0
5
17
3
General Surgery
Genito-urinary
Medicine
Geriatric Medicine
398
114
9
31
62
76
94
1
4
7
46
12
0
8
6
0
0
0
20
0
SPECIALTY
TOTAL
CONSULTANT
ASSOCIATE
SPECIALIST
STAFF
GRADE
SPECIALIST
REGISTRAR
HOUSE
OFFICER
HOSPITAL
PRACTITIONER
CLINICAL
ASSISTANT
OTHER
STAFF
0
250
55
3
21
29
74
8
6
53
1
Hematology
78
41
4
8
16
6
2
0
1
0
Histopathology
71
54
0
0
14
3
0
0
0
0
Immunology
3
2
0
0
0
1
0
0
0
0
Infectious Diseases
Intensive Care
Medicine
Medical Microbiology
and Virology
Medical Oncology
2
0
0
0
1
1
0
0
0
0
16
12
0
0
0
3
1
0
0
0
45
36
0
1
8
0
0
0
0
0
13
6
0
2
3
0
0
1
1
0
Neurology
38
17
0
0
11
6
1
1
2
0
Neurosurgery
20
8
1
1
4
6
0
0
0
0
1
0
0
0
1
0
0
0
0
0
308
88
12
27
64
94
0
3
10
10
15
8
0
1
3
0
0
2
1
0
Nuclear Medicine
Obstetrics &
Gynecology
Occupational
Medicine
Old age Psychiatry
83
31
1
15
8
16
0
1
11
0
Ophthalmology
140
55
13
20
18
24
0
1
8
1
Otolaryngology
117
41
7
12
15
31
4
2
5
0
5
4
0
0
1
0
0
0
0
0
Pediatric Cardiology
197
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN WALES 2005
Table No 3. Medical Staff by Specialty and Grade (Cont…)
3
3
0
0
0
SENIOR
HOUSE
OFFICER
0
0
0
0
0
10
5
0
0
2
2
1
0
0
0
432
121
29
54
64
148
7
0
3
6
Palliative Medicine
45
16
0
10
11
4
2
1
1
0
Plastic Surgery
Psychiatry of Learning
Disability
Psychotherapy
Rehabilitation
Medicine
Renal Medicine
36
10
0
0
14
12
0
0
0
0
40
13
0
5
3
8
0
5
5
1
5
1
0
0
0
3
0
0
1
0
15
5
0
1
1
2
0
0
6
0
44
8
3
5
13
9
5
0
0
1
Respiratory Medicine
74
25
0
2
35
10
2
0
0
0
Rheumatology
Traumatic &
Orthopedic Surgery
Urology
49
23
0
3
9
4
2
3
5
0
269
93
10
30
46
77
5
1
1
6
79
28
3
6
14
16
7
0
2
3
12
4
1
1
0
0
0
1
5
0
0
0
0
0
0
SPECIALTY
Pediatric Neurology
Pediatric Surgery
Pediatrics
Other
Dental Specialties
Dental Medical
Specialties
Oral and Maxillofacial
Surgery
Oral Surgery
Orthodontics
Pediatric Dentistry
Restorative Dentistry
TOTAL
CONSULTANT
ASSOCIATE
SPECIALIST
STAFF
GRADE
SPECIALIST
REGISTRAR
HOUSE
OFFICER
HOSPITAL
PRACTITIONER
CLINICAL
ASSISTANT
OTHER
STAFF
5
4
0
0
1
0
0
0
0
0
92
24
6
9
8
28
0
1
16
0
5
1
1
2
0
0
0
0
1
0
40
13
2
1
11
0
0
0
13
0
8
3
0
1
1
2
0
0
1
0
59
10
7
9
3
7
0
0
23
0
Note: Only considered the 'Numbers' for each professional activity. Did not consider the whole time equivalents
Source: Health Statistics and Analysis Unit, Wales Assembly Government,2005 [Accessed October 2007]
198
UK
(CONSOLIDATED DATA)
199
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK
Table No 1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL PHYSICIANS
TOTAL
MALE
%
FEMALE
%
154,246
93,423
61
60,823
39
12,351
8,150
66
4,201
34
Cardiology
2,438
1,908
78
530
22
Dermatology
1,401
630
45
771
55
Emergency Medicine
5,652
3,540
63
2,112
37
40,720
23,885
59
16,835
41
8,180
5,850
72
2,330
28
Internal Medicine
19,018
11,292
59
7,726
41
Medical Oncology
1,918
996
52
922
48
Neurology
1,266
917
72
349
28
Anesthesiology
General Physicians / General Practitioners / Family Doctors
General Surgery / Vascular Surgery
Neurosurgery
649
562
87
87
13
Obstetrics and Gynecology
6,067
2,758
45
3,309
55
Ophthalmology
2,763
1,890
68
873
32
Orthopedic Surgery and Traumatology
6,021
5,265
87
756
13
Otolaryngology
2,047
1,616
79
431
21
Pathology
4,758
2,625
55
2,133
45
Pediatric & Pediatric Surgery
8,614
3,954
46
4,660
54
Physical Medicine, Rehabilitation and Rheumatology
1,578
936
59
642
41
925
728
79
197
21
11,594
6,590
57
5,004
43
Public Health / Community Medicine / Occupational Medicine
4,670
1,771
38
2,899
62
Radiology
3,894
2,546
65
1,348
35
855
752
88
103
12
Urology / Renal Failure Surgery
1,804
1,464
81
340
19
Other Specialties
1,598
799
50
799
50
Dental group
3,465
1,999
58
1,466
42
Plastic Surgery
Psychiatry
Thoracic Surgery
Note: The data points for England and Scotland are for the year 2006; the data points for Wales are for the year 2005 and for Northern Ireland the data is for the year 2007. The consolidated data tables are based on
the latest available data for all these provinces, although they do not belong to the same year
200
Source:
1)
2)
3)
4)
5)
IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from:
<http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007 [Accessed October 2007].
ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B5: HCHS staff by gender, contract type, specialty, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB05_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007].
Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
Stats Wales (2007) GP Headcount (gender, age group) [internet], stats Wales. Available from: <http://www.statswales.wales.gov.uk/TableViewer/tableView.aspx?ReportId=1617> [Accessed October
2007]
201
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL PHYSICIANS
TOTAL
UNDER 35
35-44
45-54
55 AND OVER
154,072
52,356
45,020
36,082
20,614
12,368
4,305
4,135
2,608
1,319
Cardiology
2,438
1,018
795
413
213
Dermatology
1,401
330
476
370
226
Emergency Medicine
5,652
3,503
1,287
557
305
40,719
5,240
13,114
14,103
8,262
Anesthesiology
General Physicians / General Practitioners / Family Doctors
General Surgery / Vascular Surgery
8,180
4,384
1,880
1,228
689
Internal Medicine
13,234
6,129
3,413
2,270
1,422
Medical Oncology
1,918
764
620
319
216
Neurology
1,266
374
450
263
179
Neurosurgery
649
298
205
95
51
Obstetrics and Gynecology
6,067
2,377
1,913
1,171
606
Ophthalmology
2,763
757
943
667
396
Orthopedic Surgery and Traumatology
6,021
2,701
1,740
999
581
Otolaryngology
2,047
743
572
424
308
Pathology
4,758
1,218
1,378
1,411
751
Pediatric & Pediatric Surgery
8,614
3,963
2,362
1,471
818
Physical Medicine, Rehabilitation and Rheumatology
1,578
459
495
350
274
925
409
310
144
62
11,594
3,967
3,610
2,623
1,394
Plastic Surgery
Psychiatry
Public Health / Community Medicine / Occupational Medicine
4,670
876
1,250
1,640
904
Radiology
3,894
1,122
1,247
1,011
514
855
320
298
159
77
Thoracic Surgery
Urology / Renal Failure Surgery
1,804
702
533
388
182
Other Specialties
7,365
5,213
1,074
649
430
Dental group
3,292
1,186
920
749
437
202
Note:
1)
2)
3)
Source:
1)
2)
3)
4)
The total in this table may not be equal to the total as in table 1, since the age break up for the dental group (n=173) in Northern Ireland is not available
The age group for one specialty in England is categorized as 'Unknown'. Hence, not included in the above table
The data points for England and Scotland are for the year 2006; the data points for Wales are for the year 2005 and for Northern Ireland the data is for the year 2007. The consolidated data tables are
based on the latest available data for all these provinces, although they do not belong to the same year
The information centre,National Health Service, Department of Health, 2006 [Accessed October 2007].
Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007.
ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B6: HCHS staff by specialty by age group, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB06_HB_REG.xls&pContentDispositionType=inline> [Accessed September 2007].
Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
203
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK
Table No 3. Medical Staff by Specialty and Grade
CONSULTANT
SENIOR
REGISTRAR
HOUSE
SENIOR
HOSPITAL
(INCLUDING
HOUSE
CLINICAL
GMP /
GENERAL/
ASSOCIATE STAFF GROUP /
OTHER
OFFICERS /
CLINICAL PRACTITIONER/
SPECIALTIES TOTAL DIRECTOR
OFFICERS /
MEDICAL
GDP
MEDICAL
SPECIALIST GRADE SPECIALIST
FOUNDATION
MEDICAL
CLINICAL
STAFF
OF PUBLIC
FOUNDATION
OFFICER
GRADES1 PRACTITIONER
REGISTRAR
YEAR 1
OFFICER
ASSISTANT
HEALTH)
YEAR 2
TOTAL
113,369
39,674
3,306 7,144
21,919
28,055
5,955
85
11
3,958
685
102 2,475
PHYSICIANS
Anesthesiology 12,369
5,752
319
886
2,666
2,491
140
0
0
92
12
1
10
Cardiology
2,438
897
Dermatology
1,401
Emergency
5,652
Medicine
General
Physicians /
N.A
General
Practitioners /
Family Doctors
General Surgery
/ Vascular
8,180
Surgery
Internal
19,002
Medicine
Medical
1,918
Oncology
Neurology
1,267
543
866
N.A
Neurosurgery
Obstetrics and
Gynecology
Ophthalmology
Orthopedic
Surgery and
Traumatology
Otolaryngology
Pathology
39
106
697
77
55
233
133
633
889
N.A
N.A
N.A
2,189
169
332
4,832
300
832
448
107
0
0
133
8
0
2
97
4
0
0
340
40
11
2
2,791
111
0
0
165
34
11
18
N.A
N.A
N.A
N.A
N.A
N.A
N.A
N.A
1,517
1,826
1,972
1
0
151
13
1
8
742
2,982
6,110
2,629
7
0
1,101
230
30
40
29
87
571
315
32
0
0
52
1
0
0
668
17
22
287
214
12
0
0
45
2
0
0
649
224
4
6
231
173
11
0
0
0
0
0
0
6,068
1,838
154
331
1,537
1,928
62
2
1
156
28
0
31
2,763
999
229
329
524
514
12
4
0
135
9
0
6
6,021
2,009
222
344
1,357
1,756
248
0
0
73
5
0
6
2,047
729
108
154
394
553
29
0
0
74
1
5
0
4,759
2,902
100
95
1,222
334
20
0
0
59
20
5
3
204
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN UK
Table No 3. Medical Staff by Specialty and Grade (Cont…)
CONSULTANT
SENIOR
REGISTRAR
HOUSE
SENIOR
HOSPITAL
(INCLUDING
HOUSE
CLINICAL
GMP /
GENERAL/
ASSOCIATE STAFF GROUP /
OTHER
OFFICERS /
CLINICAL PRACTITIONER/
SPECIALTIES TOTAL DIRECTOR
OFFICERS /
MEDICAL
GDP
MEDICAL
SPECIALIST GRADE SPECIALIST
FOUNDATION
MEDICAL
CLINICAL
STAFF
OF PUBLIC
FOUNDATION
OFFICER
GRADES1 PRACTITIONER
REGISTRAR
YEAR 1
OFFICER
ASSISTANT
HEALTH)
YEAR 2
Pediatric &
Pediatric
8,614
2,603
326
645
2,033
2,745
169
2
1
51
11
5
23
Surgery
Physical
Medicine,
Rehabilitation
1,578
765
29
74
341
178
43
0
0
131
16
0
1
and
Rheumatology
Plastic Surgery
925
300
24
20
288
277
9
0
0
6
2
0
0
Psychiatry
Public Health /
Community
Medicine /
Occupational
Medicine
Radiology
Thoracic
Surgery
Urology / Renal
Failure Surgery
Other
Specialties
Dental group
Source:
1.
2.
3.
4.
11,595
4,597
521
1,439
1,206
3,228
52
2
0
427
90
4
30
4,674
1,405
204
349
366
231
7
61
9
120
81
23
1,819
3,894
2,523
30
32
1,216
72
2
0
0
18
0
0
0
855
294
6
19
284
230
14
0
0
4
0
0
3
1,804
663
73
108
391
369
168
0
0
26
2
0
4
1,598
401
50
75
284
584
76
5
0
101
8
8
6
3,298
843
144
261
404
589
26
0
0
497
72
0
462
IC (2007) NHS Hospital and Community Health Services: Medical and Dental Workforce Census England - 30 September 2006 - Detailed Results [internet], IC. Available from:
<http://www.ic.nhs.uk/webfiles/publications/nhsstaff2006/med/Medical%20and%20Dental%20Detailed%20Results%202006.pdf> [Accessed September 2007]
Workforce Statistics; Health, Social Service and Public Safety Department, Statistics and Research, Medical Staff, 2007.
ISD Scotland (2007) NHS Scotland Workforce Statistics - Table B9: HCHS medical and dental staff by specialty, grade, NHS Board and Region [internet], ISD Scotland. Available from:
<http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=WFB09_HB_REG.xls> [Accessed September 2007].
Health Statistics and Analysis Unit, Wales Assembly Government, 2005 [Accessed October 2007]
205
15. USA
206
15.1. Introduction to the United States of America
The United States of America (US or USA) is the world's third or fourth largest nation by
total area, before or after the People's Republic of China, depending on how two
territories disputed by China and India are counted. Including only land area, the United
States is third in size behind Russia and China, just ahead of Canada. The continental US
stretches from the Atlantic Ocean to the Pacific Ocean and from Canada to Mexico and
the Gulf of Mexico. Alaska is the largest state in area. Separated by Canada, it touches
the Pacific and Arctic Oceans. Hawaii occupies an archipelago in the Pacific, southwest
of North America. The commonwealth of Puerto Rico, the largest and most populous US
territory, is in the northeastern Caribbean. With a few exceptions, such as the territory of
Guam and the westernmost portions of Alaska, nearly all of the country lies in the
western hemisphere (Figure 19).
Figure 19:
USA political map
Source: www.wikipedia.org
207
According to the World Health Statistics (2007), there were 298,213,000 inhabitants in
the US in 2005. In the same year, the life expectancy at birth was estimated at 75 years
for males and 80 years for females. On October 17, 2006, the US population was
estimated by the US Census Bureau to be 300,000,000. The US population included an
estimated 12 million unauthorized migrants, of whom an estimated 1 million were
uncounted by the Census Bureau. The overall growth rate is 0.89%, compared to 0.16%
in the European Union. The birth rate of 14.16 per 1,000 is 30% below the world average,
while higher than any European country except for Albania and Ireland. In 2006, 1.27
million immigrants were granted legal residence. Mexico has been the leading source of
new US residents for over two decades; since 1998, China, India, and the Philippines
have ranked in the top four among migrants’ countries of origin every year. The United
States is the only industrialized nation in which large population increases are projected.
15.2. The US healthcare system
Unlike most other major markets, there is no government-led scheme providing access to
healthcare for all residents. The healthcare system is fragmented, with public healthcare
schemes (Medicare, Medicaid and the State Children’s Health Insurance Program)
providing basic healthcare coverage for over 80 million people and private insurance
covering around 200 million including those supplementing their Medicare coverage
(Datamonitor, Macro-environmental healthcare issues in the US, 2004). There are over
43 million uninsured people in the US, as fewer employees are being covered by
employer-funded health schemes. The following figure (Figure 20) shows the healthcare
structure in the US.
208
Figure 20:
Healthcare structure in the US
Source: internal secondary research
DATAMONITOR
15.3. Healthcare insurance
Medicare is the federal health insurance program that covers the elderly (those aged 65
and over), people with certain disabilities; and patients with end-stage renal disease.
Medicare serves all eligible beneficiaries without regard to income or health status.
Medicare recently underwent a significant reform and now provides prescription drug
coverage for outpatients for the first time. Medicaid is the joint federal and state-run
program that provides health coverage to low-income families with dependent children,
pregnant women, people with disabilities and the indigent population. The state’s
Children’s Health Insurance Programs (known as CHIPs and other names in various
states) provide benefit packages for over 5 million children under age 19 who do not
qualify for Medicaid.
The majority of the US population has private health insurance, virtually all provided by
Managed Care Organizations (MCOs) which include Health Maintenance Organizations
(HMOs), Preferred Provider Organizations (PPOs), Point of Service (POS) plans and
Provider-Sponsored Organizations (PSO). MCO, an entity that finances and manages
209
healthcare delivery through networks of doctors, hospitals and specialty providers,
dominates the private health insurance market, covering 95% of employees.
The
following table (Table 29) gives a description of the leading categories of private health
insurance plans in the US.
Table 29:
Leading Types of Private Insurance in the US
Traditional
Sub-Type
Indemnity
Preferred Provider
Organization (PPO)
Managed Care
Less Expensive
Less Restrictive
Type
Point of Service
Health Maintenance
Organization (HMO)
HMOs are comprehensive
services that assume
responsibility for financing
and delivering care. Members
must pre-select a primary care
physician and non-emergency
services require prior
authorization Payments for
within network care are
covered without reliance on
OOP-reimbursement system
Source: internal secondary research
Network
Model
Individual
Practice
Association
Description
Reimburses patients as expenses
are incurred High freedom of
choice, but high OOP costs.
Leading form of insurance from
post WWII to beginning of 1990s
but relatively rare now.
