Eastern European countries devote on average 5.47% of their GDP to health. In the twelve Central and Eastern European countries studied by the EFPIA, average treatable mortality is 159 per 100,000 compared to 67 for the EU4 (France, Germany, Italy, Spain), or roughly 137% higher. Bangladesh spends 3.5% of its GDP on care and vaccinates 95% of its children. Data published by the EFPIA in April 2026 on twelve Central and Eastern European countries show that the level of public spending is insufficient to guarantee health outcomes: the quality of governance is associated with health and financial results.
The Essentials
- Eastern Europe spends on average 5.47% of GDP on health. In the twelve Central and Eastern European countries studied by the EFPIA, average treatable mortality is roughly 137% higher than that of France, Germany, Italy and Spain (EFPIA 2026).
- Bangladesh, at 3.5% of GDP, achieves 95% vaccination coverage through a decentralized community network (UNICEF).
- Research by LSHTM scholars (Varkonyi et al., 2025) establishes an association between perceived corruption in the public sector and health system outcomes in 12 Central and Eastern European countries, without directly measuring corruption specific to the health sector.
- Documented improvements in the region include cardiovascular prevention programs and primary care monitoring, whereas hospital investments alone have not produced the same results.
- European funds conditioned on governance reforms could accelerate the transition for the 2027-2035 period.
Public Money That Does Not Reach Care
Bulgaria devotes approximately 5% of its GDP to health; France devotes 12%. This gap is real, but the data do not make it possible to determine what share of the Bulgaria-France gap is explained by health spending. In 2022, treatable mortality was approximately 116% higher than the EU average in Bulgaria (194 versus 90 deaths per 100,000 inhabitants) and approximately 139% higher in Romania (215 versus 90 deaths per 100,000 inhabitants). This “treatable” mortality results from diseases that health systems should manage before they become fatal.
And this gap has barely narrowed since accession to the European Union.
The EFPIA, the European pharmaceutical industry federation, published in April 2026 an analysis covering twelve Central and Eastern European countries, from the Balkans to the Baltic states. Across its combined CEE-EU4 sample, it documents a strong negative correlation between public health spending per capita and treatable mortality (Spearman −0.874). The data studied show that the link between public health spending and preventable mortality varies by country and period; they do not permit conclusions about healthy life expectancy.
This persistent gap signals how money circulates, or fails to circulate, within systems.
The Effects of Corruption on Care
This dilution mechanism also acts on the behavior of health professionals themselves. When a substantial portion of actual remuneration comes from informal payments rather than the official fee, institutional incentives shift: the practitioner optimizes his income more than he optimizes his patients’ outcomes. This shift is not an individual failure but a rational response to a poorly structured system. It produces cumulative effects difficult to correct through simple budget increases, since new resources arrive in a system whose unwritten rules continue to shape behavior. Reforming formal remuneration without simultaneously dismantling long-established informal norms therefore leaves actual incentives largely intact.
Research by LSHTM scholars establishes an association between perceived corruption in the public sector and health system outcomes in 12 Central and Eastern European countries, without directly measuring corruption specific to the health sector or proving causality.
A significant finding: in several countries displaying lower scores for institutional governance, treatable mortality tends to be higher at comparable spending levels. Money arrives in the system, but its circulation to patients remains unequal.
This mechanism produces a particularly harsh inequality: quality care exists, but it is reserved for those who can pay the doctor outside the official fee, access the right network, or bypass waiting lists. Others wait, delay consulting, and more often arrive at emergency departments at an advanced stage of their disease.
Preventable mortality becomes then a statistic of class as much as a statistic of system.
The Bangladeshi Case, Taken Seriously
Bangladesh presents demographics, geography and political organization very different from those of Bulgaria or Serbia, and its model would require adjustments before any transfer. Its vaccination coverage level, 95% with 3.5% of GDP, nevertheless deserves careful analysis.
The Bangladeshi system relies on a network of community health workers, trained locally, deployed in the most remote villages, paid modestly but controlled by simple and verifiable monitoring mechanisms. This network captures data, reports vaccine stockouts, identifies unvaccinated children and feeds information back to the regional level. UNICEF and WHO have documented this model since the 1990s as one of the most sustainable public health successes in the developing world.
This system stands out for its capillarity and accountability. Each health worker is known to his community, his results are visible and his failures are reported. The budget is modest, but funds reach their destination and their use is verified.
