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Health at a Glance Organization For Economic Co-
Operation And Development Digital Instant Download
Author(s): Organization for Economic Co-operation and Development
ISBN(s): 9789264079366, 926407936X
Edition: Illustrated
File Details: PDF, 1.00 MB
Year: 2001
Language: english
HEALTH

Health at a Glance
Health is essential for individuals to flourish as citizens and health systems are of growing
size and importance in OECD countries. Indeed, the health system is now the largest service
industry in most OECD countries.

Health at a Glance tells many stories, concerning changes in health status and health
systems across OECD countries covering: life expectancy, health care resources, health
system activities, health care financing, and health expenditure. At the same time, it provides
striking evidence of the sheer size of the variations across countries in most indicators of
health system resources, activity and expenditure, as reported to the OECD.

Tentative explanations for some of these variations are brought out in the commentaries.
Nevertheless, many remain unexplained. To what extent do the remaining variations provide
evidence of real differences in the funding and productivity of health systems across OECD
countries? To what extent do they indicate the need for further work to harmonise the
collection of international health data? This book poses questions and challenges to all
health policy experts, managers and statisticians.

This book presents in an easily accessible, printed form some of the key indicators which
«
Health
at a Glance

HEALTH

are otherwise published in electronic form on a CD-ROM: OECD Health Data. It brings out
variations and trends in the key indicators of health status, health care resources, health care
utilisation and health expenditure, across the OECD area, making copious use of visual aids,
such as bar charts and time series trends. Commentaries are included with the charts to
bring out policy messages conveyed by the data. Care has been taken to indicate the
preferred international definitions of the variables and major deviations from these definitions
for particular countries.

All OECD books and periodicals are now available on line

Health at a Glance
www.SourceOECD.org

www.oecd.org

ISBN 92-64-18713-8
81 2001 09 1 P

-:HSTCQE=V]\VX^: Édition 2000

© OECD, 2001.
© Software: 1987-1996, Acrobat is a trademark of ADOBE.
All rights reserved. OECD grants you the right to use one copy of this Program for your personal use only. Unauthorised reproduction,
lending, hiring, transmission or distribution of any data or software is prohibited. You must treat the Program and associated materials
and any elements thereof like any other copyrighted material.
All requests should be made to:

Head of Publications Service,

OECD Publications Service,
2, rue André-Pascal,
75775 Paris Cedex 16, France.
 Health at a Glance

ORGANISATION FOR ECONOMIC CO-OPERATION AND DEVELOPMENT

 ORGANISATION FOR ECONOMIC CO-OPERATION
AND DEVELOPMENT

Pursuant to Article 1 of the Convention signed in Paris on 14th December 1960, and which came into
force on 30th September 1961, the Organisation for Economic Co-operation and Development (OECD)
shall promote policies designed:
– to achieve the highest sustainable economic growth and employment and a rising standard of
living in Member countries, while maintaining financial stability, and thus to contribute to the
development of the world economy;
– to contribute to sound economic expansion in Member as well as non-member countries in the
process of economic development; and
– to contribute to the expansion of world trade on a multilateral, non-discriminatory basis in
accordance with international obligations.
The original Member countries of the OECD are Austria, Belgium, Canada, Denmark, France,
Germany, Greece, Iceland, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain,
Sweden, Switzerland, Turkey, the United Kingdom and the United States. The following countries
became Members subsequently through accession at the dates indicated hereafter: Japan
(28th April 1964), Finland (28th January 1969), Australia (7th June 1971), New Zealand (29th May 1973),
Mexico (18th May 1994), the Czech Republic (21st December 1995), Hungary (7th May 1996), Poland
(22nd November 1996), Korea (12th December 1996) and the Slovak Republic (14th December 2000). The
Commission of the European Communities takes part in the work of the OECD (Article 13 of the OECD
Convention).

Publié en français sous le titre :

PANORAMA DE LA SANTÉ

© OECD 2001
Permission to reproduce a portion of this work for non-commercial purposes or classroom use should be obtained
through the Centre français d’exploitation du droit de copie (CFC), 20, rue des Grands-Augustins, 75006 Paris,
France, tel. (33-1) 44 07 47 70, fax (33-1) 46 34 67 19, for every country except the United States. In the United States
permission should be obtained through the Copyright Clearance Center, Customer Service, (508)750-8400,
222 Rosewood Drive, Danvers, MA 01923 USA, or CCC Online: www.copyright.com. All other applications for
permission to reproduce or translate all or part of this book should be made to OECD Publications, 2, rue André-Pascal,
75775 Paris Cedex 16, France.
 FOREWORD

Good health is essential for people to flourish as citizens, family members, workers and consumers. Aided
by technological advances, health systems are of crucial importance in promoting good health and in curing, or
mitigating, the consequences of disease. The benefits that modern health systems provide cannot be achieved
without cost. Health expenditure has been absorbing an increasing proportion of national income and health
systems now represent the largest service industry in many OECD countries.
There is much interest among policy makers in scrutinizing variations in the growth, efficiency and equity of
health systems. In particular, there is a growing demand for evidence that can be derived for health policy from
international comparisons across health systems. The OECD has developed a large international database on
health and health system data for the OECD area. For many years that data has been published on a CD-ROM
(OECD Health Data). The main aim of this publication – Health at a Glance – is to display some of the key
indicators from OECD Health Data in an easily accessible, printed form. Hence, this document makes extensive
use of charts, graphs and tables. A subsidiary aim is to draw attention to some of the messages for policy which
can be derived from OECD Health Data.
Health at a Glance was prepared by the Health Policy Unit at the OECD. The main authors were Jeremy
Hurst and Gaetan Lafortune. The statistical analysis and preparation of the charts and tables were carried out
chiefly by Andrew Devlin, who also managed the project. Jan Bennett, Stéphane Jacobzone, Zeynep Or and
Andy Thompson all made contributions to particular sections. Secretarial support was given by Marianne
Scarborough. Editorial comments and advice were provided by Manfred Huber and Peter Scherer. All of these
people owe a debt to Jean Pierre Poullier, since it was he who created OECD Health Data.

© OECD 2001 3
 ACKNOWLEDGEMENTS

The OECD acknowledges gratefully the effort made by the national correspondents in Member countries over
many years to report their health statistics to OECD Health Data and to other international agencies with whom
OECD co-operates. It also acknowledges gratefully the helpful comments which many of our correspondents
offered on an earlier version of this document.
Particular thanks go to the United States Health Care Financing Administration, which has given financial
support to the collection of OECD Health Data over many years.
Thanks are due also to the Australian Institute of Health and Welfare for their publication International
Health: How Australia Compares. Health at a Glance was inspired by their report.

4 © OECD 2001
 TABLE OF CONTENTS

Introduction ....................................................................................................................................................... 7
1. Health status................................................................................................................................................. 11
Life expectancy at birth ................................................................................................................................. 12
Life expectancy at age 65 .............................................................................................................................. 14
Infant mortality .............................................................................................................................................. 16
Premature mortality ....................................................................................................................................... 18
Self-reported general health .......................................................................................................................... 20
2. Health care resources .................................................................................................................................. 23
Practising physicians and nurses ................................................................................................................... 24
Inpatient and acute-care beds ........................................................................................................................ 26
3. Health care utilisation ................................................................................................................................. 29
Consultations with doctors ............................................................................................................................ 30
Childhood immunisation ............................................................................................................................... 32
Admissions to hospitals and nursing homes.................................................................................................. 34
Average length of stay in acute care .............................................................................................................. 36
4. Expenditure on health ................................................................................................................................. 39
Health expenditure......................................................................................................................................... 40
Health expenditure in relation to Gross Domestic Product ........................................................................... 42
Responsibility for financing health care........................................................................................................ 44
Pharmaceutical expenditure........................................................................................................................... 46
5. Non-medical determinants of health.......................................................................................................... 49
Tobacco consumption .................................................................................................................................... 50
Alcohol consumption..................................................................................................................................... 52
Body weight................................................................................................................................................... 54
6. Demographic and economic context .......................................................................................................... 57
Total population............................................................................................................................................. 58
Share of the population aged 65 and over ..................................................................................................... 60
Gross Domestic Product per capita and income distribution ........................................................................ 62
Annex 1. Annex tables....................................................................................................................................... 65
Annex 2. Comparisons of health expenditure across countries and over time: converting national
currencies to a common monetary unit and correcting for price inflation ......................................... 95
Annex 3. Main fields covered in OECD Health Data 2001 .............................................................................. 97
Bibliography........................................................................................................................................................ 99

© OECD 2001 5
 INTRODUCTION

Aims of this report

Health systems are of growing size and importance in OECD countries. They have contributed to the steady
improvements in health status that have been enjoyed in past decades in OECD countries. At the same time they
have consumed a growing share of national resources.
Health at a Glance presents in printed form some of the key indicators found in OECD Health Data 2001.
Its main aim is to display in an easily accessible form some of the variations and trends found in major health
variables across OECD countries.
Subsidiary objectives of this publication are:
• to present health expenditure data in real terms over time and adjusted for different currencies (see
Annex 2) across countries;
• to draw attention to associations between the indicators which may be interesting for policy purposes;
• to place the OECD definitions of variables alongside the data and to report on significant departures of the
data from these definitions where such departures have been reported to the Secretariat;
• to encourage improvement in the availability and comparability of data.

Relationship of this report to OECD Health Data

Since this publication is the companion to OECD Health Data, which is released on a CD-ROM, the
indicators presented here are arranged in a similar order as they appear in OECD Health Data. However, the
indicators on “Expenditure on health”, “Financing and remuneration”, “Social protection” and the
“Pharmaceutical market” in the CD-ROM have been combined into one section on “Expenditure on health” in
this publication. We have also collected indicators on “Demographic references” and “Economic references” into
one section on “Demographic and economic context”. As a result, the six sections in this report correspond to the
ten parts in OECD Health Data as follows:

Health at a Glance OECD Health Data

Section 1: Health status Part 1: Health status

Section 2: Health care resources Part 2: Health care resources
Section 3: Health care utilisation Part 3: Health care utilisation
Section 4: Expenditure on health Part 4: Expenditure on health
Part 5: Financing and remuneration
Part 6: Social protection
Part 7: Pharmaceutical market
Section 5: Non medical determinants of health Part 8: Non-medical determinants of health
Section 6: Demographic and economic context Part 9: Demographic references
Part 10: Economic references

More details on the content of OECD Health Data 2001 can be found in Annex 3. A full list of the
indicators included in the database is available at www.oecd.org/els/health/.

© OECD 2001 7
.

INTRODUCTION

Sources
All data come from the CD-ROM, OECD Health Data 2001, unless otherwise stated. Data contained within
that database originate from a variety of sources, with the bulk of it coming directly from Member countries’
statistical agencies. Some of the data have been provided by other international agencies. This includes data on
life expectancy and infant mortality which, for European countries, have been extracted from the Eurostat
New Cronos database. Crude data on premature mortality and causes of mortality for all countries have come
from WHO-Geneva (World Health Statistics Annual), with the age-standardised death rates being calculated by
the OECD Secretariat based on the OECD population structure. Some data on childhood immunisations have
come from the WHO-Europe Health for All database. For further details on sources and methods, please consult
OECD Health Data 2001.

Indicators chosen
The indicators presented in Health at a Glance are derived largely from the “core indicators” in OECD
Health Data. That is a subset of indicators which the Secretariat considers to be of particular interest from a
health policy point of view. Also, the “core indicators” are often those most requested by users of the database.
An additional criterion for an indicator to be included in Health at a Glance is whether there are sufficient data to
justify making an “OECD” comparison. As a general rule, only those indicators for which there were data
available for at least half of the 30 OECD countries have been included.

Text and charts

Each indicator is usually presented over two pages, which display:
• a few paragraphs of commentary relating to the indicator, including the preferred international definition
of the indicator and a note on significant national variations from that definition which might affect data
comparability;
• one or two bar charts bringing out differences between countries in the indicator in the most recent year
available;
• one or two charts showing trends over time in the indicator or relationships with other variables. In the
case of trends over time, the general rule has been to show the countries with the highest and lowest rates
of change (to demonstrate the range) together with the unweighted average, for countries with complete
and unbroken data series.