Coverage is provided through a
network of contracted fee-forservice providers. Members are free
to seek service outside network but
will
incur significantly higher OOP
costs
HMO PP hybrid where members
do not have to pre—enroll with
physicians
HMO contracts with multiple
physician groups
Independent or small physician
groups that form collectives for
purposes of attracting HMO
patients
Group Model
HMO contracts with a single-multi
specialty physician group Payment
is usually on a capitated basis
Staff Model
Physicians are employees of HMO
Services are delivered through
HMO owned facilities
DATAMONITOR
A patient’s cost burden or care depends on the type of program, his or her state of health,
and the health of any dependants. Over 70% of the population under 65 years of age has
private health insurance, with more than 90% of private coverage obtained through
employers. Around 16 million people purchase their own health insurance (internal
secondary research). The following table (Table 30) shows population coverage for
public and private insurance plans in 2003 and 2004. As indicated, employment-based
210
plans are the most common among healthcare insurance plans. However, the percentage
of people covered by employment-based health insurance fell between 2003 and 2004.
Table 30:
Source of Health Coverage
Type of Coverage
2003
2004
Change%
Employment Based
Direct Purchase
Total Private
Medicare
Medicaid
Military
Total Public
No Coverage
60.4%
9.2%
68.6%
13.7%
12.4%
3.5%
26.6%
15.7%
59.8%
9.3%
68.1%
13.7%
12.9%
3.7%
27.2%
15.7%
-1.0%
1.1%
-0.7%
0.0%
4.0%
5.7%
2.3%
0.0%
Note that percentages do not add up to 100% due to the possibility for coverage under multiple plans
Source: internal secondary research
DATAMONITOR
Rising costs have led to a significant curtailment in the provision of employee-based
health insurance. Only 60% of private firms offered health benefits in 2005 compared to
69% in 2000. The majority of private coverage is obtained through employers, with the
premiums shared between employer and employee. Around 16% of single coverage
premiums and 27% of family premiums are paid by the employees, resulting in a
significant cost burden for the employers. The cost of providing healthcare insurance is
therefore, one of the most important problems affecting US companies.
15.4. Service delivery
Access to care is determined by the type of health insurance coverage, with managed care
being the most restricted system. Whether referral by a primary care physician is required
for patient access to a specialist depends on the payer:
o Medicare beneficiaries can choose to visit healthcare professionals participating in
the federal scheme;
211
o In general, state Medicaid plans must allow patients freedom of choice among
healthcare providers participating in Medicaid. States may place limits on a
Medicaid service based on criteria such as medical necessity or utilization control
(e.g., a limit on the number of covered physician visits or prior authorization
before delivery of a service). Healthcare delivery in Medicaid programs
increasingly relies on managed care, with 57% of Medicaid beneficiaries enrolled
in some form of managed care plan. Medicaid HMOs are typically closeddelivery systems that are tightly regulated by care management (restricted
networks and pre-authorization requirements) in return for assured access.
Medicaid beneficiaries in fee-for-service programs are less likely to receive
regular medical or preventive care than the commercially insured population;
o Patients with fee-for-service health plans can choose any physician they wish and
do not need to obtain a referral from a primary care physician prior to consulting a
specialist. Patients can also go to any hospital, typically paying a deductible and a
co-insurance, which will vary according to insurance plans. There is no formal coordination of medical care by a physician and the insurance plan neither reviews
nor denies use of services. Pre-authorization is not required to obtain services.
Fee-for-service plans may encourage physicians to over-treat patients since they
are paid for services rendered and there are no incentives to keep patients healthy;
o Managed care plans, on the other hand, have a greater role in determining what
services patients receive and may also influence how the doctor practices. The
extent of control over access to healthcare varies according to the type of plan,
with HMOs having the most influence over the way in which doctors and
hospitals provide care.
212
The following table (Table 31) describes access to healthcare in the US by type of health
plan.
Table 31:
Access to healthcare providers according to different health plans
Choice of doctor
Access to specialists
HMO
Must be from the HMOs
network. The primary care
physician is the primary
contact for all health services
and manages care by
coordinating necessary
services
Referral from primary care
doctor required
PPO
POS
No restrictions. However,
if a doctor does not accept
the insurance plan, he is
considered out-of-network
and the patient won’t get
coverage for the visit
To have care paid for, patient
must select a doctor from the
POS network. The alternative is
to go out-of-network at a higher
price
Referral from the primary care
doctor is required to stay in
Direct access, without need network (and pay a small fee),
for referral
but patients can opt to see any
specialist without a referral for
a higher price.
HMO = health maintenance organization; PPO = preferred provider organization; POS = point-of-service
Source: internal secondary research
DATAMONITOR
15.5. Healthcare financing and expenditure
Total health spending accounted for 15.3% of Gross Domestic Product (GDP) in the
United States in 2005, the highest share in the OECD countries (OECD Health data,
2007). The United States also ranks far ahead of other OECD countries in terms of total
health spending per capita, with spending of $6,401 (adjusted for purchasing power
parity), more than twice the OECD average of $2,759 in 2005. Between 2000 and 2005,
health spending per capita in the United States increased, in real terms, by 4.4% per year
on average. Differences in health spending across countries may reflect differences in
price, volume and quality of medical goods and services consumed. The following table
(Table 32) shows the key health expenditure indicators in 2005.
213
Table 32:
Key US health expenditure indicators, 2005
Value
(year)
Indicator
Total expenditure on health as percentage of gross domestic product
Public expenditure on health as percentage of total expenditure on health
Private expenditure on health as percentage of total expenditure on health
Per capita total expenditure on health (adjusted for purchasing power parity)
Source: OECD Health data, 2005
15.3% (2005)
45.1% (2005)
37% (2005)
$6,401 (2005)
DATAMONITOR
According to the OECD Health data (2007), only 45.1% of health spending is funded by
government revenues in the US. On the other hand, private insurance accounts for 37% of
total health spending in the US, by far the largest share among OECD countries. The
following table (Table 33) shows the sources of healthcare funds in 2004. Although the
US doesn’t have a universal national health insurance program, about 45% of
expenditures came from public sources in 2004.
Table 33:
Sources of US health spending, 2004
Source
Out of Pocket
Private insurance
Other Private
Total Private
Medicare
Medicaid
Other Public
Total Public
Combined Total
Source: : internal secondary research
Total $ billion
$235.7
$658.6
$136.5
$1,030.80
$309
$202.7
$245.8
$847.5
$1,878.30
% of Total
12.5%
35.1%
7.3%
54.9%
16.5%
15.6%
13.1%
45.1%
100%
% of Growth
5.5%
8.6%
6.8%
7.6%
8.9%
8%
7.5%
8.2%
7.9%
DATAMONITOR
The following table (Table 34) shows distribution of healthcare funds in 2004. As
indicated, professional services and hospital care represent by far the largest components.
The US pharmaceutical market is the world’s largest by a wide margin, but Americans
spend a relatively low portion (10%) of the total health budget on drugs compared to
other countries.
214
Table 34:
Destination of Health Spending, 2004
Destination
Hospital care
Professional Services
Home Health & Nursing Homes
Prescription Drugs
Administration
Other
Total
Source: internal secondary research
% Total
Spending
30.4%
31.3%
8.4%
10%
7.3%
12.6%
100.00%
% Growth
8.6%
8.1%
6.6%
8.3%
9.4%
5.2%
7.90%
DATAMONITOR
The share of health expenditure spent on pharmaceuticals in the US increased from 8.9%
of total health spending in 1995 to 12.4% in 2005 (OECD Health data, 2007). The US
was nonetheless the top spender on pharmaceuticals in 2005, with spending of $792 per
capita. The percentage of total healthcare spending attributable to pharmaceuticals in the
US increased by 78.6% from 1994 to 2004 (Kaiser Family Foundation: Trends and
Indicators in the Changing Health Care Marketplace, 2005), and was approximately $230
billion in 2005. Pharmaceutical products are widely used in the US, with an estimated
51% of the population taking prescription drugs on a daily basis and 27% taking three or
more drugs daily (USA Today/Kaiser Family Foundation/Harvard School of Public
Health: Health Care Costs Survey, 2005). Faced with such trends, the US government
and healthcare providers have put in place a number of policies and strategies aimed at
reducing pharmaceutical expenditure.
15.6. Resources
Despite the relatively high level of health expenditure in the United States, it had only 2.4
practicing physicians per 1,000 population in 2005 as indicated in the table below. There
were 7.9 nurses per 1,000 population in 2002 (latest year available). The number of acute
care hospital beds in the United States in 2005 fell to 2.7 per 1,000 population, from 4.4
beds per 1,000 population in 1980. This decline has coincided with a reduction in average
length of stays in hospitals and an increase in day-surgery patients. The following table
(Table 35) gives the absolute number and density of physicians and nurses in the recent
215
years. For a complete review of the most up to date physician statistics, please refer to the
US physician statistics section of this report.
