(Bloomberg) -- As recently as 2000, France, Italy and Spain were ranked as having the best health care systems in the world. But more than two decades and a global pandemic later, that picture has changed. Stalled-out funding combined with the rising costs of caring for aging populations now mean that European systems are struggling to fulfil their promise of fair and equitable cradle-to-grave services.

And in the near future, there may be fewer front-line workers around to help correct course. 

Last year, the World Health Organization released a report describing the aging of health care professionals in Europe as a “ticking time bomb.” In France, nearly half of doctors are over the age of 55. In Italy, a medical association predicts that about 100,000 public-sector physicians will resign or retire within the next four years due to age. 

“We really need to encourage countries to take this seriously,” said Tomas Zapata, regional adviser on health workforces for WHO Europe, who co-wrote the report. “The time to act is now.”

Strained to their limits during the Covid-19 pandemic, many of these services have just suffered one of the worst winters in their history, with some potentially facing a breaking point.

Towards the end of 2022, surges of flu, Covid and respiratory syncytial viruses filled emergency rooms. Medical professionals from Rome to Berlin walked out over concerns about understaffing and pay. Amid rising demand, almost every country in the EU reported shortages of antibiotics. 

That situation was made worse by mounting structural problems. Outside of major cities it’s getting harder to find a primary care physician or a hospital emergency room with specialized equipment. In wealthier countries, hospitals are staffed by health care professionals lured from poorer neighbors in Europe’s single market. And nurses, often left to pick up the slack, are burning out, according to the WHO.

“The COVID-19 pandemic has revealed the fragility of health systems and the importance of a robust and resilient health workforce,” said Hans Kluge, WHO regional director for Europe, at a high-level WHO summit in Romania on March 22. “We cannot wait any longer to address the pressing challenges facing our health workforce. The health and wellbeing of our societies are at stake.”

Making health systems more resilient across the OECD group of wealthy nations will cost on average about 1.4% of GDP above the level that countries were spending prior to the pandemic, a report from the organization found in October. More than half of that added spending, the authors advised, should be on front-line staff — including nurses and carers.

In a morning shift at her public hospital on the outskirts of Madrid, orthopedic surgeon Isabel Soler typically has about 40 patients waiting in front of her office door with a litany of chronic complaints: arthritis, aching joints and degenerative disease. For many, it’s not the first visit, and with little time to assess or counsel them in depth, Soler winds up simply promising to see them again. 

“They [might] have an incurable disease, but you can’t tell them that in three minutes,” the 37-year-old doctor said. “So, you tell them, OK, come back in six months.”

In January, a report by Spain’s Association of Insurers found that a quarter of all Spaniards — the highest percentage ever — are now covered by private health insurance. 

The 2008 financial crisis ushered in cuts. Across Europe, spending on health was flat as a percentage of GDP for more than a decade even as the cost of drugs, diagnostics and treatments increased, resulting in stagnant salaries and tighter hospital budgets. While spending did jump during the Covid pandemic, much of that was on one-off and emergency costs such as extra beds and vaccines.There have been some top-level responses. During a visit to a hospital outside Paris last January, French President Emmanuel Macron acknowledged “the personal and collective exhaustion” that has beset health care workers, and pledged to increase spending on medical assistants and reform the country’s fee-for-service system, in which doctors are paid based on services rendered. German Health Minister Karl Lauterbach has similarly announced plans to overhaul his country’s hospital system.  

Compared to many other regions, Europe is in a better-than-average situation in terms of numbers of doctors and nurses per capita. But that fact alone does not tell the whole story. Many health care professionals are concentrated in cities, and across the continent, the share of general practitioners, key gatekeepers for day-to-day care, has dropped. This has contributed to an ongoing game of catch-up as the pandemic backlog of delayed procedures and missed appointments collided with the post-lockdown wave of seasonal illnesses.

In Sweden, France, Switzerland and the Netherlands, more than one in five older people with chronic conditions reported that they had missed or delayed care at the height of the pandemic. Those missed appointments, detailed in a survey by the Commonwealth Fund, a US-based health care thinktank, put patients at higher risk of long term complications that might need even more time-intensive treatment in the future.

Care for older populations is generally more expensive. In 2020, about one-fifth of the EU’s 448 million people were aged over 65, according to Eurostat. That’s 3 percentage points higher than a decade earlier. 

To health care analysts, the pandemic made the urgency of reform abundantly clear. “Demand for health care is increasing, there is a need to try and meet that demand,” said Chris James, a senior health economist at the OECD. “The big question to me is then, are countries, are people, willing to pay for that?”

“Sometimes I cry because I feel guilty,” Emeline Albert, a 26-year-old nurse in Aix-en-Provence in southern France, said of the way she is now forced to work. 

Albert spends her days rushing between hospital beds, administering infusions and injections with little time to speak with her patients. According to the Samu-Urgences de France, the emergency medical service, at least 43 patients died while waiting for care as French emergency rooms buckled under a wave of respiratory infections between the start of December and the end of January — the first two months the service kept such records. While shocking, those numbers are not as high as in the UK, where up to 500 people were estimated to be dying each week at the end of 2022 due to delayed care.  