Tables
All tables are found in Annex 1 at the end of this report. In most tables, individual country data, averages for
groups of countries and annual growth rates, are presented.
Averages have been calculated for all those countries for which data are available over the complete time
period, with interpolation of up to two years and extrapolation of up to one year of data for any country with
missing data. Such interpolation and extrapolation is not shown in the tables but it does enter into the calculation
of the averages. This procedure allows additional countries to be included in the averages.
Where all 30 countries are included in the average, it is called the “OECD average”. However, in most
cases, data are only available for a subset of OECD countries. In such cases, the averages are labelled the
“x-country average”, reflecting the size of the subset.
All averages are unweighted except where otherwise stated. The rationale for using unweighted averages is
that for many indicators it is appropriate from a health policy perspective, to treat each Member country’s
experience as one observation, carrying equal weight to any other observation. However, in the chapters on
health status and on the demographic and economic context, population-weighted averages have also been
presented. That is because there is interest in capturing vital statistics for the OECD population as a whole, with
appropriate weighting for the very different sizes of OECD populations.
Growth rates are usually annual average growth rates, unless otherwise stated.

8 © OECD 2001
 INTRODUCTION

Data limitations
It is important to note that variations in the indicators across countries and through time may reflect
variations in the definitions of variables as well as variations in the phenomena being observed. In other words,
despite growing agreement about international definitions of health variables, and growing adherence to these
definitions among countries when reporting their data, there remain many definitional divergences and changes
in what is reported. Major divergences and changes which have been brought to the attention of the Secretariat
are reported in the text, below. However, it is not possible to guarantee that the Secretariat has picked up all those
which are of significance. For this reason, care should be exercised before drawing conclusions about variations
and trends in the underlying phenomena, especially for comparisons across countries. Work is continuing on
harmonising international reporting of health data. Meanwhile, for fuller explanations of the definitions of
individual variables for each country, readers are encouraged to consult the “Sources and Methods” section of
OECD Health Data, either on the CD-ROM or on the Internet. To do so, go to the OECD health web site at
www.oecd.org/els/health/, and click on “Definitions, sources and methods” from the main menu of the OECD
Health Data 2001 web page.
Particular caution should be exercised when considering time trends for Germany. Data for Germany up
to 1990 generally refers to west Germany and data from 1991 refers to unified Germany.

© OECD 2001 9
 1. HEALTH STATUS

Life expectancy at birth ............................................................................ 12

Life expectancy at age 65 ......................................................................... 14
Infant mortality ......................................................................................... 16
Premature mortality .................................................................................. 18
Self-reported general health...................................................................... 20
.

1. HEALTH STATUS

Life expectancy at birth

Life expectancy at birth is one of the oldest and At the end of the 1990s, life expectancy at birth
most widely available measures of the health status was the highest in Japan, with 77.2 years for men
of a population at the national level. It is an indicator and 84 years for women (Charts 1.1 and 1.2). Other
based only on mortality data. countries where men enjoyed relatively long life
There have been remarkable gains in life expectancy include Iceland, Sweden, Switzerland,
expectancy in almost all OECD countries over the Australia and Canada, while for women life
last four decades. These gains have been made expectancy is relatively high in Switzerland, France,
possible by rising standards of living, public health Spain, Sweden and Italy.
interventions and progress in medical care.
Although the gains in life span were not uniform
Improvements in life expectancy at birth reflect a
across countries, there has generally been a strong
decline in mortality rates at all ages, including a
convergence towards the OECD average. This is
sharp reduction in infant mortality (see the infant
particularly the case for countries such as Turkey,
mortality section) and higher survival rates at older
Mexico and Korea, which started with relatively low
ages (see next section on life expectancy at age 65).
levels of life expectancy 40 years ago. In Turkey,
From 1960 to 1998, the average (unweighted) life while life expectancy remains low for both men and
expectancy at birth across all OECD countries has women in comparison with other OECD countries,
increased by 7½ years for men (from 66.2 to 73.7 years) there have been gains of more than 20 years
and by almost 9 years for women (from 70.9 to since 1960.
79.8 years) (Charts 1.3 and 1.4, and Tables 1.1 and 1.2).
The greater gains in longevity for women over the last On the other hand, some Central and Eastern
four decades have widened the gender gap from an European countries (e.g. Hungary and Slovakia) have
average of 4.7 years in 1960 to 6.1 years by the end of experienced much lower gains in life expectancy in
the 1990s. This long-term trend, however, covers two recent decades. In Hungary, the life expectancy
different periods in many countries: the 1960s and of men has remained more or less unchanged
the 1970s, when the gender gap in longevity widened between 1960 and 1998. As a result, it is now the
markedly in several countries, and the period since 1980 lowest amongst OECD countries. While female life
which has seen a reduction in the gender gap in many expectancy in Hungary is also relatively low, it has
countries, due to the rapid gains in men’s life been rising over time. Unhealthy lifestyles, such as
expectancy over the last two decades. In 1998, poor diet and excessive alcohol and tobacco
differences in male/female life expectancy among consumption have been suggested as the main factors
OECD countries ranged from a high of 9.1 years in explaining this lack of progress in men’s life
Hungary to a low of 4.5 years in Iceland. expectancy in Hungary (OECD, 1999).

Definition and deviations

Life expectancy at birth is the average number of years a person can be expected to live from the
time he or she is born, assuming that age-specific mortality levels remain constant.
Each country calculates its own life expectancy, using life table methodologies that can vary
somewhat. These differences in methodology can affect the comparability of the life expectancy
measures presented here, as different life table methods can change a nation’s life expectancy by a
fraction of a year.

12 © OECD 2001
 LIFE EXPECTANCY AT BIRTH

Chart 1.1. Female life expectancy at birth, 1998 Chart 1.2. Male life expectancy at birth, 1998

Turkey 71 Hungary 66.1

Hungary 75.2 Turkey 66.4
Slovakia 76.7 Slovakia 68.6
Mexico 77 Poland 68.9
Poland 77.3 Korea1 70.6
Korea1 78.1 Czech Republic 71.1
Czech Republic 78.1 Portugal 71.7
Denmark 78.6 Mexico 72.4
Portugal 78.8 Ireland 73.5
Ireland 79.1 Finland 73.5
United States 79.4 Luxembourg 73.7
Greece 79.4 Denmark 73.7
United Kingdom 79.7 United States 73.9
New Zealand 80.4 Germany 74.5
Luxembourg 80.5 Greece 74.6
Germany 80.5 France 74.6
Netherlands 80.7 Austria 74.7
Finland 80.8 United Kingdom 74.8
Austria 80.9 Spain 74.8
Belgium 81.1 Belgium 74.8
Norway 81.3 New Zealand 75.2
Canada1 81.4 Netherlands 75.2
Iceland 81.5 Italy1 75.3
Australia 81.5 Norway 75.5
Italy1 81.6 Canada1 75.8
Sweden 81.9 Australia 75.9
Spain 82.2 Switzerland 76.5
France 82.2 Sweden 76.9
Switzerland 82.5 Iceland 77
Japan 84 Japan 77.2

60 65 70 75 80 85 60 65 70 75 80 85
1. 1997 data. 1. 1997 data.

Chart 1.3. Female life expectancy at birth, Chart 1.4. Male life expectancy at birth,
1960-1998 1960-1998

17 country unweighted average Hungary Japan 17 country unweighted average Hungary Japan
Years of life Years of life
90 90

80 80

70 70

60 60
1960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 1960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98

© OECD 2001 13
.

1. HEALTH STATUS

Life expectancy at age 65

Life expectancy at age 65 is a broad, mortality- second after Mexican males, with 17.1 additional years
based indicator of the health of elderly people. It has (Charts 1.5 and 1.6). It is important to keep in mind that
been steadily improving over the last few decades in differences in methodologies used to calculate life
most OECD countries. Far from showing signs of expectancy may affect national estimates by a fraction
reaching a limit, the life expectancy for people at age of a year.
65 has been increasing, on average, at least as fast for
women or even faster for men since 1980 compared In general, the factors that have been behind
with the period from 1960 to 1980 (Charts 1.7 improvements in life expectancy at birth also explain
and 1.8, and Tables 1.3 and 1.4). These gains in the steady gains in life expectancy at age 65. These
longevity at old age, combined with the reduction in include rising standards of living, improved working
fertility rates, have led to a steadily rising proportion conditions, and advances in medical care and public
of older persons in OECD countries (see Section 6, health interventions. In many countries, improved
indicator “Share of the population aged 65 and over”). life expectancy at age 65 has been driven mainly by a
reduction in mortality from cardiovascular diseases
From 1960 to 1998, the average (unweighted) life
(Australian Institute of Health and Welfare, 1998a;
expectancy at age 65 for the 21 OECD countries with
World Health Organisation and Ministero della
complete time series has increased by 4.1 years for
Sanità Repubblica Italiana, 1999).
women and 2.7 years for men, thereby increasing the
gender gap from 2.2 to 3.6 years. By the end of As the life expectancy of people at older ages
the 1990s, people at age 65 in these 21 OECD increases, the quality of life of the elderly population
countries could expect to live, on average, an becomes an important policy concern in many
additional 19 years for women and 15.4 years for men. countries. There is some evidence indicating that life
Increases in life expectancy at age 65 were expectancy without severe disability at age 65 has
particularly strong in Japan, with gains of almost 8 years increased in most OECD countries for which data are
for women and 5½ years for men between 1960 available (with the exception of Australia), thereby
and 1998. As a result, Japanese women now enjoy the suggesting that elderly people live in better
longest life expectancy at age 65, with an expectation of functional health than in the past (Jacobzone et al.,
22 additional years of life, while Japanese men come 2000a).

Definition and deviations

Life expectancy at age 65 is the average number of years which a person at that age can be
expected to live, assuming that age-specific mortality levels remain constant.
The same caution about national sources applies as for total life expectancy.

14 © OECD 2001
 LIFE EXPECTANCY AT AGE 65

Chart 1.5. Female life expectancy at age 65, 1998 Chart 1.6. Male life expectancy at age 65, 1998

Turkey 14.3 Hungary1 12.1

Hungary1 15.9 Turkey 12.7
Czech Republic 16.9 Poland 13.4
Poland 17 Czech Republic 13.4
Korea2 17.3 Korea2 13.6
Ireland3 17.4 Ireland3 13.7
Portugal 17.9 Portugal 14.4
Denmark 17.9 Netherlands 14.7
United Kingdom2 18.5 Luxembourg3 14.7
Mexico 18.7 Denmark 14.7
Greece 18.7 Finland 14.9
Netherlands 18.8 United Kingdom2 15
Germany 19 Germany 15.3
United States 19.1 Belgium 15.6
Finland 19.1 Austria 15.6
Luxembourg3 19.2 Norway 15.7
Austria 19.3 Italy2 15.8
New Zealand 19.5 United States 16
Norway 19.6 New Zealand 16.1
Iceland 19.8 Greece 16.2
Belgium 19.8 Sweden 16.3
Sweden 20 Spain 16.3
Australia 20 France2 16.3
Canada2 20.1 Canada2 16.3
Italy2 20.2 Australia 16.3
Spain 20.3 Iceland 16.4
Switzerland 20.6 Switzerland 16.7
France2 20.8 Japan 17.1
Japan 22 Mexico 17.6

10 15 20 25 10 15 20 25
1. 1996 data. 2. 1997 data. 3. 1995 data. 1. 1996 data. 2. 1997 data. 3. 1995 data.

Chart 1.7. Female life expectancy at age 65, Chart 1.8. Male life expectancy at age 65,
1960-1998 1960-1998

14 country average Hungary Japan 14 country average Hungary Japan

Years of life Years of life
25 25

20 20

15 15

10 10
1960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 1960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98

© OECD 2001 15
.