Table 35:
Physicians and Nurses
Indicator
Value (year)
Physicians (number)
Physicians (density per 1,000 population)
Nurses (number)
Nurses (density per 1, 000 population)
730,801 (2000)
2.4 (2005)
2, 669, 603 (2000)
7.9 (2002)
Source: OECD Health Data, 2007
DATAMONITOR
15.7. The US pharmaceutical market
The US pharmaceutical market generated an estimated $230 billion in sales in 2005 (IMS
Health, 2006). Of that, approximately 10% was generic sales, giving the US generics
market a sales value of $24 billion in 2005. In volume terms, however, the generics
market dominates, accounting for 56% of all prescriptions dispensed in the US. The
following table (Table 36) shows the share of market held by original brands, branded
generic and true generics. Generics experienced dramatic growth in 2005, with true
generics reaching 50.1% of all prescriptions dispensed and branded generics accounting
for an additional 9.1% (internal secondary research). During 2005, $17 billion in branded
product sales were exposed to generic competition for the first time. The biggest brands
to lose exclusivity were Allegra (fexofenadine), Duragesic (fentanyl), Zithromax
(azithromycin) and Rochepin (ceftriaxone). Using 2005 sales figures, Datamonitor
research estimates that $19.5 billion are at risk of losing exclusivity in 2007; $17 billion
in 2008 and $6.5 billion in 2009.
216
Table 36:
Generic and branded trends in the US, 2004-2005
Percent of Prescription Value
Generics
Branded Generics
Combined Generics
Brands
Percent of prescription volume
Generics
Branded Generics
Combined Generics
Brands
Source: internal secondary research
2004
2005
CAGR
7.80%
9.60%
17.40%
82.60%
8.90%
9.80%
18.70%
81.30%
2.7%
1.4%
2%
-0.4%
2004
2005
CAGR
43.60%
10.60%
54.20%
45.80%
50.10%
9.10%
59.20%
40.80%
3.9%
-4.1%
2.3%
-2.7%
DATAMONITOR
The data in the following table (Table 37) reflects sales activity by therapeutic category
in 2005. Cytostatics (oncology) drugs represented the strongest growth category.
217
Table 37:
US retail sales by therapeutic category, 2005
Category
Cardiovascular
Central Nervous System
Alimentary/Met.
Respiratory
Anti-Infectives
Musculoskeletal
Genitourinary
Cytostatics
Blood Agents
Dermatologicals
Sensory Organs
Diagnostic Agents
Systemic Hormones
Miscellaneous
Hospital Solutions
Parasitology
Total
Source: internal secondary research
$m
% Change
34,383
41,718
24,814
17,186
14,287
10,453
10,881
8,239
5,543
4,615
3,212
2,731
2,827
1,588
4
232
8%
2%
3%
9%
6%
-11%
3%
15%
9%
-3%
7%
10%
8%
12%
-4%
12%
182,713
6%
DATAMONITOR
The top three pharmaceutical companies in the US in 2005 by US sales were Pfizer,
GlaxoSmithKline (GSK) and Johnson & Johnson (Pharma Handbook 2006, VOI
Consulting). R&D investments by Pharmaceutical Research and Manufacturers of
America (PhRMA) member companies amounted to $39.4 billion in 2005 (up from $37
billion in 2004), which is equivalent to 19.2% of domestic drug sales. Total investments
in biotechnology and pharmaceutical R&D by both PhRMA member companies and nonmembers totaled $51.3 billion. The average time for eventually approved drugs to spend
in clinical trials is seven years. The rate at which the 10 top US pharmaceutical
companies initiated clinical trials for new drugs rose by 52% in the 2003–05 period as
compared with 1998–2002. At the beginning of 2006, the top 46 companies had 1,270
products in preclinical or clinical testing. 144 were in Phase III; 250 were in Phase II.
Cross-border trade declined from $491 million in 2004 to $351 in 2005. A number of
factors, including increased focus on drug safety, patent expirations of a number of
218
leading drugs, the strengthening of the Canadian versus the US dollar and restricted
availability of supplies were implicated in this slowdown.
219
15.8. Bibliography
o World Health Organization (2007), World health statistics [Internet]. Available
from:
<http://www.who.int/whosis/database/core/core_select_process.cfm?country=usa
&indicators=selected&language=en> [Accessed October 2007].
o World Health Organization (2007), World health statistics [Internet]. Available
from:
<http://www.who.int/whosis/database/core/core_select_process.cfm?country=us&
indicators=healthpersonnel> [Accessed October 2007].
o Datamonitor (2004), Macro-environmental healthcare issues in the US, 2004.
o OECD data (2007), OECD United States Health data 2007 [Internet] Available
from: < http://www.oecd.org/dataoecd/46/2/38980580.pdf> [Accessed October
2007].
o Datamonitor (2006), Global Generics Guide: Part 2 - Benchmarking country
markets and strategic issues, June 2006, DMHC 2216.
220
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.1. Total Physicians by Specialty and Gender
SPECIALTY
TOTAL
MALE
%
FEMALE
%
TOTAL PHYSICIANS
Aerospace Medicine
Allergy/ Immunology
902,053
468
4,112
657,140
434
3,031
73
93
74
244,913
34
1,081
27
7
26
Anesthesiology
Cardiovascular Disease
Child Psychiatry
Colon/ Rectal Surgery
40,494
22,349
7,234
1,291
31,492
20,210
3,952
1,133
78
90
55
88
9,002
2,139
3,282
158
22
10
45
12
Dermatology
Diagnostic Radiology
Emergency Medicine
Family Medicine
10,593
24,231
29,144
81,701
6,519
18,858
22,687
54,307
62
78
78
66
4074
5373
6457
27394
38
22
22
34
Forensic Pathology
Gastroenterology
672
12,017
444
10,670
66
89
228
1347
34
11
General Practice
General Preventive Medicine
11,049
2,211
8,950
1,392
81
63
2099
819
19
37
37,857
154,002
498
5,440
32,387
105,987
259
5,111
86
69
52
94
5470
48015
239
329
14
31
48
6
Neurology
Nuclear Medicine
Obstetrics/ Gynecology
Occupational Medicine
14,331
1,500
42,600
2,626
10,787
1,202
24,507
2,110
75
80
58
80
3544
298
18093
516
25
20
42
20
Ophthalmology
Orthopedic Surgery
18,870
24,140
15,498
23,039
82
95
3372
1101
18
5
Otolaryngology
Pathology-Anatomic/ Clinical
9,917
19,339
8,757
12,795
88
66
1160
6544
12
34
Pediatric Cardiology
Pediatrics
1,842
72,288
1,320
33,875
72
47
522
38,413
28
53
General Surgery
Internal Medicine
Medical Genetics
Neurological Surgery
221
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.1. Total Physicians by Specialty and Gender (Cont…)
SPECIALTY
TOTAL
Physical Medicine & Rehabilitation
MALE
%
FEMALE
%
7,685
5,047
66
2638
34
Plastic Surgery
Psychiatry
7,021
41,598
6,202
27,663
88
67
819
13935
12
33
Public Health & General Preventive Medicine
Pulmonology
Radiation Oncology
Radiology
1,501
10,074
4,378
8,813
1,051
8,574
3,327
7,473
70
85
76
85
450
1500
1051
1340
30
15
24
15
Thoracic Surgery
Transplant Surgery
Urological Surgery
Vascular Medicine
4,897
125
10,676
21
4,722
115
10,120
16
96
92
95
76
175
10
556
5
4
8
5
24
5,350
7,483
4,410
5,146
82
69
940
2337
18
31
99,823
39,304
87,383
23,836
88
61
12440
15468
12
39
488
342
70
146
30
Other Specialties
Unspecified
Inactive
Not Classified
Address Unknown
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
222
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No 2. Total Physicians by Specialty and Age
SPECIALTY
TOTAL PHYSICIANS
TOTAL
UNDER 35
35-44
45-54
55-64
65 AND OVER
902,053
140,093
212,050
222,469
157,596
169,845
468
21
49
157
127
114
Allergy/ Immunology
Anesthesiology
Cardiovascular Disease
Child Psychiatry
4,112
40,494
22,349
7,234
347
5,130
1,970
563
783
11,460
5,281
2,001
1,219
13,733
7,404
2,207
1,116
6,947
5,091
1,546
647
3,224
2,603
917
Colon/ Rectal Surgery
Dermatology
1,291
10,593
75
1,683
399
2,569
410
2,762
289
2,380
118
1,199
Diagnostic Radiology
Emergency Medicine
24,231
29,144
4,203
6,546
6,485
8,234
7,291
8,022
4,747
5,162
1,505
1,180
Family Medicine
Forensic Pathology
Gastroenterology
General Practice
81,701
672
12,017
11,049
13,638
33
1,174
57
24,083
177
3,194
345
25,410
224
3,948
1,953
13,087
133
2,718
3,443
5,483
105
983
5,251
2,211
37,857
154,002
498
217
8,120
31,233
56
702
8,923
42,131
127
726
8,519
42,895
153
334
7,140
25,840
109
232
5,155
11,903
53
Neurological Surgery
Neurology
5,440
14,331
803
1,651
1,416
3,690
1,406
4,431
1,027
3,126
788
1,433
Nuclear Medicine
Obstetrics/ Gynecology
1,500
42,600
108
6,423
290
11,034
407
11,390
415
8,738
280
5,015
Occupational Medicine
Ophthalmology
Orthopedic Surgery
Otolaryngology
2,626
18,870
24,140
9,917
11
2,010
3,766
1,419
200
4,549
5,836
2,575
984
5,329
6,454
2,512
791
4,328
5,073
2,032
640
2,654
3,011
1,379
Pathology-Anatomic/ Clinical
Pediatric Cardiology
Pediatrics
Physical Medicine & Rehabilitation
19,339
1,842
72,288
7,685
1,937
244
16,118
1,122
4,256
610
20,556
2,607
5,580
492
18,224
2,260
4,259
280
11,856
1,133
3,307
216
5,534
563
Aerospace Medicine
General Preventive Medicine
General Surgery
Internal Medicine
Medical Genetics
223
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No 2. Total Physicians by Specialty and Age (Cont…)
SPECIALTY
TOTAL
Plastic Surgery
UNDER 35
35-44
45-54
55-64
65 AND OVER
7,021
699
1,728
2,101
1,665
828
41,598
1,501
10,074
4,193
2
1,130
7,697
67
2,925
11,311
419
3,145
10,126
435
2,178
8,271
578
696
Radiation Oncology
4,378
569
1,204
1,357
864
384
Radiology
Thoracic Surgery
Transplant Surgery
Urological Surgery
8,813
4,897
125
10,676
462
169
1,202
2,350
1,128
38
2,477
1,806
1,516
60
2,610
2,044
1,196
14
2,672
2,151
888
13
1,715
Vascular Medicine
21
Psychiatry
Public Health & General Preventive Medicine
Pulmonology
7
4
7
3
Other Specialties
Unspecified
Inactive
5,350
7,483
99,823
98
3,132
52
526
1,760
1,317
1,347
1,346
4,542
1,474
724
8,972
1,905
521
84,940
Not Classified
Address Unknown
39,304
488
17,703
4
14,262
2
4,399
4
1,846
112
1,094
366
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
224
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity
PATIENT CARE
SPECIALTY
TOTAL PHYSICIANS
TOTAL
PATIENT
CARE
TOTAL
OFFICE
BASED
902,053
718,473
563,225
36
35
10
Abdominal Surgery
118
106
98
Addiction Medicine
212
168
121
Addiction Psychiatry
249
235
163
Abdominal Radiology
Adolescent Medicine (Internal Medicine)
HOSPITAL BASED
RESID./
PHYS.