In the UK, overall satisfaction with the National Health Service fell to just 29% in the annual British Social Attitudes survey released in March — down from a peak of 70% in 2010 and the lowest level recorded in the survey’s 40-year history. Waits in emergency departments and for appointments with family doctors have been getting longer in recent years, which the public blames on lack of funding and staff. To keep up with demographic and technological trends, the NHS will likely need billions more a year on top of its £150 billion budget just to stay afloat. As opposition Labour leader Keir Starmer said in January: “If you don't reform the NHS, I fear it will die.”

Many systems on the continent face similar financial pressures and challenges.

Lower-income countries in the EU’s single market have become feeder nations for their wealthier neighbors, training new physicians and nurses only to lose them to higher-wage markets. Zapata cited the example of Romania, which produces the most medical school graduates per capita in the EU with more than 25 per 100,000, but has a below-average density of health-care workers. 

“That means many doctors are migrating,” he said.

A well trodden path is to Germany, where Romanian doctors constitute the biggest immigrant group in a country where more than one in 10 physicians were educated elsewhere. With annual salaries for specialists in Germany averaging €166,400 ($176,780), émigré doctors can earn at least three times more than if they stayed in Romania. The medical merry-go-round does not end there. German doctors are moving to neighboring Switzerland, where median salaries are roughly 20% higher.

Disparity in access to quality health care isn’t restricted by national borders. Inside EU countries, doctors are flocking to cities for better job prospects and infrastructure. This has created swathes of so-called medical deserts — often poor and rural areas where it’s difficult or impossible to find a physician.

That problem is especially acute in France, where thousands of doctors took to the streets earlier this year to call for better working conditions and to demand that the flat fee general practitioners charge patients for an appointment be doubled to €50. An exodus of health care workers has left 60,000 nurse jobs empty in public hospitals, according to the country’s leading nurses’ union. About one in 10 of those remaining are on leave for burnout or depression, the union said. Others have switched to better-paying and more flexible freelance contracts. 

In general, the lack of reliable primary care has a trickle-down effect, diverting patients to hospitals for day-to-day problems that would have been better dealt with in a doctor’s office. As a result, hospitals with fewer resources are limited in what they can do for patients suffering serious emergencies.

“The basic concept is that everyone should get the help they need, regardless of background,” said Akil Awad, 37, an anesthesiologist and intensive care specialist in Stockholm. “That’s the idea I grew up with and the premise I entered the profession under.” But today, he said, a near-constant shortage of staffed beds in his hospital has created a “one-in-one-out” mentality, where a patient might receive care on a Monday but not on a Wednesday, depending on timing and luck.

Though the pandemic drew attention to problems that needed fixing, Awad said, the time in the spotlight didn’t result in real change. “We were called heroes, and that’s all very well, but it is not what we want,” he said. “We want more slack and margin in the system.”

Frustrated workers leaving the profession can create a snowball effect. At age 34, Jenny Pettersson already has seniority over most of her emergency room colleagues at Danderyds Sjukhus, one of Stockholm’s main hospitals. Institutional knowledge disappears when new nurses have fewer experienced colleagues to learn from, said Pettersson, a union representative. Last year, every region in Sweden reported shortages of clinical nurse specialists.

“It’s like we always need to top up with newly graduated nurses,” she said, adding that these incoming nurses often are “shocked by the amount of work which is required” when they first arrive. “We run around and put out fires, and when my shift is over, I think, ‘Phew, none of my patients died today.’”

More than 2,000 miles away, on the southern tip of Europe, authorities are grappling with even more acute staff shortages. The pediatric, rehabilitation, and long-term care units at the hospital in the walled Sicilian town of Mussomeli are closed because there is no one to run them. The three other hospital units that serve the 10,000-person town “are really struggling,” said mayor Giuseppe Catania.

In Sicily, local governments cut spending on new medical staff hires a decade ago to help cover about €5 billion in debt. Emergency units now have about half the doctors they need, according to the physicians’ union CIMO FESMED. The crisis resulted from a mix of factors, Catania said, citing a shortage of open student spots in medical schools and the low salaries on offer in public hospitals. With few good local options, the 53-year-old mayor is looking across the ocean for a solution.

This month, Mussomeli will welcome 13 doctors from Argentina who will work at the local hospital on nine-month contracts. They will earn gross monthly salaries of €6,000 ($6,400) – more than ten times the average wage for a doctor at a public hospital in Buenos Aires, but roughly half of what doctors earn at some private clinics that cater to Italians with means to buy supplemental insurance coverage. 

Yet with their limited scope, efforts to import doctors can only be a stopgap, said Riccardo Spampinato, 66, a union official who runs a specialized dental unit in Sicily for disabled patients.

“We are missing two generations of doctors,” Spampinato said, referring to older specialists who are shifting to the private sector and younger doctors never hired due to spending cuts. If the system isn’t fixed soon, he predicted, all that will remain will be “poor hospitals for poor people.”

While the problems are significant, Zapata, the WHO advisor, says that there are solutions. Countries can use forecasting models to predict doctor demand 15-20 years out and start taking measures to meet it. Governments can create incentives to improve recruitment, retention and distribution of health workers in rural areas. Finally, they can make caring professions more attractive by improving flexibility and work-life balance and tending to the mental health of current workers.

“Covid gave us a window of opportunity for political changes and political commitment,” Zapata said, adding,  “that window of opportunity is closing.” 

--With assistance from Emily Ashton and Scott Squires.

©2023 Bloomberg L.P.