1. HEALTH STATUS

Infant mortality

Infant mortality rates are one of the most widely Infant mortality rates are related to a number of
used indicators in international comparisons to judge social and economic factors, including the average
the effect of economic and social conditions on income level in a country, the income distribution
human health. They are an important indicator of the and the availability and access to health services.
health of both pregnant women and newborns. Higher average income per capita is generally related
to lower infant mortality rates, although this
Over the last four decades, infant mortality has relationship tends to be less pronounced in developed
declined steadily in all OECD countries (Charts 1.10 countries (Chart 1.12). It is likely that the higher
and 1.11, and Table 1.5). Infant mortality rates were health expenditure per capita which tends to be
on average (unweighted) more than 5 times higher associated with higher GDP per capita plays a role in
in 1960 than they were by the end of the 1990s. The explaining the relationship. Infant mortality rates
decline in infant mortality has been particularly have also been shown to be influenced by the
impressive in Portugal, as it came down from distribution of income within societies. Countries
77.5 deaths per 1 000 children in 1960 – twice as with a more equal distribution of a certain level of
high as the OECD average at that time – to 5.5 per income tend to have lower infant mortality rates than
1 000 by 1999 – lower than the OECD average now more unequal societies (Hales et al., 1999). Cross-
(Chart 1.11). Reductions in infant mortality rates country variations in infant mortality rates have also
have also been remarkable in Japan in the 1960s, in been associated more specifically with variations in
Korea and Mexico in the 1970s, and in Turkey in the availability of certain health care resources, such
the 1980s. as the number of doctors and the number of hospital
Although progress has been achieved in all beds (Grubaugh and Santerre, 1994).
countries, and disparities across countries are Between 40% and two-thirds of infant mortality
narrowing, there continue to be significant variations in OECD countries are deaths occurring during the
in levels of infant mortality among OECD countries first week of life (early neonatal mortality). After the
(Chart 1.9). In 1999, the countries with the lowest first week of life, the main causes of infant mortality
rates of infant mortality were Iceland, Sweden, in most countries are congenital anomalies and
Japan, Finland and Norway, with less than 4 deaths sudden infant death syndrome (Australian Institute of
per 1 000 live births. Health and Welfare, 1998b).

Definition
Infant mortality is the number of deaths of children under one year of age expressed per 1 000 live
births.

16 © OECD 2001
 INFANT MORTALITY

Chart 1.9. Infant mortality in OECD countries, Chart 1.10. Average annual decline in infant
1999 mortality rates, 1960-1999

Iceland 2.4 -3.1% Netherlands

Sweden 3.4 -3.1% Slovakia
Japan 3.4 -3.2% Australia
Finland 3.6 -3.2% New Zealand1
Norway 3.9 -3.3% United States2
Denmark 4.2 -3.4% United Kingdom
France 4.3 -3.7% Czech Republic
Austria 4.4 -3.8% Switzerland
Switzerland 4.6 -4.0% Norway
Germany 4.6 -4.0% Sweden
Czech Republic 4.6
-4.1% Turkey
Luxembourg 4.7
-4.1% Mexico
Spain 4.9
-4.1% Denmark
Italy 5.1
-4.2% Ireland
Netherlands 5.2
-4.2% Canada1
Belgium 5.3
-4.2% Iceland
Portugal 5.5
-4.3% Hungary
Ireland 5.5
-4.4% Finland
Canada1 5.5
-4.4% Belgium
Australia 5.7
-4.6% Poland
United Kingdom 5.8
Greece
-4.6% France
5.9
New Zealand1 6.8
-4.8% Luxembourg
United States2 7.2
-4.8% Greece
Korea3 7.7 -5.0% Germany
Slovakia 8.3 -5.3% Austria
Hungary 8.5 -5.4% Italy
Poland 8.9 -5.5% Spain
Mexico 14.5 -5.5% Japan
Turkey 22 37.5 -6.6% Portugal
0 5 10 15 20 25 30 35 40 -7 -6 -5 -4 -3 -2 -1 0
Deaths per 1 000 live births %
1. 1960-1997. 2. 1960-1998.
1. 1997 data. 2. 1998 data. 3. 1996 data.

Chart 1.11. Infant mortality, Chart 1.12. Infant mortality and GDP per capita
1960-1999 ($PPP), 1999

29 country average Portugal Sweden

Deaths per 1 000 live births Infant deaths per 1 000 live births
100 40
TUR
90
35
R2 = 0.58
80 (of log transformed variables)
30
70
25
60

50 20

40 MEX 15
30 BEL
CAN 10
POL ITA IRL AUS
20 HUN
KOR
NZL
NLD USA
GRC GBR DNK 5
10 CZE PRT ESP FRA CHE LUX
FIN NOR
SWE ISL AUT
DEU JPN
0 0
1960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 99 0 5 000 10 000 15 000 20 000 25 000 30 000 35 000 40 000 45 000
GDP per capita ($PPP)

© OECD 2001 17
.

1. HEALTH STATUS

Premature mortality

Premature mortality is measured by the total women, the main causes of premature mortality are
potential years of life lost (PYLL) due to deaths prior cancers (29%), followed by external causes (18%), and
to age 70 given current age-specific death rates. As a circulatory diseases (14%). For men, it is external
measure, it is weighted towards deaths amongst the factors such as car accidents and violence which
young: a death at 5 years of age represents 65 PYLL; represent the most important source of premature death
one at 60 years of age only 10. (30%), followed by cancers (19%) and circulatory
In the last four decades, premature mortality, so diseases (18%).
measured, has on average more than halved across
An investigation of the determinants of
OECD countries (Tables 1.6 and 1.7). While the
premature mortality using the extensive list of
decline has been more rapid for females than for
explanatory variables and the long time series that are
males between 1960 and 1990, since 1990 PYLL has
now available in OECD Health Data suggests that a
on average been declining at the same rate for men
large number of medical and non-medical factors are
and women.
involved (Or, 2000a). Everything else being equal,
In 1997 (or latest year available), death rates of higher health expenditure per capita is associated with
men and women under 70 years of age were still lower premature mortality for women. There is no
relatively high in Mexico, Hungary, Poland and significant effect for men, perhaps because a high
Slovakia (Charts 1.13 and 1.14). In the United States proportion of premature mortality among males is due
as well, premature mortality was still 20% higher for to accidents and violence. Certain non-medical
men and 32% higher for women than the (unweighted) determinants of health are however the most important
average for the 22 countries with complete time series. factors affecting PYLL. Occupational status is the
Japan, Sweden and Iceland registered the lowest level most important factor, followed by GDP per capita,
of premature mortality for both males and females. with an increase in both the proportion of non-manual
Charts 1.15 and 1.16 show the causes of death that workers and GDP per capita associated with a
contributed the most to premature mortality in OECD reduction in PYLL. By contrast, and as expected,
countries in 1995. Cancers (malignant neoplasms) and pollution and the consumption of alcohol, tobacco and
external causes of death (including car accidents) fat are unfavourable for PYLL. That suggests further
accounted for almost half of premature deaths for both scope for the promotion of healthy lifestyles in
men and women. While the main causes of premature OECD countries (see Section 5). A more recent study
deaths are generally similar between genders, there are indicates that higher numbers of doctors are also
significant differences in rankings and the numbers of associated with reduced premature mortality, both for
premature deaths associated with each cause. For women and for men (Or, 2000b).

Definition
Premature mortality is measured by the indicator “potential years of life lost” (PYLL) under
age 70. This indicator adds up potential years of life lost prior to age 70, given current age-specific
death rates (for example, a death at 5 years of age is counted as 65 years of PYLL). The indicator is
expressed per 100 000 females and males.

18 © OECD 2001
 PREMATURE MORTALITY

Chart 1.13. Female PYLL before age 70, Chart 1.14. Male PYLL before age 70,
all causes, 1997 all causes, 1997

Japan 2 182 Sweden1 3 773

Sweden1 2 304 Japan 3 996
Iceland1 2 353 Iceland1 4 052
Spain 2 493 Netherlands 4 315
Finland1 2 539 Norway 4 547
Italy 2 548 Canada 4 818
Norway 2 628 Italy 4 856
Greece 2 635 United Kingdom 4 897
Austria 2 647 Australia 4 920
France 2 659 Luxembourg 5 152
Australia 2 736 Greece 5 372
Canada 2 780 Austria 5 433
Switzerland2 2 796 Germany 5 499
Germany 2 803 Spain 5 545
Netherlands 2 813 Switzerland2 5 565
Luxembourg 2 848 Ireland1 5 676
United Kingdom 2 995 Denmark1 5 687
Ireland1 3 036 France 5 760
Belgium3 3 100 New Zealand 5 837
Korea 3 142 Belgium3 5 967
Czech Republic 3 378 Finland1 6 117
Denmark1 3 493 United States 6 852
New Zealand 3 511 Korea 7 241
Portugal 3 632 Czech Republic 7 334
United States 3 872 Portugal 7 965
Slovakia 3 916 Slovakia 8 926
Poland1 4 269 Poland1 9 961
Hungary 4 967 Mexico3 11 084
Mexico3 6 451 Hungary 11 303

0 2 000 4 000 6 000 8 000 10 000 12 000 0 2 000 4 000 6 000 8 000 10 000 12 000
PYLL per 100 000 females PYLL per 100 000 males
1. 1996 data. 2. 1994 data. 3. 1995 data. 1. 1996 data. 2. 1994 data. 3. 1995 data.

Chart 1.15. Leading causes of female premature Chart 1.16. Leading causes of male premature
mortality, 27 country average,1 1995 mortality, 27 country average,1 1995

Malignant neoplasms External causes Malignant neoplasms External causes

Circulatory system Perinatal Circulatory system Perinatal
Congenital anomalies Other Digestive system Other

24% 23%
29%
30%

5%
7%
5%

8%
18%
19%
18%
14%

1. Includes all OECD countries except Iceland, Switzerland and Turkey. 1. Includes all OECD countries except Iceland, Switzerland and Turkey.

© OECD 2001 19
.

1. HEALTH STATUS

Self-reported general health

A major challenge is to complement the general health, for three reasons. First, there remain
traditional emphasis on mortality-based measures of some variations in the question and answer
health status with a set of reliable morbidity categories used to measure self-rated general health
measures, to provide a fuller description of the health across surveys/countries. Second, translation of
status of populations across space and time. Reliable survey questions and answers into different
morbidity data are still scarce across the OECD area. languages affects the responses. Third, and probably
However, an increasing number of countries are most importantly, people’s overall assessment of
conducting health interview surveys which allow their own health is subjective and can be affected by
respondents to report on their health status. A a number of factors, such as cultural background,
frequently asked question is “How is your health in education and access to health care services.
general? Very good, good, fair, bad or very bad”? Within each country, for people aged 15 years
Despite the general and subjective nature of this and over, men are more likely than women to report
question, indicators of self-rated general health have their health to be good or better, with the exception
been found in several countries to be a good predictor of Finland, Iceland, Ireland and New Zealand. As
of future health care use and mortality (for instance, expected, positive self-reported health generally
see Miilunpalo et al., 1997). declines with age. In many countries, there is a
In over half of OECD countries, 75% or more of particularly marked decline in self-rated general
the adult population report their health to be “good” health after age 45 and a further decline after age 65.
or better (Charts 1.17 and 1.18, and Table 1.8). The Looking at trends over time (Charts 1.19
United States and Canada have the highest and 1.20), from the late 1970s to the late 1990s, self-
percentage of people assessing their health to be reported “good or better health” status has remained
“good” or better, with over 90% of the population generally stable for both men and women in the four
(males and females combined) in these two countries countries for which long time series are available
reporting being in “good/very good/excellent” health. (Finland, the Netherlands, Sweden and the United
On the other hand, reported “good or better health” States). Variations in self-reported health over time
status is lowest in Portugal, in Asian countries (Japan may reflect both changes in true health status and
and Korea) and in Central and Eastern European changes in health expectations. If improvements in
countries (Hungary, Poland and Slovakia). Here, less true health status in the population are accompanied
than half of the population report being in “good” or by an equal rise in health expectations, it is not
“very good” health. Caution is required however in surprising that self-reported health status has
making cross-country comparisons of self-reported remained more or less stable over time.