FELLOWS
STAFF
95,391
59,857
24
OTHER PROFESSIONAL ACTIVITY
ADMIN.
14,997
MED.
TEACH.
10,223
RESEARC
H
14,471
1
8
6
3
2
1
9
47
24
4
7
41
31
6
4
4
13
10
9
1
2
1
451
362
238
51
73
34
35
17
Adult Reconstructive Orthopedics
206
202
163
27
12
3
1
Aerospace Medicine
468
274
157
5
27
Allergy & Immunology
Anatomic Pathology
783
725
708
2,984
2,800
2,452
4,274
1
Adolescent Medicine Pediatrics)
Allergy
OTHER
117
149
3
13
17
15
6
29
8
224
124
27
28
117
12
1,012
734
544
190
32
55
126
65
Anatomic/Clinical Pathology
14,983
13,154
9,142
2,178
1,834
494
257
464
614
Anesthesiology
38,307
37,198
30,046
4,105
3,047
281
506
239
83
508
354
271
38
45
100
11
25
18
1
1
22,349
20,965
17,519
1,442
283
323
707
71
32
14
13
1
6
3
3
6
Child and Adolescent Psychiatry
7,234
6,725
5370
582
773
211
140
126
32
Child Neurology
Clinical and Laboratory Dermatological
Immunology
Clinical and Laboratory Immunology
(Internal Medicine)
Clinical and Laboratory Immunology
(Pediatrics)
1,239
1,095
795
162
138
20
41
77
6
2
2
2
7
5
4
1
1
2
1
1
Blood Banking / Transfusion Medicine
Cardiothoracic Radiology
Cardiovascular Disease
chemical Pathology
1
2,004
1
1
225
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
Clinical Biochemical Genetics
TOTAL
PATIENT
CARE
TOTAL
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
OFFICE
BASED
8
3
3
789
771
621
6
4
1
3
Clinical Genetics
Clinical Liboratorv lrnmunoIn’ (Allergy
& lmniunoInj)
Clinical Molecular Genetics
102
77
53
48
42
37
10
2
2
Clinical Neurophysiology
569
560
425
Clinical Pathology
545
286
207
79
Clinical Pharmacology
349
55
42
1,290
1262
1,155
55
55
54
Clinical Cardiac Electrophysiology
Clinical Cytogenetics
Colon & Rectal Surgery
Cosmetic Surgery
Craniofacial Surgery
MED.
TEACH.
ADMIN.
RESEARC
H
OTHER
5
118
122
42
32
3
6
8
1
24
7
8
9
1
5
1
2
2
1
1
6
1
2
4
3
117
23
93
26
13
60
15
210
9
65
6
13
6
3
2
13
1
7
7
4
2
1
432
415
339
46
30
4
9
2
2
1,304
1,203
896
107
200
33
42
24
2
5
2
2
591
574
466
104
104
98
10,570
10,302
8,793
1,057
457
423
339
54
36
36
3
31
2
334
225
205
Diagnostic Radiology
24,230
23,489
17,618
Emergency Medicine
28,799
27708
19,930
4,896
4,050
3,252
Critical Care Medicine (Anesthesiology)
Critical Care Medicine (Internal
Medicine)
Critical Care Medicine (Obstetrics &
Gynecology)
Cytopathology
Dermatologic Surgery
Dermatology
Dermatopatbology
Developmental-Behavioral Pediatrics
Diabetes
Endocrinology, Diabetes and Metabolism
1
81
27
2
3
7
3
4
452
54
82
115
17
30
2
5
5
22
20
15
10
80
4
3,923
1,948
146
241
126
228
3832
3946
659
286
79
67
431
367
125
135
563
23
6
226
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
Endovascular Surgical Neuroradiology
TOTAL
PATIENT
CARE
TOTAL
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
OFFICE
BASED
4
3
3
32
4
2
375
371
354
1
16
80,809
77863
65,006
7,898
4,959
Family Practice/ Psychiatry
43
43
Foot and Ankle, Orthopedics
59
59
45
10
4
Forensic Pathology
672
475
413
35
Forensic Psychiatry
291
268
183
50
Gastroenterology
12,017
11,366
9,742
994
General Practice
11,049
10,638
9,347
Epidemiology
Facial Plastic Surgery
Family Medicine
General Preventive Medicine
MED.
TEACH.
ADMIN.
RESEARC
H
OTHER
1
2
3
1
15
9
3
1
1,219
1391
181
155
27
44
10
9
134
35
8
1
630
118
166
346
21
1,291
229
26
42
114
43
14
2,147
1681
1209
260
212
230
38
147
51
31,485
30,535
20894
7406
2,235
399
264
172
115
442
402
326
43
33
18
18
2
2
2,912
2,611
1,948
284
379
124
67
104
6
706
684
521
89
74
8
7
7
2392
2282
2188
94
39
38
17
16
468
431
360
71
10
18
8
1
1,471
1,435
1,378
57
7
19
4
6
Hand Surgery (Orthopedics)
81
81
81
Hand Surgery (Plastic Surgery)
13
13
13
9
9
245
223
197
2,301
1,745
1,405
General Surgery
Geriatric Medicine (Family Practice)
Geriatric Medicine (Internal Medicine)
Geriatric Psychiatry
Gynecology
Gynecological Oncology
Hand Surgery
Hand Surgery (Surgery)
Head & Neck Surgery
Hematology (Internal Medicine)
Hematology (Pathology)
Hematology/ Oncology
Hepatology
9
65
26
5
11
5
1
275
85
83
378
10
458
440
335
71
34
2
3
9
4
3,923
3,803
2,657
964
182
14
22
76
8
96
75
59
16
2
8
11
227
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
Hospitalist
TOTAL
PATIENT
CARE
TOTAL
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
OFFICE
BASED
MED.
TEACH.
ADMIN.
RESEARC
H
OTHER
8
7
3
4
297
63
47
16
24
13
190
7
Infectious Disease
6,191
4905
3,656
618
631
265
234
745
42
Internal Medicine
112,934
107,738
78801
20639
8,298
2031
1,227
1,553
385
16
16
16
1
1
1
Internal Medicine/ Family Practice
14
14
14
Internal Medicine/Emergency Medicine
88
88
88
Internal Medicine/Neurology
12
12
12
Internal Medicine/Psychiatry
100
100
100
Internal Medicine/Pediatrics
6
29
13
4
4
5
Immunology
Internal Medicine (Preventive Medicine)
Internal Medicine/ Dermatology
3,718
3666
2,200
1,347
119
Interventional Cardiology
851
842
628
188
26
Legal Medicine
181
52
46
Maternal & Fetal Medicine
590
498
355
Medical Genetics
372
273
174
Medical Management
302
21
20
Medical Microbiology
63
42
32
5,503
4,730
61
Medical Oncology
Medical Toxicology (Emergency
Medicine)
Medical Toxicology (Pediatrics)
Medical toxicology (Preventive
Medicine)
Molecular Genetic Pathology (Pathology)
Musculoskeletal Oncology
1
6
45
8
5
71
143
24
46
18
4
36
13
15
67
4
1
263
4
6
8
4
6
7
3
9
2
4,097
182
451
161
59
534
19
58
26
30
2
1
1
2
2
2
11
9
5
4
49
10
4
4
64
61
63
1
2
4
2
3
228
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
TOTAL
PATIENT
CARE
TOTAL
Musculoskeletal Radiology
OFFICE
BASED
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
12
MED.
