Adequate infrastructure, encompassing both physical facilities and equipment such as diagnostic and therapeutic equipment as well as digital and information technology (IT) tools, is vital for the resilience and long-term productivity of any health system. In this regard, the COVID‑19 pandemic highlighted how sufficient equipment in intensive care units and other healthcare facilities can mitigate crucial delays in diagnosis and treatment (OECD, 2023[1]). While an optimal level of capital investment in the health sector is challenging to define and is subject to many country-specific factors, it is of critical importance for countries to maintain their ability to address future crises, as insufficient investment can overextend service provision and may even lead to system failure. In the long-term, persistent underinvestment combined with deteriorating equipment and facilities can impact day-to-day service delivery and lead to higher overall costs.
Capital investment levels in healthcare tend to fluctuate more from year to year compared to current health expenditure, as they are often subject to complex, long-term plans that are influenced by political priorities and aligned with prevailing economic conditions. Capital expenditure can also be affected by the needs to respond to acute and unforeseen events, such as a pandemic. In 2022, EU countries allocated an average of 0.6% of their GDP to capital expenditure in health, equivalent to about 6% of current health expenditure (Figure 8.15). Both in terms of GDP share and overall health spending, European countries report widely varying levels of capital investment in their healthcare systems. Germany led with 1.3% of GDP allocated to capital spending in the health sector, followed by Portugal at 1.2%. Romania reported the highest capital expenditure on health relative to total health expenditure at 15%. Both in terms of GDP and health expenditure shares, Bulgaria, Czechia and Malta displayed the lowest levels of capital spending in 2022. For some countries, a significant proportion of their 2022 capital spending levels may reflect emergency investments necessitated by the pandemic rather than sustained capital expenditure.
Following a plateau in investment from 2015 to 2017, average capital spending grew by around 20% in real terms across the EU in the years just prior to the pandemic, mirroring to some extent the overall growth in current health spending during the same period. Capital spending has since stalled, not displaying any noticeable growth since the beginning of the pandemic in 2020 (Figure 8.16).
Germany has followed average EU trends in capital spending in the health sector, especially in recent years, while Austria has been experiencing consistent negative growth since 2018. On the other hand, capital spending in Spain has increased significantly faster than the EU average between 2019 and 2022, reaching almost double its 2015 level in real terms. In Denmark, investments in the health sector have jumped by around 25% in the first year of the pandemic but dropped again in 2021. Though France has run behind the EU average since 2018, a growth of 10% from 2020 to 2022 has narrowed this gap.
The European Union contributes to its Member States’ flows of capital investment in health via the Cohesion Policy funds, aimed at reducing health inequalities and increasing the effectiveness and accessibility of national health systems (European Commission, 2024[2]). In the wake of the pandemic, the EU committed to significantly strengthen its investment support in health. This includes initiatives such as the over EUR 800 billion “Next Generation EU” recovery package, as well as programmes such as “EU4Health 2021‑27”, which seek to build stronger, more resilient and more accessible health systems.