Definition and deviations

Self-reported general health reflects people’s overall perception of their health, possibly including
all physical and psychological dimensions. Typically, survey respondents are asked a question along the
following lines: “How is your health in general? Very good, good, fair, bad, very bad”. OECD Health
Data provides figures related to the proportion of people reporting their health to be “good/very good”
combined.
There remain some variations in the formulation of the question and answers in different surveys/
countries, which limit data comparability.

20 © OECD 2001
 SELF-REPORTED GENERAL HEALTH

Chart 1.17. Females, percentage reporting their Chart 1.18. Males, percentage reporting their
health as “good” or better, latest year available health as “good” or better, latest year available

Portugal 27.1 Portugal 38.5

Hungary 38.9 Japan 47.2

Poland 40.2 Hungary 48.1

Slovakia 40.7 Poland 48.2

Korea 40.8 Slovakia 48.6

Japan 42 Korea 48.7

Czech Republic 50.4 Czech Republic 57.7

Italy 50.6 Italy 61

Germany 64 Finland 67.6

Spain 64.7 Germany 68.3

Finland 70 Spain 72.4

Austria 70.1 Austria 72.5

Netherlands 73.5 United Kingdom 75.3

Belgium 74.9 Sweden 80.1

United Kingdom 75 Netherlands 80.6

Denmark 75.6 Norway 81.1

Sweden 75.7 Iceland 81.3

Norway 78.2 Belgium 81.6

Switzerland 80.4 Denmark 82.9

Iceland 82.3 Australia 83.6

Australia 83.3 Ireland 84.9

France 85 Switzerland 86.2

Ireland 86.3 New Zealand 87.3

New Zealand 88.2 France 90.5
Canada 89.7 Canada 91.2
United States 90 United States 91.4

0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
Percentage Percentage

Chart 1.19. Trends in the female population Chart 1.20. Trends in the male population
aged 15 and over reporting their health aged 15 and over reporting their health
to be good or better to be good or better

Finland Netherlands Sweden United States Finland Netherlands Sweden United States
Percentage reporting their health to be good or better Percentage reporting their health to be good or better
100 100

90 90

80 80

70 70

60 60

50 50
1975 77 79 81 83 85 87 89 91 93 95 97 99 1975 77 79 81 83 85 87 89 91 93 95 97 99

© OECD 2001 21
 2. HEALTH CARE RESOURCES

Practising physicians and nurses............................................................... 24

Inpatient and acute-care beds.................................................................... 26
.

2. HEALTH CARE RESOURCES

Practising physicians and nurses

Doctors and nurses are the primary resource for the United States and Canada. The regulations
producing health care in any health system. The controlling patient access to physician services
numbers of doctors and nurses per capita can have (direct access to specialists or not) and methods of
significant impact on the cost, utilisation and remuneration play an important role in determining
outcome of health services. their cost. For example, there is some evidence to
Numbers of physicians per 1 000 population suggest that in countries where physicians are paid
have been increasing steadily over time in all OECD by salary or capitation (a fixed payment per period
countries: the average number of physicians per for each patient registered with the doctor), a higher
1 000 population increased from 1.1 in 1960 to 3.0 number of doctors is associated with lower health
in 1999 (Table 2.1). In most countries the bulk of the expenditure whereas in countries where physicians
growth has taken place in the 1970s and 1980s, but are paid by fee-for-service, a higher number of
many physician/population ratios have continued to doctors is associated with higher health expenditure,
rise in the last 10 years. after controlling for other factors (OECD, 1994b).
The average hides, however, significant variation Nurse numbers, as reported to OECD, also
in physician numbers across countries (Chart 2.1). vary significantly across countries (Table 2.2 and
Chart 2.3 suggests that physician numbers increased Chart 2.2). Numbers have been increasing in nearly
fastest in Turkey with an average annual growth rate all countries for which we have data except in
of 4.3% and slowest in Canada with an average annual Australia and Canada in the 1990s (Chart 2.4).
growth rate of 1.5%.
Empirical evidence from OECD countries The relative productivity of different types of
suggests that higher doctor numbers are significantly health personnel, in particular doctors relative to
associated with lower mortality, after controlling for nurses, has been explored by health economists. In the
other determinants of health (Grubaugh and Santerre, United States, some studies suggested that between
1994; Or, 2000b). 25% to 60% of physician services could be carried out
by nurses (Reinhardt, 1972; Stein et al., 1990).
There is no simple relationship between the
number of doctors in a country and the total The possibility of increasing doctors’
expenditure on health. Surprisingly, the physician productivity with more paramedical help is
stock appears to be relatively low in some countries recognised by other studies (Hershey and Kroop,
where health expenditure is known to be high such as 1979; Richardson and Maynard, 1995).

Definition and deviations

Practising physicians are defined as the number of full-time equivalent physicians who are
actively practising medicine in public and private institutions.
Most countries provide headcounts rather than full-time equivalents. Finland, Italy and Spain
provide the numbers of physicians entitled to practise rather than practising physicians, which makes
per capita ratios relatively high compared to other countries.
Practising nurses are defined as the number of actively practising certified/registered nurses
employed in public and private hospitals, clinics and other health facilities.
Nursing assistants (also called licensed practical nurses or enrolled nurses) are not included in nurse
numbers in some countries such as Australia, Austria, Canada and the United States. Most countries report
head-count numbers, while the Czech Republic, France, Germany, Hungary and the United Kingdom
report full-time equivalents. The United Kingdom and Spain provide only publicly employed nurses
(nurses employed in the National Health Service). Finland reports all nurses entitled to practice.

24 © OECD 2001
 PRACTISING PHYSICIANS AND NURSES

Chart 2.1. Practising physicians1 Chart 2.2. Practising and certified nurses
per 1 000 population, late 1990s per 1 000 population, late 1990s

Turkey 1.2 Turkey 1.1

Korea 1.3 Mexico 1.2
Mexico 1.7 Korea 1.4
United Kingdom 1.8 Spain 3.6
Japan 1.9
Greece 3.6
Canada 2.1
Portugal 3.8
Poland 2.3
United Kingdom 4.5
New Zealand 2.3
Italy 4.6
Ireland 2.3
Hungary 5
Australia 2.5
United States 2.7
Poland 5.1

Norway 2.8 France 6

France 3 Luxembourg 7.1

Czech Republic 3 Denmark 7.3

Austria 3 Canada 7.5
Sweden 3.1 Japan 7.8
Spain 3.1 Australia 8.1
Netherlands 3.1 Czech Republic 8.2
Luxembourg 3.1
United States 8.3
Finland 3.1
Austria 9
Portugal 3.2
New Zealand 9.6
Hungary 3.2
Germany 9.6
Iceland 3.3
Norway 10.1
Switzerland 3.4
Germany Sweden 10.2
3.4
Denmark 3.4 Netherlands 12.7

Belgium 3.8 Iceland 13.8

Greece 4.1 Finland 14.4

Italy 5.9 Ireland 16.5

0 1 23 4 5 6 7 0 2 4 6 8 10 12 14 16 18
Physicians per 1 000 population Nurses per 1 000 population
1. Data for Finland, Italy and Spain are physicians entitled to practise.

Chart 2.3. Practising physicians Chart 2.4. Trends in number of certified nurses
per 1 000 population, 1960-1998 per 1 000 population

Australia Austria Canada

19 country average Turkey Canada Sweden United States
Physicians per 1 000 population Nurses per 1 000 population
3.5 11

3.0 10

9
2.5

8
2.0
7
1.5
6
1.0
5

0.5
4

0 3
1960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 1980 82 84 86 88 90 92 94 96 98

© OECD 2001 25
.

2. HEALTH CARE RESOURCES

Inpatient and acute-care beds

Hospitals and nursing homes are both important cases, this relates to exclusion of nursing home beds
components of health care provision. However, in the from the reported figures. There are smaller variations
case of hospitals, with the rapid development of new across countries in acute beds, which will mainly be in
medical technologies and growing pressure for cost hospitals (Chart 2.6).
containment in the past 30 years, they have had to
modify radically the way they operate. In most Charts 2.7 and 2.8, respectively, show annual
OECD countries, hospitals have found opportunities changes in average numbers of inpatient and acute
to improve efficiency with shorter hospital stays and hospital beds per 1 000 population in the OECD
an increasing proportion of day-surgery patients. countries for which there are complete time series.
Since 1980, the average annual decline has been
Accordingly, the number of hospital and nursing
1.4 per cent for inpatient beds and 1.7 per cent for
home beds has declined steadily in the past three
acute-care beds. Table 2.3 shows for countries with
decades in the OECD area. Table 2.3 shows that the complete time series data with no suggestions of
average number of inpatient care beds has dropped breaks that Finland and the United Kingdom had the
from 8.9 per 1 000 population in 1980 to less than 7 largest declines in bed numbers per 1 000 over this
in 1998. There remain however notable variations in period. Bed numbers per 1 000 in Japan increased by
the reported data across countries (Chart 2.5). In some 1.0% per annum over the period.

Definition and deviations

Inpatient beds are defined as including all available beds in public and private inpatient
institutions, including nursing homes.
The United Kingdom and Ireland include only public beds. Beds in nursing homes are not included
for Canada, Ireland, Portugal, Korea and the United Kingdom.
Acute-care beds are beds accommodating patients where the principal clinical intent is to do one
or more of the following: manage labour (obstetrics), cure illness or provide definitive treatment of
injury, perform surgery, relieve symptoms of illness or injury (excluding palliative care), reduce
severity of illness or injury, protect against exacerbation and/or complication of an illness and/or injury
which could threaten life or normal functions, perform diagnostic or therapeutic procedures.
Some countries still define acute-care beds by a length of stay criterion following earlier OECD
guidance.

26 © OECD 2001
 INPATIENT AND ACUTE-CARE BEDS

Chart 2.5. Total inpatient beds Chart 2.6. Acute-care beds

per 1 000 population, late 1990s per 1 000 population, late 1990s

Mexico 1.1 Turkey 2.2

Turkey 2.5 United Kingdom 2.4
United States 3.7
Sweden 2.6
Sweden 3.8
Finland 2.6
Spain 3.9
Portugal1 4
Ireland 2.9

Canada 4.1 United States 3.1

United Kingdom 4.2 Spain 3.2
Denmark 4.5 Norway 3.2
Greece 5
Canada 3.2
Korea1 5.1
Portugal 3.3
Poland 5.3
Italy 5.5
Denmark 3.3

New Zealand 6.2 Netherlands 3.7

Belgium 7.3 Australia 3.9

Finland 7.8 Greece 4
Luxembourg 8
France 4.3
Hungary 8.2
Korea 4.4
France 8.5
Australia 8.5
Belgium 4.6

Czech Republic 8.9 Italy 4.9

Austria 8.9 Luxembourg 5.5

Germany 9.3 Switzerland 5.6
Ireland1 10.1
Austria 6.3
Netherlands 11.3
Hungary 6.5
Norway 14.5
Japan 16.5 Germany 6.5

Switzerland 18.1 Czech Republic 6.7

0 2 4 6
10 12 14 16 18 20 8 0 1 2 3 4 5 6 7 8
Beds per 1 000 population Beds per 1 000 population
1. Beds in nursing homes are not included.

Chart 2.7. Total inpatient beds Chart 2.8. Acute-care beds

per 1 000 population, 1960-1998 per 1 000 population, 1980-1998

17 country average United Kingdom Japan 18 country average Hungary Sweden

Beds per 1 000 population Beds per 1 000 population
18 12

16
10
14

12 8

10
6
8

6 4

4
2
2

0 0
1960 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 1980 82 84 86 88 90 92 94 96 98

© OECD 2001 27
 3. HEALTH CARE UTILISATION

Consultations with doctors........................................................................ 30

Childhood immunisation........................................................................... 32
Admissions to hospitals and nursing homes ............................................. 34
Average length of stay in acute care ......................................................... 36
.