TEACH.
ADMIN.
RESEARC
H
OTHER
45
33
Neonatal-Perinatal Medicine
4008
3,590
2,592
450
548
88
105
210
15
Nephrology
Neurodevelopment Disabilities
(Psychiatry & Neurology)
Neurodevelopmental Disabilities
(Pediatrics)
Neurological Surgery
7,175
6,526
5,410
700
416
129
122
383
15
4
4
1
2
1
1
1
1
5379
5,219
4112
803
304
38
48
43
31
Neurology
Neurology/Diagnostic
Radiology/Neuroradiology
Neuropathology
12508
11,353
9,179
1,248
926
176
216
691
72
25
22
12
9
1
1
1
1
360
238
178
28
32
7
32
73
10
1
1
1
1,556
1,521
1,240
182
99
2
19
7
7
3
2
1
1,500
1,338
979
124
235
50
29
62
21
142
136
119
6
11
1
1
4
Neuropsychiatry
Neuroradiology
Nuclear Cardiology
Nuclear Medicine
Nuclear Radiology
1
1
Nutrition
165
94
86
8
12
6
44
Obstetrics
232
211
184
27
5
11
5
Obstetrics & Gynecology
9
38,285
37,317
31,066
4,236
2,015
325
419
169
55
Occupational Medicine
2,626
1,864
1,571
1
292
529
41
83
109
Ophthalmology
18687
18,257
16,404
1,155
698
115
128
151
36
45
45
40
2
3
21,824
21,359
17,216
3,094
1,049
114
134
76
141
518
511
466
23
22
4
1
2
83
80
63
9
8
3
2
2
2
Oral & Maxillofacial Surgery
Orthopedic Surgery
Orthopedic Surgery of the Spine
Orthopedic Trauma
Osteopathic Manipulative Medicine
229
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
Other (ie, a specialty other than those
appearing above)
Otolaryngology
Otology/Neurology
Pain Management
Pain Management (Physical Medicine &
Rehabilitation)
Pain Medicine
TOTAL
TOTAL
PATIENT
CARE
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
OFFICE
BASED
MED.
TEACH.
ADMIN.
RESEARC
H
OTHER
4,933
3,176
1,682
1,172
322
707
132
762
156
9659
9473
7998
1043
432
67
81
26
12
6
2
124
121
104
9
8
1
2
1,755
1,731
1,502
152
77
6
10
17
17
192
17
186
174
12
1
3
1
1
Palliative medicine
Pediatric Emergency Medicine
(Pediatrics)
Pediatrics/ Emergency Medicine
86
57
42
15
14
4
3
8
548
516
234
90
8
17
6
1
19
19
Pediatric Allergy
188
164
154
10
5
4
12
3
Pediatric Anesthesiology
373
366
245
102
19
2
5
238
194
25
31
78
7
11
1
Pediatric Cardiology
192
19
1842
1,701
1,269
Pediatric Cardiothoracic Surgery
37
35
24
Pediatric Critical Care Medicine
Pediatric Emergency Medicine
(Emergency Medicine)
Pediatric Endocrinology
1,167
1,118
734
271
113
10
18
72
70
40
23
7
1
1
842
721
479
149
93
6
595
561
366
142
53
8
Pediatric Gastroenterology
Pediatric Hematology / Oncology
1
20
1
17
93
5
8
15
3
1,702
1449
973
283
193
27
26
193
7
Pediatric Infectious Disease
358
310
160
123
27
7
10
26
5
Pediatric Nephrology
507
425
287
85
53
13
25
41
3
Pediatric Ophthalmology
183
181
176
Pediatric Orthopedics
335
324
259
17
48
Pediatric Otolaryngology
134
131
104
16
11
Pediatric Pathology
114
104
72
19
13
5
2
6
4
1
3
2
2
2
4
230
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
Pediatric Psychiatry/Child Psychiatry
TOTAL
PATIENT
CARE
TOTAL
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
78
OFFICE
BASED
MED.
TEACH.
ADMIN.
RESEARC
H
OTHER
78
78
Pediatric Pulmonology
631
577
416
103
58
8
10
36
Pediatric Radiology
656
618
498
33
87
5
23
6
4
3
2
1
1
1
8
1
4
16
2
Pediatric Rehabilitation Medicine
Pediatric Rheumatology
120
97
57
32
31
25
Pediatric Surgery (Surgery)
796
743
608
52
83
10
25
Pediatric Urology
Pediatric/Physical Medicine &
Rehabilitation
Pediatrics
183
179
147
20
12
2
2
10
10
56,945
54150
4,161
1,019
7
7
Pediatric Surgery (Neurology)
Pediatrics/ Medical Genetics
Pediatrics/Dermatology
32
6
1
16
2
835
718
223
8
1
37
14
10
42,691
7298
7
1
1
Pharmaceutical Medicine
66
6
6
Phlebology
37
37
36
Physical medicine & Rehabilitation
7,617
7,326
5,585
890
851
169
43
43
36
Plastic Surgery
6,577
6,466
5602
631
233
25
43
23
20
1
1
1
1
6,117
1,446
542
814
266
8
6
5
5
2
Plastic Surgery Within the Head & Neck
Proctology
Procedural Dermatology
Psychiatry
Psychiatry/Neurology
Psychoanalysis
Psychosomatic Medicine
1
1
21
21
39,715
36,647
14
14
531
513
9
9
1
1
21
26,264
4,266
14
505
8
1
231
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
Public Health and General Preventive
Medicine
Pulmonary Critical Care Medicine
TOTAL
PATIENT
CARE
TOTAL
OFFICE
BASED
1,501
296
224
3,563
3,491
2372
Pulmonology
6,511
5,700
Radiation oncology
4,378
4,262
Radiological Physics
Radiology
312
100
964
155
7
17
45
3
4,949
94
657
199
198
391
23
3,453
480
329
41
26
42
7
1
1
3,878
565
504
4,340
3,840
3,254
Selective Pathology
212
210
148
Sleep Medicine
132
116
56
55
968
963
10
9
Sport Medicine (Orthopedic Surgery)
Sports Medicine (Emergency Medicine)
Sports Medicine (Family Practice)
650
79
126
74
61
14
22
25
2
307
279
88
103
285
24
56
6
99
3
14
6
37
11
7
1
852
79
32
1
8
1
54
393
390
320
Sports Medicine (Internal Medicine)
40
38
36
Sports Medicine (Pediatrics)
Sports Medicine (Physical Medicine &
Rehabilitation)
Surgical Critical Care (Surgery)
37
37
20
12
12
10
532
517
375
Surgical Oncology
Thoracic Surgery
Transplant Surgery
Transplantation Medicine
Trauma Surgery
Undersea & Hyperbaric Medicine
Unspecified
OTHER
64
4,530
Spinal Cord Injury Medicine
RESEARC
H
729
628
Rheumatology
MED.
TEACH.
ADMIN.
72
4,932
Reproductive Endocrinology
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
2
1
1
2
7
2
2
1
1
16
1
2
12
123
2
1
1
5
6
5
2
95
46
3
47
7
8
14
1
272
358
59
52
64
14
19
3
4
4
2
14
275
245
198
4,897
4,708
4,078
124
111
92
1
1
239
201
126
75
15
53
44
30
14
6
6,311
6,045
4,294
539
64
1
1
1,212
35
6
3
1
2
112
55
232
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.3. Total Physicians by Specialty and Professional Activity (Cont…)
PATIENT CARE
SPECIALTY
Urgent Care Medicine
TOTAL
TOTAL
PATIENT
CARE
OFFICE
BASED
HOSPITAL BASED
RESID./
PHYS.
FELLOW
STAFF
S
29
OTHER PROFESSIONAL ACTIVITY
MED.
TEACH.
ADMIN.