Eastern Europe invested in hospitals. Bangladesh invested in relays. The two approaches do not exclude each other, but they produce very different results when hospital governance is deficient.
Gains Where They Actually Occur
Among documented improvements in the region are cardiovascular prevention programs, cervical cancer screening campaigns in Poland, networks of family physicians in the Czech Republic. These programs have one thing in common: they follow identified patients, measure simple indicators and correct failures rapidly.
The Czech Republic is often cited in regional comparisons as a case of successful convergence. Its life expectancy at age 65 has progressed significantly since 2004, faster than the regional average. Health economists attribute part of this trajectory to the organization of primary care, reformed in the early 2000s to give general practitioners a coordination role, not just a prescribing one.
By contrast, Romania and Bulgaria have devoted a significant portion of their recent investments to hospital modernization. New operating rooms exist. But if the patient only arrives at the hospital when his cancer is at stage three, equipment changes little about the outcome.
WHO Europe qualifies primary health care as an effective and efficient approach to improving health and accelerating universal coverage in countries of the region.
The question of primary care governance intersects with other regulatory challenges the journal has documented, particularly in systems where biometrics and digital data attempt to replace administrative failures.
European Funds: Conditional Levers
The additional difficulty is that conditionality operates on input indicators more easily verified than on outcome indicators. It is easier to observe that a law has been adopted or a digital registry created than to measure whether informal payments have actually declined or whether disadvantaged patients consult earlier. This asymmetry of observability incentivizes recipient governments to produce formal reforms compliant with fund access criteria without modifying underlying practices. Conditioning disbursements on independently verifiable health outcome indicators, rather than on legislative compliance indicators, would shift this logic and make the European lever harder to circumvent without increasing its amount.
Central and Eastern European countries receive substantial European structural funds, part of which is earmarked for health. The EFPIA recommends governance and spending efficiency reforms to improve health outcomes.
Conditionality is a tool the European Union has used since the 1990s, with uneven results. It has accelerated judicial and environmental reforms in some countries. It has also generated political resistance and formal workarounds in others.
In health, conditionality is even more delicate. Health systems are deeply embedded in administrative histories, medical corporatisms and local institutional cultures. A reform imposed from outside without internal political anchorage often produces legislative texts without real implementation.
What European funds can do more effectively, according to researchers following the region, is first to support health information systems, so that countries know what is happening in their hospitals, and then to finance primary care personnel training. Both investments are less visible than a state-of-the-art scanner. They are probably more useful.
The 2027-2035 horizon is that of the next European multiannual financial framework. If negotiations integrate health outcome indicators into cohesion fund access conditions, this could create useful pressure. This scenario remains conditional: it assumes political will from the Union and real capacity to absorb reforms in countries where governments oscillate between adherence to European standards and resistance to institutional constraints.
The General Principle This Region Makes Visible
What Eastern Europe illustrates with harmonized data on twelve countries holds well beyond health. Health outcomes are associated with governance, public spending and several social and economic determinants, without this study establishing that budget results depend causally on its allocation and implementation. Weak institutions and corruption can reduce spending efficiency, but the effect of a budget increase must be evaluated empirically according to context.
The health case is particularly readable because outcomes are measurable and data are relatively well harmonized in Europe. But the same reasoning applies to education, infrastructure, vocational training policies. Universal health coverage in China illustrates another facet of the same problem: the extension of formal coverage without real equalization of access to care.
LSHTM researchers advance that health outcome indicators should weigh in the evaluation of cohesion policies equally with fund absorption indicators. This point increasingly structures discussions on the next generation of reforms in the region.
Bangladesh has a network of community care equipped with performance monitoring mechanisms. The Czech Republic reformed its primary care in the early 2000s to strengthen the coordination role of general practitioners. Both approaches rest on measurable outcomes monitoring.
Health convergence between Eastern and Western Europe will play out on this terrain over the next ten years.
Sources
- EFPIA, Healthcare Investment and Outcomes in Central and Eastern Europe, April 2026
- Varkonyi et al., Corruption and health outcomes in Central and Eastern Europe, London School of Hygiene and Tropical Medicine, 2025 (LSHTM)
- WHO Europe, Universal Health Coverage monitoring, data 2023-2024
- UNICEF, State of the World’s Children / Immunization data, Bangladesh, 2023-2024