3. HEALTH CARE UTILISATION

Consultations with doctors

In some countries, patients can approach a The biggest increases over this period have been in
specialist directly and in others they are either Hungary, Mexico and Turkey which were building
required or encouraged to approach a general up their physician numbers and services. France and
practitioner “gatekeeper” who will decide whether Australia have also had a rapid increase in
they need referral to a specialist or not. The great consultations.
bulk of patient contacts with health care systems It might be assumed that more doctors would
involve a consultation with a doctor on an lead to more consultations. However, Chart 3.4
ambulatory care basis either in a primary care clinic suggests that there was only a weak positive
or in a hospital outpatient department. In either case, association between the growth in the number of
doctors are patients’ main agents of information physicians per capita and the growth in the number of
regarding appropriate treatment. An important consultations per capita between 1980 and 1996/97
preoccupation for health policy is to provide the right in countries for which data have been reported. On
incentives to doctors both to ensure quality of care average, the percentage growth in consultations has
been smaller than the percentage growth in the
and to control costs.
number of physicians. It is not clear whether the
By the late 1990s, there were considerable length and quality of consultations has been rising: if
differences across countries in per capita consultations it has not, it would imply that productivity per doctor
with doctors (Chart 3.1). In 1997 the average for the has been declining. However, it should be noted that
18 countries for which data are available was around the figures for consultations do not include other
seven visits per capita (Table 3.1). activities of doctors, such as non-ambulatory hospital
work. Also, the figures for physicians are mainly
The number of consultations with doctors per headcounts which are not adjusted for increasing
capita has increased in all countries since 1980, part-time working, partly as a result of increasing
except in Poland and Portugal (Charts 3.2 and 3.3). female participation.

Definition and deviations

Consultations with doctors refer to the number of ambulatory contacts with physicians.
Consultations in physicians’ offices, in primary-care clinics and in the outpatient wards of hospitals as
well as home visits should be included. Both public and private consultations should be included.
Several countries exclude consultations with specialists, others do not include contacts for maternal
and child care. Turkey excludes visits to private practitioners.

30 © OECD 2001
 CONSULTATIONS WITH DOCTORS

Chart 3.1. Doctor consultations Chart 3.2. Change in doctor consultations

per capita, late 1990s per capita, 1980-late 1990s

Turkey 2.1 -18% Poland

Mexico 2.3
-8% Portugal
Sweden 2.8 Decrease
in 4% Czech Republic
Luxembourg 2.8
consultations
Portugal 3.4
8% Sweden

Finland 4.2 11% Japan

Iceland 5.2 11% Belgium

United Kingdom 5.4
14% Canada
Poland 5.4
15% Austria
Netherlands 5.7

United States 5.8 17% United Kingdom

Increase
in
Italy 6 18% Denmark
consultations
Denmark 6
20% Netherlands
Canada 6.4
21% United States
Australia 6.4

Germany 6.5
31% Finland

France 6.5 63% France

Austria 6.5 63% Australia

Belgium 7.9
67% Turkey
Czech Republic 12.4
77% Mexico
Japan 16

Hungary 19.7 79% Hungary

0 5 10 15 20 25 -40 -20 0 20 40 60 80 100

Consultations per capita Percentage change

Chart 3.3. Trends in doctor consultations Chart 3.4. Relationship between changes
per capita, 1980-1997 in physician density and physician consultations,
1980-1996/97
18 country average Hungary Poland
Consultations per capita Growth in consultations per capita (%)
20 100

18 Correlation coefficient = 0.44

80
Mexico
16 Hungary
France Turkey
14 60

Australia
12
40
Finland
10
United States
United Kingdom Denmark 20
8 Canada Japan Belgium
Austria

6 Czech Republic Sweden 0

Portugal
4
Poland
-20
2

0 -40
1980 82 84 86 88 90 92 94 96 0 10 20 30 40 50 60 70 80 90 100
Growth in physicians per 1 000 population (%)

© OECD 2001 31
.

3. HEALTH CARE UTILISATION

Childhood immunisation

Childhood immunisation rates are often used as Charts 3.7 and 3.8 present trends in the immu-
proxies for health outcomes – changes in health nisation rates for DTP and measles respectively
status attributable to interventions. Over the past since 1975 in selected OECD countries. In general,
decades, childhood immunisation has yielded childhood immunisation rates have continued to
considerable reductions in the rate of several major increase over time across most OECD countries, or
infectious diseases and has contributed to the they have remained stable at a very high level (close
reduction of infant and child mortality in both to 100%) in countries like the Czech Republic and
developed and developing countries. the Netherlands. In Portugal, the percentage of
By the late 1990s, most children in OECD children vaccinated against measles has increased
countries were vaccinated against diphtheria, tetanus from 31% in 1975 to 96% in 1998, while the propor-
and pertussis (DTP) and measles, with an average of tion of those immunised against DTP has gone up
93.8% of children immunised against DTP and 90.5% from 51% in 1975 to 98% in 1998. It is likely that
immunised against measles (Table 3.2, Charts 3.5 this rapid progress in immunisation rates has played a
and 3.6). Childhood immunisation rates were significant role in the spectacular reduction in child
particularly high in central and eastern European mortality there (Section 1). There has also been a
countries and in Scandinavian countries, with the remarkable improvement in immunisation coverage
proportion of children vaccinated against DTP and in Turkey since the mid-1980s and in Mexico over
measles now approaching 100% in these countries. the last decade.

Definition and deviations

Childhood immunisation refers to two measures: the percentage of 1-year-old children vaccinated
against diphtheria, tetanus and pertussis combined (DTP), and the proportion of 1-year-old children
vaccinated against measles.
The age of complete immunisation differs across countries due to different immunisation
schedules. Immunisation data are: for 2-year-olds for measles in Australia, for ages 18-24 months for
DTP in Belgium, and for both DTP and measles for 2-year-olds in Canada and Finland, for ages
14-15 months in the Netherlands and 19-35 months in the United States.

32 © OECD 2001
 CHILDHOOD IMMUNISATION

Chart 3.5. Diphtheria, tetanus and pertussis Chart 3.6. Measles immunisation rates
immunisation rates for young children, for young children, latest year available
latest year available

Turkey 79
Italy 75
Germany 75
United States 84
Ireland 77
Germany 85
Turkey 81
Ireland 86
New Zealand 82
Canada 86.8
Belgium 82.4
New Zealand 88.4
Switzerland 83
Norway 89.4 France 83
Australia 89.8 Norway 88
Greece 90 United Kingdom 88.1
Austria 90 Greece 90
United Kingdom 92.4 Austria 90
Italy 95 Australia 91
Spain 95.1 Luxembourg 91

Mexico 96.2 United States 92

Denmark 92
Netherlands 97
Korea 94.3
Belgium 97.1
Spain 95
Portugal 97.8
Czech Republic 95
Luxembourg 98
Mexico 95.7
France 98
Portugal 96
Czech Republic 98
Netherlands 96
Poland 98.1 Canada 96
Finland 99 Sweden 96.3
Denmark 99 Japan 96.5
Slovakia 99.1 Poland 97.1
Sweden 99.3 Finland 98
Korea 99.5 Slovakia 99.3

Iceland 99.9 Iceland 99.9

Hungary 99.9 Hungary 100

70 80 90 100 70 80 90 100

Chart 3.7. Trends in the proportion of children Chart 3.8. Trends in the proportion of children
vaccinated against diphtheria, vaccinated against measles
tetanus and pertussis

Czech Republic Netherlands Portugal Turkey Czech Republic Netherlands Portugal Turkey

100 100

90 90

80 80

70 70

60 60

50 50

40 40

30 30
1975 77 79 81 83 85 87 89 91 93 95 97 99 1975 77 79 81 83 85 87 89 91 93 95 97 99

© OECD 2001 33
.

3. HEALTH CARE UTILISATION

Admissions to hospitals and nursing homes

Admission rates to hospitals and nursing homes It is important to point out that these trends are
– involving at least one overnight stay in a bed – are not necessarily indicative of an overall fall in hospital
one of the main indicators of health system activity. utilisation. Day cases are not counted as inpatients
Tables 3.3 and 3.4 and Charts 3.9 and 3.10 show because they do not involve an overnight stay. They
that inpatient and acute-care admissions respectively have increased sharply in many countries. In the
vary considerably across OECD countries with an United States, about half of all surgical operations are
OECD average of 169 and 161 per 1 000 population now carried out on a day care basis. The Secretariat
respectively in 1998. is now trying to collect data on day cases.
Inpatient admissions per 1 000 population have, In the United Kingdom, it has been suggested
since 1970, increased on average for a group of that the quality of primary-care practice could be
OECD countries for which we have data (Chart 3.11 related to admission rates for chronic diseases, lower
and Table 3.3). Trends in acute-care admissions have admission rates indicating better preventive care
been more stable, on average (Table 3.4, Chart 3.12). (Aveyard, 1997). However, the interpretation of
The averages conceal considerable variations in admissions as an indicator of quality of care is not
trends. Canadians experienced a reduction in the straightforward, as other external factors such as the
rates of inpatient admissions, falling from about one socio-economic characteristics of the population and
admission for every sixth person in 1970 to one morbidity are important determinants (Giuffrida
admission for every tenth person in 1998. The United et al., 1999). Hospital policies and financial
States was the only other country to experience a incentives facing hospitals (reimbursement systems)
decline. also affect admission rates.

Definition and deviations

Inpatient admissions measure the number of patients who were admitted and stayed at least one
night in inpatient institutions, including nursing homes. Day cases such as same-day surgery are
excluded.
Acute-care admissions are admissions for which the principal clinical intent is to do one or more
of the following: manage labour (obstetrics), cure illness or provide definitive treatment of injury,
perform surgery, relieve symptoms of illness or injury (excluding palliative care), reduce severity of
illness or injury, protect against exacerbation and/or complication of an illness and/or injury which
could threaten life or normal functions, perform diagnostic or therapeutic procedures.
Some countries still define acute-care admissions by a length of stay criterion following earlier
OECD guidance.

34 © OECD 2001
 ADMISSIONS TO HOSPITALS AND NURSING HOMES

Chart 3.9. Inpatient admissions Chart 3.10. Acute-care admissions

per 1 000 population, late 1990s per 1 000 population, late 1990s

Mexico 56.3 Turkey 71

Turkey 73.9 Netherlands 99
Canada 100.6
Canada 99
Japan 101.0
Spain 110
Netherlands 107.8
Spain 113.8 Portugal 119

Portugal 120.0 United States 119

United States 125.3 Ireland 141

New Zealand 132.0
Norway 156
Ireland 144.7
Australia 158
Poland 147.1
Sweden 159
Greece 150.0
United Kingdom 150.9 Switzerland 164

Australia 161.0 Italy 176

Norway 164.8 Belgium 180
Switzerland 169.8
Iceland 181
Italy 180.4
Denmark 190
Sweden 181.0
Czech Republic 190
Denmark 199.9
Belgium 200.0 Germany 201

Czech Republic 202.6 Finland 202

Germany 205.4 France 204
France 230.0
Luxembourg 213
Iceland 232.4
United Kingdom 214
Hungary 237.5
Finland 265.0
Hungary 219

Austria 286.3 Austria 264

0 50 100 150 200 250 300 350 0 50 100 150 200 250 300
Inpatient admissions per 1 000 population Acute-care admissions per 1 000 population

Chart 3.11. Inpatient care admissions Chart 3.12. Acute-care admissions

per 1 000 population, 1970-1998 per 1 000 population, 1980-1998

16 country average Japan Canada 15 country average Turkey Canada

Inpatient admissions per 1 000 population Acute-care admissions per 1 000 population
180 180

160 160

140 140

120 120

100 100

80 80

60 60

40 40

20 20

0 0
1970 72 74 76 78 80 82 84 86 88 90 92 94 96 98 1980 82 84 86 88 90 92 94 96 98

© OECD 2001 35
.