RESEARC
H
202
198
169
3
1
10,493
10,247
8,808
933
506
88
83
54
1,445
1431
1,271
97
63
4
6
4
Vascular Medicine
21
20
19
Vascular Neurology
15
15
1
14
2,494
2,388
2,039
164
Urology
Vascular and interventional Radiology
Vascular Surgery
Inactive
39,304
Not Classified
99,823
Address Unknown
1
185
OTHER
21
1
39
39
21
7
488
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
233
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table.No.4 Total Physicians by Specialty, Age & Gender
SPECIALTY
MALE PHYSICIANS BY AGE AND SELF-DESIGNATED SPECIALTY,
2005
TOTAL
TOTAL
PHYSICIANS
Aerospace Medicine
657,140
UNDER
35
77,699
65 AND
OVER
35-44
45-54
55-64
134,871
161,211
130,416
152,943
FEMALE PHYSICIANS BY AGE AND SELF-DESIGNATED
SPECIALTY, 2005
TOTAL
UNDER
35
244,913
62,394
35-44
45-54
77,179
61,258
65 AND
OVER
55-64
27,180
16,902
434
18
43
142
117
114
34
3
6
15
10
3,031
175
454
887
925
590
1,081
172
329
332
191
57
Anesthesiology
31,492
3,608
8,694
10,926
5,590
2,674
9,002
1,522
2,766
2,807
1,357
550
Cardiovascular Disease
Allergy/ Immunology
20,210
1,584
4,520
6,723
4,854
2,529
2,139
386
761
681
237
74
Child Psychiatry
3,952
223
921
1,143
1,006
659
3,282
340
1,080
1,064
540
258
Colon/ Rectal surgery
1,133
55
306
371
284
117
158
20
93
39
5
1
Dermatology
6,519
651
1,226
1,618
1,939
1,085
4,074
1,032
1,343
1,144
441
114
Diagnostic Radiology
18,858
3,015
4,650
5,664
4,121
1,408
5,373
1,188
1,835
1,627
626
97
Emergency Medicine
22,687
4,392
6,128
6,478
4,619
1,070
6,457
2,154
2,106
1,544
543
110
Family Medicine
54,307
6,337
13,816
18,175
10,992
4,987
27,394
7,301
10,267
7,235
2,095
496
444
17
97
147
94
89
228
16
80
77
39
16
10,670
851
2,711
3,546
2,596
966
1,347
323
483
402
122
17
8,950
38
222
1,376
2,648
4,666
2,099
19
123
577
795
585
1,392
104
415
429
258
186
819
113
287
297
76
46
Forensic Pathology
Gastroenterology
General Practice
General Preventive
Medicine
General Surgery
32,387
5,871
7,187
7,438
6,817
5,074
5,470
2,249
1,736
1,081
323
81
Internal Medicine
105,987
17,627
25,793
30,375
21,386
10,806
48,015
13,606
16,338
12,520
4,454
1,097
14
Medical Genetics
Neurological surgery
Neurology
Nuclear Medicine
Obstetrics/
Gynecology
Occupational Medicine
259
26
59
73
62
39
239
30
68
80
47
5,111
714
1,300
1,307
1,007
783
329
89
116
99
20
5
10,787
982
2,444
3,377
2,681
1,303
3,544
669
1,246
1,054
445
130
1,202
78
218
301
352
253
298
30
72
106
63
27
24,507
1,448
4,673
6,817
7,081
4,488
18,093
4,975
6,361
4,573
1,657
527
2,110
7
120
722
674
587
516
4
80
262
117
53
234
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table.No.4 Total Physicians by Specialty, Age & Gender (Cont…)
MALE PHYSICIANS BY AGE AND SELF-DESIGNATED SPECIALTY,
SPECIALTY
2005
UNDER
65 AND
TOTAL
35-44
45-54
55-64
35
OVER
FEMALE PHYSICIANS BY AGE AND SELF-DESIGNATED
SPECIALTY, 2005
UNDER
65 AND
TOTAL
35-44
45-54
55-64
35
OVER
Ophthalmology
15,498
1,311
3,358
4,322
3,965
2,542
3,372
699
1,191
1,007
363
112
Orthopedic Surgery
23,039
3,396
5,465
6,184
5,001
2,993
1,101
370
371
270
72
18
8,757
1,083
2,142
2,223
1,950
1,359
1,160
336
433
289
82
20
12,795
946
2,433
3,528
3,112
2,776
6,544
991
1,823
2,052
1,147
531
1,320
143
389
376
231
181
522
101
221
116
49
35
Pediatrics
Physical Medicine &
Rehabilitation
Plastic Surgery
33,875
5,191
7,963
9,132
7,447
4,142
38,413
10,927
12,593
9,092
4,409
1,392
5,047
674
1,671
1,548
756
398
2,638
448
936
712
377
165
6,202
547
1,440
1,839
1,571
805
819
152
288
262
94
23
Psychiatry
Public Health &
General Preventive
Medicine
Pulmonology
27,663
1,951
4,330
6,959
7,475
6,948
13,935
2,242
3,367
4,352
2,651
1,323
1,051
1
37
246
327
440
450
1
30
173
108
138
8,574
852
2,259
2,743
2,063
657
1,500
278
666
402
115
39
Radiation Oncology
3,327
389
863
1,045
692
338
1,051
180
341
312
172
46
Radiology
7,473
380
1,914
1,416
1,740
2,023
1,340
82
436
390
304
128
Thoracic Surgery
4,722
151
1,056
1,453
1,176
886
175
18
72
63
20
2
35
54
13
13
10
3
6
1
1,003
2,263
2,497
2,647
1,710
556
199
214
113
25
5
4
2
7
3
5
3
2
217
Otolaryngology
Pathology-Anatomic/
Clinical
Pediatric Cardiology
Transplant Surgery
115
Urological Surgery
10,120
Vascular Medicine
16
Other Specialties
4,410
65
377
1,020
1,260
1,688
940
33
149
327
214
Unspecified
5,146
1,980
1,205
981
560
420
2,337
1,152
555
385
164
101
Inactive
87,383
27
687
2,662
6,942
77,065
12,440
25
630
1,880
2,030
7,875
Not Classified
23,836
9,784
8,983
2,942
1,290
837
15,468
7,919
5,279
1,457
556
257
342
4
4
88
246
146
24
120
Address Unknown
2
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
235
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No 5. D.O.s by Specialty & Age
SPECIALTY
TOTAL PHYSICIANS
TOTAL
PHYSICIANS
57,449
<35
35-44
45-54
55-64
>=65
12,468
16,226
15,061
7,211
6,483
94
113
4
18
5
24
35
38
32
23
18
10
2,451
669
579
74
744
217
793
255
235
107
100
16
Child Psychiatry
Colon/ Rectal surgery
253
18
33
3
90
3
84
4
35
4
11
4
Dermatology
Diagnostic Radiology
Emergency Medicine
Family Medicine
403
730
3,251
14,342
63
154
550
2,578
122
232
1,072
4,624
132
199
1,115
4,299
62
103
452
1792
24
42
62
1,049
Forensic Pathology
Gastroenterology
General Practice
General Preventive Medicine
17
371
3,319
223
48
11
19
10
132
329
61
5
129
1,224
86
1
55
993
39
1
7
762
18
General Surgery
Internal Medicine
1,096
6,576
266
1,844
380
2,220
256
1,701
106
611
88
200
6
70
3
7
2
26
1
23
10
4
Neurology
Nuclear Medicine
Obstetrics/ Gynecology
Occupational Medicine
611
53
2,063
229
114
8
478
199
6
703
23
200
18
547
126
83
8
270
61
15
13
65
19
Ophthalmology
Orthopedic Surgery
Otolaryngology
Pathology-Anatomic/ Clinical
385
1,071
347
433
33
83
20
108
126
355
122
89
127
370
126
115
71
186
51
85
28
77
28
36
Pediatric Cardiology
Pediatrics
16
2,522
7
1,016
4
787
4
447
1
213
59
Aerospace Medicine
Allergy/ Immunology
Anesthesiology
Cardiovascular Disease
Medical Genetics
Neurological surgery
236
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No 5. D.O.s by Specialty & Age (Cont…)
SPECIALTY
Physical Medicine & Rehabilitation
TOTAL
PHYSICIANS
1,009
<35
35-44
45-54
55-64
>=65
299
343
262
68
37
76
1,425
35
7
296
24
313
7
22
460
13
20
240
10
3
116
5
Pulmonology
Radiation Oncology
Radiology
Thoracic Surgery
379
77
398
66
58
9
24
2
114
24
103
16
138
29
84
26
65
15
108
18
4
79
4
Urological Surgery
Vascular Medicine
181
5
13
1
43
2
74
2
38
13
Other Specially
Unspecified
311
6,567
5
2,339
57
1,729
116
905
77
485
56
1,109
Inactive
Not Classified
2,748
2,440
1
1293
86
658
307
164
317
61
2,037
264
Plastic Surgery
Psychiatry
Public Health & General Preventive Medicine
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
237
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.6 Number of Osteopathic Physicians
D.O.S CATEGORIES
NUMBER
Number of living D.O.s
58,940
Number of active D.O.s under age 65
Number of D.O.s over age 65
52,827
6,113
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007]
Table No.7 Active D.O.s by gender
GENDER
Total
NUMBER
52,827
PERCENTAGE
100
Female
15,929
30.2
Male
36,898
69.8
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007]
Table No.8 Active D.O.s by age category
AGE CATEGORY (YEARS)
NUMBER
PERCENTAGE
Total
52,827
100
<35
13,230
25
35-44
16,911
32
45-54
15,142
28.7
55-64
7,117
13.5
427
0.8
Missing/ unknown
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007]
