Seasonal influenza vaccines are available every year in EU/EEA countries, but their financing arrangements and patient costs vary by country. Vaccination coverage in adults varies across European countries. Coverage gaps likely result from a combination of administrative, economic, behavioral, social, and health factors; no single source allows them to be reduced to administrative factors alone. What this gap reveals goes beyond public health: it says something specific about states’ capacity to transform an available innovation into real collective benefit.
Key Points
- For the same flu vaccine, adult 50+ coverage ranges from 18% (Italy) to 61% (Denmark), a ratio of 1 to 3.4 entirely attributable to deployment architecture (EHMA Vaccination Handbook 2026).
- France reaches 42%, Austria 28%: intermediate levels reflecting partial degrees of integration, trained pharmacists but fragmented registries, or existing registries but incomplete delegation.
- Denmark combines two elements that other countries keep separate: delegation to trained pharmacists and a digital active recall system.
- European fragmentation produces structural waste: millions of doses ordered, stored, then destroyed, while at-risk populations remain unprotected.
- The key political tension is coordination: each state can address its shortcomings in isolation, but the EU has yet to establish conditions for a binding minimal common architecture.
Influenza Kills More Than Most Diseases We Take Seriously
Each winter, seasonal influenza kills between 15,000 and 70,000 people in Europe depending on the year, according to the European Centre for Disease Prevention and Control. The majority of these deaths occur in people over 65. The WHO set a target vaccination coverage of at least 75% for elderly people. Data allow identification of certain countries achieving 75% among elderly people—Belarus, Denmark, Ireland, and the United Kingdom in 2022/2023—but strict comparisons for all adults aged 50 and over are limited by heterogeneous national age thresholds, ranging from 50 to 65.
The vaccine exists and is available annually in the EU/EEA; reimbursement conditions and supply security vary by country and season. Underimmunization against influenza depends on logistical and administrative factors, but also on behavioral, clinical, economic, and trust determinants.
Comparisons of coverage and spending between countries require homogeneous data. Pharmacist training methods, vaccination procedures, and patient follow-up arrangements vary by country. These reminders are not advertisements. They are automatic reminders for parents or guardians in the Danish children’s vaccination program, established from the DDV registry and inviting appointment scheduling; the source does not confirm that they systematically indicate vaccination location. This system was implemented progressively, according to data from the Danish Statens Serum Institut.
In France, official coverage published for 2024-2025 is 54% among those 65 and older. It extended vaccination rights to pharmacists in 2019, then to nurses and midwives in subsequent years. The effects of these extensions on adult vaccination coverage should be evaluated using comparable data. The modalities of information exchange between health professionals and vaccination systems must be clarified by verifiable data. The existence and modalities of active reminders at the national level must be clarified by verifiable data.
Devices actually present or absent must be described precisely.
18% in Italy: The Anatomy of an Administrative Ceiling
Italy presents the most instructive case, precisely because it is not the worst in terms of resources. The country has a universal health system, sufficient numbers of general practitioners, and a significant pharmaceutical industry. Italy allows flu vaccination in participating pharmacies and has a national registry; integration gaps do not allow concluding the complete absence of either mechanism.
The general practitioner remains an important actor, but is not the sole entry point: vaccination can also be provided by health services and participating pharmacies. Yet the general practitioner is overloaded, and adult vaccination is not their primary activity. Access arrangements for vaccination and patient follow-up vary depending on health systems.
In Austria, available data indicate limited vaccination coverage among those 65 and older. Official documentation does not allow presenting pharmacy vaccination as organized delegation according to Länder. Modalities of vaccine registration and data sharing must be clarified using verifiable sources. Austria combines national coordination with regional and local implementation arrangements.
Delegation to trained local actors and active patient follow-up can contribute to improving access to vaccination. Coverage gaps between countries may stem from institutional, health, economic, and social factors. The respective contribution of institutional choices must be established by comparable data.
The Real Cost of Fragmentation
Suboptimal vaccination coverage has a direct cost: preventable hospitalizations, premature deaths, lost working days. Improved vaccination coverage can help reduce hospital costs. European fragmentation can be associated with vaccine dose waste.
Doses may be ordered based on coverage projections that do not materialize. They are stored, then destroyed once their expiration date passes. In the absence of consolidated data at the European level on the volume of unused doses, it would be inaccurate to cite a precise figure. Available data do not allow establishing a general link between coverage level and dose destruction rate.
There is an absurd logic to this situation. The European Union partially finances vaccination programs. It negotiates framework contracts with manufacturers. It publishes recommendations on target rates. And it then allows each state to deploy the product with its own mechanisms, without requiring these mechanisms to achieve a minimum level of effectiveness.
The result is predictable: countries that already had the best infrastructure improve it further; countries lacking coordination continue to lack coordination.
This is precisely the diagnosis posed by Jean-Marc Daniel in his work on the role of the state and market regulation, particularly in his contributions to the Montaigne Institute: the state, here understood as a public institution, national or supranational, produces its best results when it orients existing actors toward a common target rather than when it fills, in silos, specific gaps it identifies. Applied to adult vaccination: the EU would have more effect defining a binding minimal architecture—registry interoperability, accreditation of pharmacists as vaccination actors, active recall protocols—than separately financing national campaigns that stop at administrative borders.