3. HEALTH CARE UTILISATION

Average length of stay in acute care

The average length of stay (ALOS) in hospital Chart 3.14 shows that acute-care ALOS has
has often been treated as an indicator of efficiency. been falling steadily over time for the majority of
All other things being equal, a shorter stay will OECD countries, with the average for 19 countries
reduce the cost per episode. However, length of stay decreasing from 11 days in 1980 to less than 8 days
should only be used with caution as an indicator of by the end of 1990s.
efficiency. If the stay is too short, there may be
adverse effect for treatments or for the comfort and Falling acute length of stay has helped to bring
recovery of the patient. In addition, if a falling length about falling acute bed numbers across many OECD
of stay leads to a rising readmission rate, costs may countries in the past two decades. The number of
fall little or even rise. Also, a shorter stay can transfer acute beds required depends positively both on the
costs to other parts of the health sector or onto admission rate and on average length of stay.
patients and their families. While the evidence on the Admission rates have been fairly stable across many
impact of reductions in length of stay on the quality OECD countries in the past 20 years (Table 3.4).
of services delivered is unclear, recent research in the Hence, falling acute length of stay has been
United States suggests that the extent of cost savings associated mainly with falling acute bed numbers
resulting from length of stay reductions is small. It is (Chart 3.15). The correlation coefficient is 0.51.
the number of patients and not the number of days of Turkey is an exception; its admission rate has been
hospitalisation that appears to be driving costs increasing faster than length of stay has been falling.
(Carey, 2000). Consequently acute beds per 1 000 population have
been rising in Turkey.
Chart 3.13 and Table 3.5 show that wide
disparities exist across OECD countries in terms of It may be possible to improve the comparability
average length of stay for acute care. In the late 1990s, of the data across countries by focussing on
acute-care ALOS varied from 4.5 days in Finland and particular diseases or conditions. Chart 3.16 presents
4.9 days in New Zealand to 10.7 days in Germany and levels and trends in acute-care ALOS for normal
11.4 days in Switzerland. One national study suggests delivery (obstetrics) in a number of OECD countries.
that patient characteristics (age, severity of illness, There are striking variations in ALOS between
income, education, etc.) and hospital characteristics countries. However, in all those for which we can
(workload, physician characteristics) are major make comparisons over time, there have been sharp
determinants of average length of stay (Martin and reductions in length of stay. Length of hospitalisation
Smith, 1996). The evidence presented here suggests for maternity care has become a key issue in some
that additional factors may come into play in countries where some patients have complained
international comparisons. about premature discharge.

Definition
Acute average length of stay (ALOS) refers to the average number of days (with an overnight stay)
that patients spend in an acute-care inpatient institution and is measured by dividing the total number of
days stayed for all patients in acute-care inpatient institutions during a year by the number of
admissions.
Acute care is where the principal clinical intent is to do one or more of the following: manage
labour (obstetric), cure illness or provide definitive treatment of injury, perform surgery, relieve
symptoms of illness or injury (excluding palliative care), reduce severity of illness or injury, protect
against exacerbation and/or complication of an illness and/or injury which could threaten life or normal
functions, perform diagnostic or therapeutic procedures.

36 © OECD 2001
 AVERAGE LENGTH OF STAY IN ACUTE CARE

Chart 3.13. Average length of stay in acute care, Chart 3.14. Average length of stay in acute care,
late 1990s 1980-1998

Finland 4.5 19 country average Korea Austria

New Zealand 4.9 Days
United Kingdom 5 16

Denmark 5.3
14
Turkey 5.4
France 5.5
12
United States 5.9
Iceland 5.9 10
Sweden 6
Norway 6.1 8
Australia 6.2
Ireland 6.5 6
Austria 6.5
Canada 7 4
Italy 7.2
2
Portugal 7.3
Luxembourg 7.7
0
Spain 8 1980 82 84 86 88 90 92 94 96 98
Hungary 8.2
Czech Republic 8.6
Belgium 8.8
Netherlands 9.5
Korea 10
Germany 10.7
Switzerland 11.4

0 2 4 6 8 10 12
Days

Chart 3.15. Average annual rates of change Chart 3.16. Average length of stay
of acute average length of stay and acute beds for normal delivery1
per 1 000 population, 1980-19981
1980 1990 1998
Average annual rate of change
of acute beds (%) Days
3.0 10
9.5
9.2
Correlation coefficient = 0.51 Turkey 9
2.0
8
7.6
1.0 6.9 7
6.8
6.3
5.9 5.8 5.8 6
0 Hungary 5.6
5.4
4.7 5
Germany 4.6
Belgium 4.4
-1.0 4.2 4.1 4.2
3.9 4
Portugal Czech Switzerland 3.8
3.5
3.7
Luxembourg Republic 3.2
United States 3 2.9 2.9 3
-2.0 Netherlands 2.7
France Canada Ireland
2 2 2
Norway Denmark 1.8
Australia
-3.0
1
Finland Sweden
-4.0 0
-4.0 -3.5 -3.0 -2.5 -2.0 -1.5 -1.0 -0.5 0 CHE GBR USA CAN NLD AUS SWE ESP FIN ITA DEU
Average annual rate of change
of acute average length of stay (%) 1. Data for 1980 refers to 1981 for the Netherlands; 1990 data refers
1. Belgium rates are 1980-1997. to 1988 for Germany and 1998 data refers to 1997 for Germany.

© OECD 2001 37
 4. EXPENDITURE ON HEALTH

Health expenditure.................................................................................... 40
Health expenditure in relation to Gross Domestic Product ...................... 42
Responsibility for financing health care ................................................... 44
Pharmaceutical expenditure...................................................................... 46
.

4. EXPENDITURE ON HEALTH

Health expenditure

Rising health expenditure has been a cause of growth in per capita health expenditure, respectively,
concern in most if not all OECD countries for several between 1970 and 1998 among countries which do
decades. Much of the reason for that is that on average not report a break in their expenditure series.
around three quarters of the funding of health Chart 4.4 shows the annual rate of change of
expenditure is public. Hence, rising health expenditure health expenditure per capita for the same 19 country
has added to the burden of taxes and social average. It suggests that on average there has been a
contributions. Chart 4.1 (see also Table 4.1) shows fall in the rate of growth of health expenditure in
how health expenditure per capita, converted to US$ these countries over 28 years. The average annual
using purchasing power parity (PPP) exchange rates, growth rate in the 1970s, sometimes referred to as the
varied across OECD countries in 1998.1 Average decade of “cost explosion” in health care, was 5.8%.
spending was about $1 700 per capita but there was a In the following decade it was 3.3%. Between 1990
more than tenfold variation in the range. and 1998 it was 2.9%.
Chart 4.2 shows how real2 health expenditure There is a suggestion, here, that OECD countries
per capita grew in the 18 countries (listed below in have experienced increasing success with their cost-
Table 4.1) for which we have complete health containment endeavours over time. Previous work at
expenditure data from 1970-1998. Reported health the OECD has identified some of the reforms by
expenditure grew fastest in Norway over this period. which OECD countries succeeded in containing costs
Chart 4.3 shows growth in real health following the 1970s (OECD, 1992 and 1994a). These
expenditure per capita expressed as index numbers included such measures as the adoption of global
for an average across 19 countries and for Norway budgets by many public insurers and the ascendancy
and Denmark which had the highest and lowest of managed care in the United States.

Definition and deviations

Total expenditure on health is the amount spent on health care goods and services plus capital
investment in health care infrastructure. This includes outlays by both public and private sources
(including households) on medical services provided by hospitals, nursing homes, outpatient facilities,
ambulance services, home health care providers, laboratories, pharmacies and other retailers of
therapeutic goods. Also included are outlays on public health and prevention programmes and
administration. Excluded are health-related expenditure such as training, research, environmental health
programmes and water and sanitation projects.
Currently, comprehensive health expenditure estimates for 12 countries are derived from National
Health Accounts (NHA) and comply, for the most part, with the set of classifications and boundaries
outlined in the System of Health Accounts (OECD, 2000). These countries are Australia, Canada, the
Czech Republic, Denmark, Finland, France, Germany, Iceland, Korea, the Netherlands, New Zealand,
and the United States. For countries with no NHA, proxy estimates are reported to the OECD based on
health spending identified in the National Accounts. Estimates derived from NHA generally result in
higher quality reporting to OECD Health Data than is the case in the absence of NHA. Typically,
problems are due to underestimation. In Austria, Sweden, and the United Kingdom, the boundary
between health and social care is drawn differently, thus lowering spending estimates. For Belgium,
Ireland and the United Kingdom, private expenditure is suspected to be underestimated. Luxembourg’s
close social and economic integration with neighbouring countries results in severe estimation
problems with health expenditure. There are significant breaks in the expenditure series for Belgium,
Portugal and Sweden.

1. For an explanation of “purchasing power parity” conversion rates see Annex 2.

2. For a note on “real” comparisons of health expenditure, see Annex 2.

40 © OECD 2001
 HEALTH EXPENDITURE

Chart 4.1. Health expenditure per capita Chart 4.2. Average annual growth rate,
(US$ economy-wide PPP), 1998 real health expenditure per capita, 1970-1998

Turkey 316
Denmark 1.8
Mexico 419
Poland 524 New Zealand 2.5

Hungary 717
Netherlands 2.6
Korea 740
Czech Republic 937 Canada 2.9
Spain 1 194
Finland 3.2
Greece 1 198
Portugal 1 203 Switzerland 3.3
New Zealand 1 440
Australia 3.5
United Kingdom 1 510
Finland 1 510 United Kingdom 3.5
Ireland 1 534
Sweden 1 732 France 3.8

Japan 1 795 Italy 3.9

Italy 1 824
Austria 1 894 Austria 4.0

France 2 043
United States 4.4
Belgium 2 050
Australia 2 085 Japan 4.5
Iceland 2 113
Ireland 4.9
Denmark 2 132
Netherlands 2 150 Spain 4.9
Luxembourg 2 246
Canada Luxembourg 5.2
2 360
Germany 2 361 Iceland 5.3
Switzerland 2 853
United States 4 165
Norway1 5.5

0 500 1 500 2 500 3 500 4 500 0 1 2 3 4 5 6

US$ PPP Average annual growth rate (%)
1. 1970-1997.

Chart 4.3. Real health expenditure per capita, Chart 4.4. Annual growth in real health
deflated by GDP prices, 1970-1998 expenditure per capita, 19 country average,
Index 1970 = 100 1970-1998

19 country average Norway Denmark

Real annual growth in health expenditure
Real health expenditure per capita per capita (%)
450 10

400 9

8
350
7
300
6
250
5
200
4
150
3
100
2

50 1

0 0
1970 72 74 76 78 80 82 84 86 88 90 92 94 96 98 1971 73 75 77 79 81 83 85 87 89 91 93 95 97

© OECD 2001 41
.

4. EXPENDITURE ON HEALTH

Health expenditure in relation to Gross Domestic Product

With issues of affordability and cost relative prices of health services across countries will
containment in mind, it is important to examine how be included in the estimated health expenditure
health expenditure per capita varies with Gross differences. Health services are labour intensive, so
Domestic Product (GDP) per capita between there is a tendency for the relative price of health
countries and over time. If health expenditure per care to be higher where living standards are higher, at
capita rises faster than GDP per capita it will mean least across countries using similar health
that there is a reduced share of GDP for other technology.
desirable goods and services.
Chart 4.5 (see also Table 4.2) shows how
Chart 4.7 shows a well-known relationship expenditure on health varied as a percentage of GDP
which suggests that per capita health expenditure is across OECD countries in 1998. The United States
determined partly by per capita GDP. A logarithmic had the highest share at 12.9%.
relationship has been fitted which means that the
slope of the line can be interpreted as the “income Chart 4.6 shows the change in the health
elasticity” of health expenditure. The “income expenditure share of GDP across OECD countries
elasticity” of health expenditure, here, can be thought between 1970 and 1998. The largest changes, as
of as the responsiveness of health expenditure to reported to the OECD, were in the United States and
changes in national income and is defined as the Switzerland at 6.0% and 5.0% per year, respectively.
percentage change in health expenditure per capita Chart 4.8 shows what has happened to the
divided by the percentage change in GDP per capita. average share of health expenditure in GDP for
The calculated elasticity is about 1.3. That 20 OECD countries between 1970 and 1998. It shows,
corresponds broadly with other estimates of income also, the shares for the countries with the highest and
elasticity from international comparisons (Gerdtham the lowest change in share – the United States and
and Jonsson, 2000). A pure income elasticity relates Denmark, respectively. It can be seen that the rate of
the rise in the volume of health care to the rise in rise in the average share stabilised in the 1990s. This
was partly as a result of the slackening in the rate of
income. However, the estimate here probably
growth of health expenditure (Chart 4.4) and partly as
includes a relative price effect as well as a volume
a result of strong economic growth in the OECD area
effect because health expenditure in national at the time (Table 6.3). It remains to be seen whether
currency units has been converted to US$ using such stabilisation will be maintained in the face of
economy-wide purchasing power parity (PPP) continuing technical change in health care, population
exchange rates, rather than health care-specific PPPs ageing (see Section 6) and any slowdown in economic
(see Annex 2). That means that any differences in the growth.