238
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.9 Active (in patient care) D.O.s by self-identified specialty category
CATEGORY
NUMBER
PERCENTAGE
Total
Family medicine
52,827
18,234
100%
35%
Internal medicine
Pediatrics
3,256
1,660
6%
3%
OB/Gyn
OMT/OMM
1,544
459
3%
1%
14,115
267
13,292
27%
1%
25%
Nonprimary care
Unknown
D.O.s assumed to be in postdoctoral training
Source: AOA (2007) Fact sheet 2006 [internet], AOA. Available from: <http://www.osteopathic.org/pdf/ost_factsheet.pdf> [Accessed September 2007]
239
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.10 Physicians by Age & Location
STATE
TOTAL PHYSICIANS
Alabama
Alaska
TOTAL
PHYSICIANS
902,053
10,809
<35
35-44
140,093
1,672
45-54
212,050
2,576
55-64
222,469
2,974
>= 65
157,596
1,880
169,845
1,707
1,643
143
460
463
350
227
14,699
6,315
108,053
13,816
1,709
931
14,594
1,762
3,575
1,503
23,204
3,512
3,686
1,715
24,522
3,520
2,584
1,071
21,731
2,528
3,145
1,095
24,002
2,494
Connecticut
14,234
2,224
3,230
3,616
2,429
2,735
Delaware
District Of Columbia
Florida
2,372
4,815
52,324
366
1,131
4,939
573
973
11,101
567
908
13,419
383
867
9,245
483
936
13,620
Georgia
Hawaii
Idaho
22,222
4,528
2,825
3,212
547
198
5,813
1,013
728
6,002
1,183
761
3,636
881
556
3,559
904
582
Illinois
38,513
7,883
8,941
8,852
6,596
6,241
Indians
Iowa
Kansas
Kentucky
14,977
6,319
6,978
10,646
2,172
1,009
1,005
1,628
3,706
1,483
1,642
2,704
4,122
1,661
1,743
2,770
2,537
1,061
1,230
1,841
2,440
1,105
1,358
1,703
Louisiana
12,650
2,236
2,975
3,041
2,212
2,186
Mains
Maryland
Massachusetts
4,095
25,498
31,908
374
3,979
6,293
889
5,961
7,964
1,130
6,273
7,325
798
4,579
5,115
904
4,706
5,211
Michigan
Minnesota
Mississippi
27,316
16,373
5,872
5,106
2,773
750
6,465
4,184
1,471
6,340
4,256
1,520
4,583
2,583
1,036
4,822
2,577
1,095
Missouri
15,322
2,957
3,709
3,788
2,468
2,400
Montana
Nebraska
2,496
4,727
109
834
540
1,180
732
1,215
545
733
570
765
Arizona
Arkansas
California
Colorado
240
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.10 Physicians by Age & Location (Cont…)
TOTAL
STATE
PHYSICIANS
<35
35-44
45-54
55-64
>= 65
Nevada
New Hampshire
New Jersey
5,196
4,003
29,786
519
410
4,013
1,457
952
6,889
1,270
1,102
7,724
874
705
5,558
1,076
834
5,602
New Mexico
New York
North Carolina
North Dakota
5,292
82,301
24,698
1,712
647
15,818
4,055
188
1,196
18,117
6,437
435
1,354
18,788
6,515
463
1,139
13,686
3,705
339
956
15,892
3,986
287
Ohio
Oklahoma
33,618
6,950
6,420
933
8,267
1,501
7,823
1,804
5,288
1,329
5,820
1,383
Oregon
Pennsylvania
11,301
41,358
1,241
7,199
2,748
8,919
2,817
10,495
2,244
7,008
2,251
7,737
Rhoda Island
South Carolina
South Dakota
Tennessee
4,259
10,992
1,936
17,349
851
1,726
191
2,560
1,042
2,837
484
4,341
974
2,673
582
4,783
615
1,829
366
2,888
777
1,927
313
2,777
Texas
Utah
Vermont
Virginia
53,571
5,857
2,624
23,049
8,950
881
368
3,561
14,030
1,527
574
5,482
12,994
1,463
687
5,763
8,974
1,032
470
3,974
8,623
954
525
4,269
Washington
West Virginia
19,349
4,681
2,223
739
4,489
1,043
5,075
1,075
3,798
941
3,764
883
Wisconsin
Wyoming
15,855
1,113
2,222
71
4,157
261
4,316
307
2,508
230
2,652
244
Possessions
APO’s and FPO’s
Address Unknown
11,379
991
488
1,538
229
4
2,366
422
2
3,356
158
4
1,836
90
112
2,283
92
366
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
241
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.11 Total Physicians by professional activity and Location
PATIENT CARE
STATE
TOTAL PHYSICIANS
Alabama
TOTAL
TOTAL
PATIENT
CARE
OFFICE
BASED
OTHER PROFESSIONAL ACTIVITY
HOSPITAL BASED
RESID/
PHYS.
FELLOWS
STAFF
MED.
TEACH.
ADMIN
RESEARCH
OTHERS
902,053
718,473
563,225
95,391
59,857
14,997
10,223
14,471
143,401
10,809
9,020
7,305
1,134
581
135
91
136
1,427
Alaska
1,643
1,417
1,180
34
203
36
10
15
165
Arizona
14,699
11,385
9,546
962
877
249
160
138
2,767
Arkansas
6,315
5,247
4,259
636
352
60
91
49
868
California
108,053
84,424
70,352
8,368
5,704
1,810
1,035
1,837
18,947
Colorado
13,816
10,995
9,168
1,047
780
258
155
215
2,193
Connecticut
14,234
11,161
8,438
1,696
1,027
312
188
334
2,239
Delaware
2,372
1,891
1,516
203
172
43
20
27
391
District Of Columbia
4,815
3,629
2,246
858
525
196
111
152
727
Florida
52,324
39,848
33,841
2,786
3,221
724
456
406
10,890
Georgia
22,222
18,227
14,944
1,841
1,442
367
249
323
3,056
Hawaii
4,528
3,601
2,923
321
357
75
63
48
741
Idaho
2,825
2,321
2,087
68
166
35
17
8
444
Illinois
38,513
31,172
23,433
5,449
2,290
635
435
475
5,796
Indiana
14,977
12,450
10,238
1,263
949
205
150
180
1,992
Iowa
6,319
4,920
3,899
667
354
61
94
130
1,114
Kansas
6,978
5,591
4,488
664
439
90
94
56
1,147
Kentucky
10,646
8,833
7,268
1,017
548
136
119
80
1,478
Louisiana
12,650
10,509
8,266
1,554
689
142
193
107
1,699
4,095
3,214
2,656
211
347
92
52
29
708
Maryland
25,498
19,280
14,223
2,730
2,327
786
300
1,216
3,916
Massachusetts
31,908
24,567
17,482
4,631
2,454
599
315
1,188
5,239
Michigan
27,316
21,808
16,220
3,903
1,685
460
331
374
4,343
Maine
242
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.11 Total Physicians by professional activity and Location (Cont…)
PATIENT CARE
TOTAL
STATE
TOTAL
OFFICE
PATIENT
HOSPITAL BASED
BASED
CARE
Minnesota
Mississippi
16,373
13,177
10,392
1,967
OTHER PROFESSIONAL ACTIVITY
MED.
TEACH.
ADMIN
818
243
177
RESEARCH
287
OTHERS
2,489
5,872
4,815
3,866
460
489
73
52
32
900
Missouri
15,322
12,486
9,402
2,034
1,050
213
215
265
2,143
Montana
2,496
1,983
1,767
26
190
32
16
12
453
Nebraska
4,727
3,840
2,995
595
250
68
71
50
698
Nevada
5,196
4,241
3,732
202
307
68
30
19
838
New Hampshire
New Jersey
New Mexico
4,003
3,154
2,596
257
301
52
32
54
711
29,786
24,099
18,890
2,908
2,301
520
292
524
4,351
5,292
4,151
3,260
469
422
95
66
73
907
New York
82,301
65,260
44,688
13,319
7,253
1,574
1,026
1,591
12,850
North Carolina
24,698
19,785
15,779
2,511
1,495
380
305
447
3,781
North Dakota
Ohio
Oklahoma
1,712
1,422
1,162
113
147
27
20
5
238
33,618
26,868
20,227
4,562
2,079
458
392
421
5,479
6,950
5,590
4,521
650
419
102
96
44
1,118
Oregon
11,301
8,816
7,454
703
659
177
123
140
2,045
Pennsylvania
41,358
32,052
23,579
5,679
2,794
758
503
903
7,142
4,259
3,444
2,477
623
344
77
46
64
628
10,992
9,074
7,266
1,053
755
140
158
85
1,535
Rhode Island
South Carolina
South Dakota
1,936
1,597
1,329
95
173
24
15
6
294
Tennessee
17,349
14,367
11,716
1,767
884
247
200
224
2,311
Texas
53,571
44,311
35,515
5,874
2,922
734
704
621
7,201
Utah
5,857
4,722
3,810
615
297
99
60
103
873
Vermont
2,624
2,000
1,479
323
198
49
39
54
482
243
PHYSICIANS CHARACTERISTICS AND DISTRIBUTION IN USA 2006
Table No.11 Total Physicians by professional activity and Location (Cont…)
PATIENT CARE
TOTAL
STATE
TOTAL
OFFICE
PATIENT
HOSPITAL BASED
BASED
CARE
OTHER PROFESSIONAL ACTIVITY
MED.
TEACH.
ADMIN
RESEARCH
OTHERS
Virginia
23,049
18,503
14,374
2,347
1,782
408
248
250
3,640
Washington
19,349
15,016
12,477
1,324
1,215
349
198
401
3,385
4,681
3,793
2,861
549
383
62
76
33
717
15,855
12,951
10,696
1,462
793
228
189
182
2,305
West Virginia
Wisconsin
Wyoming
1,113
900
787
34
79
17
7
4
185
11,379
9,672
7,700
806
1,166
184
133
47
1,343
APO’s end FPO’s
991
874
450
21
403
33
5
7
72
Address Unknown
488
Possessions
Source: American Medical Association, 2007, Physician Characteristics and Distribution in the US, 2007 Edition
244