Coordinate Rather Than Build in Parallel
The competing reading deserves serious consideration. Dani Rodrik, an economist specializing in globalization effects and industrial policies, emphasizes that supranational common architectures tend to ignore local institutional contexts and produce standards that the most fragile states cannot meet due to implementation capacity gaps. In this reading, imposing a common European adult vaccination architecture risks widening another gap: between states that already have necessary information systems and those that would have to build them from scratch to comply with a standard.
This counterpoint is honest. It points to a real risk. But available data suggest that this risk is smaller than the cost of inaction. European countries have developed vaccination registries and digital identity infrastructures according to variable timetables and modalities. These countries started from a modest budgetary base.
Financial, political, institutional, logistical, and behavioral obstacles must be evaluated country by country. In low-coverage countries, technical capacities and public health priorities may influence adult vaccination.
European coordination can take the form of a political proposal conditioning access to certain common funding on the establishment of an interoperable registry and active recall mechanism. European funds have used ex-ante conditionalities and instruments supporting administrative reforms; available evaluations are insufficient to generally attribute their success to “soft conditionality.” On the limits of these conditionality mechanisms, the fragmentation of European economic policies is a documented case of gap between common intention and national implementation.
Two Trajectories Take Shape for Adult Vaccination in Europe by 2030
Several adult vaccination coverage trajectories in Europe can be envisioned over a ten-year horizon.
The first trajectory is convergence through diffusion. Several European countries are implementing reforms to their vaccination systems and information systems. If these reforms succeed, the European average could improve. This trajectory does not assume any supranational initiative: it rests on each state’s capacity to learn from models that work and adapt its own mechanisms. The signal to monitor is the deployment pace of interoperable national registries and the effective extension of vaccination rights to pharmacists in countries where it remains limited.
The second trajectory is differentiated stagnation. Without a convergence mechanism, national trajectories could remain divergent. Italy already has pharmacy delegation mechanisms and a national registry; any projection to 2030 should be presented as a scenario with assumptions. Some countries have low coverage or weak monitoring capacities, but data do not allow characterizing South and Central Europe as a structurally homogeneous bloc lagging behind. In this trajectory, country gaps could evolve based on innovation deployment and health infrastructure development.
What would distinguish the two trajectories is not primarily a matter of financial resources. European cohesion funds are available for digital health infrastructure investments. What is lacking is an explicit political decision: treating adult vaccination coverage as a performance indicator of public health architecture, just like infant mortality or emergency care access times. Vaccination policies and programs are primarily the responsibility of member states; the European Union provides regulatory frameworks, financing, and coordination or support within the limits of its competencies. It is technically feasible.
It is politically achievable, provided health ministers accept being evaluated on this indicator during the Commission’s annual reviews.
Digital health is a domain where blockages resemble those faced by European technological sovereignty: the capacity to build exists, standards are defined, but the political coordination to implement them at scale is lacking. Regulating without building a common architecture produces the same effects in both domains: declarations of intent, disparate national initiatives, and a gap that persists relative to leaders.
Active Recall as a Signal of a Public Health Vision
The active recall in the Danish model consists of a personalized message sent to each eligible patient. This message essentially states: you are eligible, access is facilitated for you, the time has come. This approach reflects a political choice about the relationship between the state and citizens regarding health, not a technological feat.
This posture assumes a functioning registry, interconnection between care actors, and a willingness not to wait for patients to take the initiative themselves. Controlled or quasi-experimental studies would be necessary to attribute a coverage gap to personalized recall rather than other national differences.
This distinction between broadcast information and targeted patient activation is documented in behavioral vaccination literature. Access friction is an important determinant, but available evidence does not support making it the primary universal factor, ahead of hesitation, trust, or health provider recommendations. Reasons for adult non-vaccination may include lack of reminder, access constraints, health provider recommendations, beliefs, and trust.
Reducing access barriers can be an important lever, but priority should be determined based on barriers measured in each country and target group. And reducing access barriers may mobilize variable resources depending on arrangements. Opening to pharmacists, digital registries, and automated reminders are potential options; nothing justifies presenting them as necessary and universal conditions. Several European countries have implemented mechanisms to facilitate adult vaccination. Others have the instructions before their eyes.
Adult vaccination coverage could become an evaluation criterion for governments just as unemployment or growth are. It remains today a public health indicator discussed by experts at specialized conferences, limiting electoral pressure on these 18%. If it enters public debate with the same force as emergency room waiting lists, governments of lagging countries will have a political incentive to act.
Sources
- EHMA, Improving Vaccination Coverage Rates in Adult Populations: A Handbook for Health Managers and Policymakers, 2026: https://ehma.org/improving-vaccination-coverage-rates-in-adult-populations-a-handbook-for-health-managers-and-policymakers/
- Jean-Marc Daniel / Montaigne Institute, Finance and State Transformation: https://www.institutmontaigne.org
- European Centre for Disease Prevention and Control (ECDC), Annual surveillance data for seasonal influenza and vaccination coverage in Europe
- Statens Serum Institut (Denmark), National adult vaccination coverage data, digital recall program 2012-2018
- Ministry of Health and Prevention (France), Vaccination Coverage Data 2024