42 © OECD 2001
 HEALTH EXPENDITURE IN RELATION TO GROSS DOMESTIC PRODUCT

Chart 4.5. Expenditure on health as a percentage Chart 4.6. Change in health expenditure
of Gross Domestic Product, 1998 as a share of Gross Domestic Product, 1970-1998

Turkey 4.8 Denmark 0.3

Korea 5.1
Mexico 5.3 Finland 1.3

Luxembourg 6.0 Netherlands 1.5

Poland 6.4
United Kingdom Ireland 1.7
6.8
Ireland 6.8 United Kingdom 2.3
Hungary 6.8
Canada 2.3
Finland 6.9
Spain 7 Turkey 2.4
Czech Republic 7.1
Luxembourg 2.5
Japan 7.4
Portugal 7.7 Austria 2.7
Sweden 7.9
Japan 2.8
Austria 8
New Zealand 8.1 New Zealand 2.9
Italy 8.2
Australia 2.9
Denmark 8.3
Iceland 8.4 Italy 3.1
Greece 8.4
Spain 3.4
Belgium 8.6
Australia 8.6 Iceland 3.5
Netherlands 8.7
Norway1 3.6
Canada 9.3
France 9.4 France 3.7

Germany 10.3 Switzerland 5.0

Switzerland 10.4
United States 12.9
United States 6.0

0 2 4 6 8 10 12 14 0 1 2 3 4 5 6 7
Percentage of GDP Percentage points
1. 1970-1997.

Chart 4.7. Per capita Gross Domestic Product Chart 4.8. Health expenditure as a percentage
and per capita health expenditure, 1998 of Gross Domestic Product, 1970-1998

20 country average Denmark United States

Log of per capita health expenditure (US$ economy-wide PPP) Percentage of GDP
9.0 14
y = 1.3339x - 5.8538
R2 = 0.9221
8.5 12
AUS USA
CAN
BEL
8.0 CHE
DEU 10
FRA LUX
7.5 ITA SWE DNK
NZL ISL
NLD
8
PRT
7.0 GRC ESP JPN
CZE FIN AUT
HUN KOR 6
IRL GBR
6.5
POL
4
6.0 MEX

5.5
TUR 2

5.0 0
8.6 8.8 9.0 9.2 9.4 9.6 9.8 10.0 10.2 10.4 10.6 10.8 1970 72 74 76 78 80 82 84 86 88 90 92 94 96 98
Log of per capita GDP

© OECD 2001 43
Exploring the Variety of Random
Documents with Different Content
ovat niiden joukossa, ja kun poliisi on oikeutettu luovuttamaan ne
teille, niin te ehkä saatte ne muutaman päivän kuluttua".

Voi, kaikkea tätä virkavaltaisuutta ja virkamiehen turhantarkkuutta!

Kuinka kiitollinen Volenski olikaan, että hän oli siitä riippumaton.
Muutaman päivän kuluttua todellakin! Se aika kuluisi, jos madame
Demidoville ilmoitettaisiin, ja tämä vaatisi kynttilänjalkoja omana
omaisuutenaan. Muutaman päivän kuluttua Volenski toivoi olevansa
Pietarissa palattuaan Lontoosta, ja kohtalokkaat paperit olisi
toimitettu Taranjeville, ja sitten hän itse eroaisi veljeskunnasta. Sen
hän oli vakavasti päättänyt. Viime päivät olivat läksyttäneet häntä
sillä tavalla, että sen unohtamiseen menisi elämän pituinen aika.

"Olen suuressa kiitollisuudenvelassa teidän armollenne", hän

vastasi hieman kuivasti, "niistä vaivoista, joita olette nähnyt tämän
asian takia. Koska minun on pakko lähteä kaupungista muutamaksi
päiväksi, jätän asian nyt tykkänään teidän huostaanne."

"Luullakseni ette voi tehdä paremmin", sanoi paroni von

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"Otaksun", sanoi Ivan koetteeksi, "että madame Demidoville on

ilmoitettu asiasta?"

"Odotan madame Demidovia tänne aamulla, sillä lähetin hänelle

viran puolesta ilmoituksen pyytäen häntä käymään luonani. Hän
palasi Wieniin eilen tutkittuaan Oderbergin läpikotaisin ja päätti antaa
meidän tehdä voitavamme hänen puolestaan."
 "Epäilemättä hän sitten on tuntemassa hänen ylhäisyytensä
kynttilänjalkoja", sanoi Ivan henkäisten helpotuksesta
huomatessaan, ettei madame Demidov kaiken todennäköisyyden
mukaan voisi puhutella Grünebaumia yksityisesti sinä lyhyenä
aikana, joka kuluisi hänen oman käyntinsä ja sitä seuraavan
poliisietsinnän välillä.

Hän otti hattunsa ja kumarsi kohteliaasti rakastettavalle paronille

kiittäen häntä vielä hänen ystävällisyydestään, sitten hän sanoi
nopeasti hyvästi ja poistui pikaisesti.

Kohtalokkaiden paperien etsintä oli täydellisesti vallannut hänen

mielensä. Ivan Volenskin oli mahdotonta ajatella muuta mielettömästi
ajaessaan kadonneita papereita takaa. Hän näytti melkein
unohtaneen Heumarktin vangin olemassaolonkin, Pietarin toverit,
jotka eivät vieläkään olleet kuulleet uutisia, ja ne, jotka olivat
Wienissä, jotka lienevät ihmetelleet, koska ja kuinka hän oikeastaan
oli lähtenyt tärkeälle matkalleen ja kuinka pian heidän manifestinsa
tulisi keisarin käsiin ja Dunajevski ja muut toverit olisivat turvallisesti
rajan takana. He eivät aavistaneetkaan, että koko se rakennus,
johon sosialistinen veljeskunta luotti, voisi millä hetkellä tahansa
murskaantua.

Ja viivyttely… viivyttely oli niin vaarallista! Mitä kreivi Lavrovski oli

tehnyt? Olivatko venäläiset salapoliisit salaliiton jäljillä?
Onnistuisivatko he keksimään vangin, ennenkuin uskaliaasta
ryöstöstä oli millään tavalla hyödytty. Missään tapauksessa ei voisi
seurata muuta kuin vaaroja asialle ja sen kannattajille, kun paperit,
joissa olivat kaikki heidän salaisuutensa, olivat vieraissa käsissä.
Niiden takaisin saaminen merkitsi kaikille elämää tai kuolemaa, ja
tämä ainainen, piintynyt ajatus mielessään Volenski sulloi kokoon
muutamia tarpeellisia esineitä ja oli pian valmis lähtemään
Lontooseen iltapäiväjunassa.

Hänellä oli neljäkymmentätuntia kestävällä Englannin matkallaan

runsaasti aikaa ajatella kaiken tämän juonittelun ja vehkeilyn
hulluutta, joka epäilemättä vei kaikki ne, jotka siihen ryhtyivät,
henkensä ja vapautensa menettämisen vaaraan. Hän itse, jolla oli
runsaita varoja ja loistava ura edessään, kuinka hullu hän olikaan
ollut vaarantaessaan kaikki tulevaisuuden mahdollisuutensa
haaveellisten aatteiden takia, joiden kehittymiseen menisi vielä ehkä
vuosisatoja, mutta joiden parasta ei suinkaan edistettäisi
tyhmänrohkeilla iskuilla, jollaisia Dunajevski, Taranjev ja hänkin
suunnittelivat. Voisiko kourallinen nuoria kiihkoilijoita toimittaa
vallankumouksen Venäjälle, kun musikat, joiden hyväksi he
vehkeilivät, eivät ojentaneet heille auttavaa kättä?

Niin, uudistukset tuohon isoon maahan tulisivat kyllä joskus. Äkkiä

ehkä, kuten Ranskassa, rajusti — ja ne lakaisisivat kuin hirmumyrsky
valtaistuimen ja hallitsijasuvun tieltään — mutta tämä tapahtuisi, kun
kansan hetki olisi tullut, kun kansakunta itse tietäisi, mitä se haluaisi,
kun vapaus-sana lakkaisi olemasta vain muutamain suussa, ja siitä
olisi tullut kaikkien hartain toive. Se olisi aikaa, jolloin kaikki
venäläiset, joilla oli miehen kunto, liittyisivät vapauden puoltajiksi ja
kävisivät valtaistuimen kimppuun, jos se olisi heidän tiellään,
lakaisisivat tieltään hallitsevat mahdit, elleivät ne taipuisi kansan
tahdon mukaan. Mutta siirrettäköön se siksi, kunnes kansa tahtoisi.
Sytyttäköön se kipinän heidän sydämissään, sijoittakoon jumalallinen
käsi aatteen sinne, älköönkä se kytekö hitaasti ja pakonalaisesti
muutamien fanaatikkojen puhaltamana.
 Tällaisten ristiriitaisten ajatusten vallassa oli Volenski saapunut
Englannin pääkaupunkiin. Hän jätti matkalaukkunsa Charing Cross
Terminus-hotelliin aikoen matkustaa Wieniin samana iltana, ja heti
kuin
hän oli haukannut kevyen aamiaisen, hän lähti ajurilla Great Portland
Streetin n:oon 14.

Tällä kerralla hän tunsi maaperän varmaksi. Ei tarvinnut käyttää

apuna diplomaattisia taitojaan. Hän meni suoraa päätä myymälään,
pyysi saada puhutella mr Daviesia ja sanoi tyynesti ja
liikemiesmäisesti kohtalaisen hyvällä englanninkielellä:

"Näin teidän myymälässänne päivä tai pari sitten pari antiikkista

kultaista ja posliinista kynttilänjalkaa, jotka minua silloin miellyttivät.
Silloin minulla ei ollut aikaa niitä katsella, mutta olen sangen
mielissäni, jos näytätte ne minulle. Ne olivat kultaa, ja niissä oli hyvin
sievät vieux Vienne-tekoiset Amorit jousineen ja nuolineen.
Muistatteko niitä, joita tarkoitan?"

"Aivan, herra, aivan. Valitan kuitenkin, etten voi palvella teitä, sillä
myin nuo samat kynttilänjalat eräälle asiakkaalleni myöhään eilen
iltapäivällä. Hän on suuri kaikenlaisten muinaisesineiden keräilijä, ja
kuten teitäkin, häntäkin suuresti viehätti vieux Vienne-Amorien
sirous. Mutta minulla on eräitä sangen kauniita kynttilänjalkoja, sekä
antiikkisia että nykyaikaisia, joita varmaankin haluatte katsella —"

"En", sanoi Volenski, jonka kiihtyneet aivot kieltäytyivät uskomasta

juutalaisen vakuutusta todeksi, "tahdon juuri ne — minun täytyy ne
saada — en välitä siitä, mitä ne maksavat. Kas tässä", hän lisäsi,
kun hän huomasi, että Davies alkoi katsella häntä epäilevästi, "on
wieniläisen liiketoverinne antama suositus, näette siitä, että olen
ystävä, ja jos olette rehellinen minua kohtaan, ei teille tapahdu
mitään ikävyyksiä, mutta jos kieltäydytte auttamasta minua
omaisuuteni takaisinsaamisessa — sillä nuo kynttilänjalat kuuluvat
minulle — niin toimitan niin, että poliisi käy kimppuunne varastettujen
tavarain tallettajana. Tuokaa nyt minulle nuo kynttilänjalat heti ja
mainitkaa minkä hinnan niistä tahdotte. Minulla on kiire, sillä aion
matkustaa pian."

Isaac Davies otti virkaveljensä antaman kortin ja väänteli sitä

käsissään katsellen Volenskia yhä epäilevästi.

"Sanon teille, ettei mitään ikävyyksiä tapahdu teille", sanoi Ivan

kärsimättömästi. "Olenpa halukas maksamaan teille sangen sievän
summankin näistä kynttilänjaloista. Huomaatte siis, että voitte vain
voittaa olemalla rehellinen minua kohtaan. Grünebaum antoi minulle
tämän kortin, jotta teidän ei tarvitsisi mitään pelätä."

"Sir, olen kertonut teille totuuden", sanoi Isaac Davies viimein

kuivasti ja lisäsi kohauttaen välin pitämättömästi olkapäitään: "Teidän
uhkauksenne eivät vaikuta mitään minuun, minua ei voida syyttää
mistään. Grünebaumin liike on hyvä ja tunnettu liike Wienissä.
Minulla on täysi oikeus ostaa häneltä tavaroita ilman, että minun
tarvitsee pelätä saavani varastettua tavaraa. En usko, että
Grünebaumin minulle lähettämät tavarat ovat todellakin varastettuja
ja vaadin teitä osoittamaan väitteenne todeksi. Siis kaikki teille
antamani tiedot johtuvat siitä, että wieniläinen kirjeenvaihtajani on
teitä suositellut, eikä siitä, että pelkäisin teidän uhkauksianne tai
poliisia."

"Siis", huohotti Ivan, joka alkoi käsittää, että juutalainen puhui totta
ja että kynttilänjalat olivat todellakin taas poissa hänen ulottuvillaan,
"kynttilänjalat ovat myydyt".
 "Mr James Hudsonille, jonka osoite on 108 Curzon Street, Mayfair,
suurelle antikviteettien kerääjälle ja erikoistuntijalle. Olette ehkä
kuullutkin puhuttavan hänestä? Ettekö? No, lähetin eilen nämä
kynttilänjalat hänen nähtävikseen, sillä tiesin hyvin, että jos hän ne
näkisi, hän mieltyisi niihin. Ne olivat hyvin kauniita, sir, ja jos teillä
sattuu olemaan jotakin muuta samantapaista, niin olen kovin
mielissäni —"

"Asiaan, mies. Jumalan tähden, kertokaa minulle, ostiko hän ne?"

"Kyllä, sir", sanoi Isaac Davies suuttuneena omituisen asiakkaan

kärsimättömyydestä. "Tiesin, että hän sen tekisi. Mitä nyt voin tehdä
puolestanne, sir? Enkö mitään? Hyvästi, sir."

Ja nähdessään, että hänen myymäläänsä astui uusi asiakas.

Isaac Davies kääntyi eikä enää välittänyt Volenski-parasta, jonka
toiveet tämä uusi kauhea isku murskasi.

Häntä seurasi todellakin huono onni. Aina silloin tällöin toivon säde
pilkisti hänen kurjuutensa pimeyteen, kunnes sen sitten taas jokin
tavaton yllätys karkoitti, ja viimeinen onnettomuus näytti aina
edellistä pahemmalta.

Onnettoman nuoren miehen kärsivällisyys alkoi loppua, ja hän jo

ajatteli heittäytyä ensimmäisen ohiajavan omnibussin alle. Mutta tätä
hän ajatteli vain silmänräpäyksen verran, sillä sitten hän heti käsitti,
että hänen kuolemansa asioiden ollessa sillä asteella merkitsisi
hänen tovereilleen ehdotonta iankaikkista turmiota — varsinkin kun
he eivät olleet tietoisia heitä uhkaavasta vaarasta, koska he eivät
ollenkaan tietäneet, että vaaralliset paperit olivat kadonneet. Yhä
edelleen oli heidän kohtalonsa hänen kylmäverisyytensä,
rohkeutensa ja sitkeytensä vallassa ja hän päätti taas kerran
ponnistaa voimansa pelastaakseen heidät. "Viimeisen kerran", hän
ajatteli toiveikkaasti.

Volenskin täytyi nyt ottaa käytäntöön ovelammat keinot, ja hän

kokosi kaikki voimansa keksiäkseen tällaisen suunnitelman. Hän oli
melkein mekanisesti poistunut juutalaisen puodista, ja tiedottomasti
hän suuntasi askeleensa Curzon Streetia kohden. Hänen täytyi
välttämättä tavata mr James Hudson — siihen kelpaisi mikä tekosyy
tahansa — hän koettaisi keksiä sellaisen. Hänen täytyi heti miettiä
valmiiksi, mitä hän sanoisi mr James Hudsonille, kun hän tapaisi
hänet. Hän tunsi hänet hyvin maineeltaan. Hän oli upporikas, mitä
eriskummallisin mies ja erittäin jalomielinen, ja hän oli ollut suuressa
naisten suosiossa prinssi Albertin aikoina. Epäilemättä hän oli
gentlemanni, ja jos — Niin, se oli selvää. Koko keskustelu välähti läpi
hänen kuumeisten aivojensa, ikäänkuin hän olisi nähnyt sen
näyttämöllä.

Henkilöt: Kohtelias, hyväntahtoinen vanha herrasmies,

nykyaikainen
Bayard-tyyppi — mr James Hudson. Nuori mies, jolla on
menneisyys,
johon sisältyy naisen kunnia — hän itse. Näyttämö: Mayfairissa
Curzon
Streetin varrella olevan talon vierashuone.

Nuori mies, jolla on menneisyys: "Sir, teidän käsissänne on naisen

kunnia. Tahdotteko antaa minulle kirjeen takaisin?"

Kohtelias vanha herrasmies: "Kirjeen, sir, minkä kirjeen?"

N. m. j. o. m.: "Se on kätketty kynttilänjalkaan, joka koristaa teidän

uuninreunustaanne. Sir, monta vuotta sitten hulluttelimme. Teimme
syntiä, hän ja minä. Koska meillä ei ollut minkäänlaista tilaisuutta
lähestyä toisiamme, niin käytimme näitä siroja pieniä esineitä
rakkauden postilaatikkona. Eräs näistä kirjeistä — naisen —
unohdettiin sinne — hän on nyt naimisissa — minä olen naimisissa
— olemme kaikki naimisissa — mutta teidän, sir, hallussanne on
kynttilänjalat — teidän hallussanne on naisen kohtalo! Tahdotteko
antaa minulle takaisin kirjeen?"

Kohtelias vanha herrasmies: "Olkaa hyvä ja ottakaa se — se

kuuluu teille!" Esirippu.

Näkyi selvästi, että Volenski-paran ajatukset olivat nyt melkein

kuin mielipuolen haaveita. Hänen kiihtynyt olemuksensa, hänen rajut
kiihkeät liikkeensä herättivät ohikulkijain huomiota.

Hän ponnisteli hirveästi hillitäkseen itsensä, ja saavuttuaan

Curzon Streetin 18:aan hän soitti kelloa ja kysyi ovea avaavalta
lakeijalta, oliko mr James Hudson kotona.

Hieno otus, jolla oli polvihousut, silkkisukat ja puuteroitu tukka,

silmäsi häntä enemmän kuin kuuden jalan majesteettisesta
korkeudesta ja kysyi, kuten Volenskista tuntui, hyvin hämmästyneellä
äänellä:

"Herra Hudson, sir?"

"Niin, oletteko hyvä ja annatte hänelle korttini, ja sanokaa hänelle,

että haluan puhua hänen kanssaan heti."

"Olen pahoillani, etten voi ottaa korttia, sir", sanoi lakeija vakavasti
ja lisäsi juhlallisesti: "Mr James Hudson kuoli, sir, tänä aamuna äkkiä
kello puoli kolmen aikaan. Kuolema johtui halvauksesta, sir. Hänet
haudataan Highgaten hautausmaahan torstaina, sir, kello
seitsemältä: eikä mitään kukkia, hänen pyynnöstään. Isännöitsijä voi
tavata teitä, sir, jos asianne on tärkeä."

Ääni tuntui Volenskista tulevan äärettömän kaukaa niin kaukaa,

että se kuului sellaiselta, kuin se ei olisi ollut peräisin tästä
maailmasta. Miehen kasvot alkoivat tanssia hänen edessään ja
pyöriä hänen ohitseen peloittavalla nopeudella samoin kuin
huonekalut ja ikkunat. Hänellä oli vain sen verran voimia, että hän
jaksoi käskeä miestä toimittamaan hänelle ajurin, nousta siihen ja
huutaa ajajalle, että tämä veisi hänet Charing Cross Terminus-
hotelliin. Sen jälkeen hän onneksi menetti tajuntansa hetkeksi.
Väsyneet aivoparat kieltäytyivät käsittämästä tätä viimeistä
onnettomuutta, tätä viimeisen toivon menetystä. Volenski ei
ollenkaan voinut muistaa, kuinka hän pääsi huoneeseensa hotelliin
tai mitä tapahtui sitä seuraavina päivinä, sillä hänen tiukkaa
sielullista ja ruumiillista jännitystään seurasi hermoston voipumus.

Hotellista lähetettiin noutamaan lääkäriä, joka asiain niin ollen

katsoi itsellään olevan oikeuden avata Volenskin lompakko, ja kun
hän näki, että se oli täynnä seteleitä ja maksumääräyksiä, niin hän
määräsi häntä hoitamaan pari sairaanhoitajatarta ja määräsi hänelle
kaikkea muutakin, mikä oli välttämätöntä, pääasiassa ehdotonta
rauhaa ja lepoa.
XIV

Sillä aikaa kuin Volenski oli saanut kokea kaikenlaisia vaiheita

kiihkomielisen intonsa takia, hänen toverinsa, Wienin sosialistisen
veljeskunnan jäsenet, olivat eläneet hyvin ankaraa ahdistuksen
aikaa ja pelänneet, mitä tuleman piti.

Nyt oli kulunut viikko siitä, kun Ivan Volenskin oli pitänyt lähteä
Wienistä Pietariin mukanaan hänelle uskotut paperit, eikä tähän
päivään mennessä häneltä ollut tullut mitään tietoja.

Hän oli luvannut antaa heille joitakin uutisia itsestään, heti kuin
hän olisi tullut Pietariin. Jos kaikki olisi ollut oikein, hänen olisi pitänyt
olla siellä jo kaksi päivää sitten, ja nyt hän olisi varmaankin jo
antanut paperit Taranjeville. Miksi hän sitten ei sähköttänyt tai
antanut jotakin selitystä ainakin rauhoittaakseen heitä, että
kohtalokkaat paperit olivat turvassa?

Edellisenä iltana he olivat tavanneet toisensa kokoushuoneessaan

Franzgassen varrella, ja kokous oli ollut synkkä ja kiihkeä. He olivat
jo alkaneet arvella, että heidän rohkean lähettiläänsä osaksi oli tullut
heidän tavallinen kohtalonsa ja että minä päivänä tahansa, millä
hetkellä tahansa, heidän päälleen voisi langeta musertava isku.
 Kun kerran heidän paperinsa olisivat kolmannen osaston käsissä,
niin heistä tuskin kukaan onnistuisi pakenemaan. Ja
kuolemanpelkoakin kiusallisempaa ja katkerampaa olisi se, että
heidän niin suurenmoisesti suunniteltu ja niin rohkeasti toteutettu
salahankkeensa päättyisikin pelkästään vain heidän omaan
turmioonsa, eikä kaikesta voitettaisi muuta, kuin että vankijoukkue
saisi tallustella Siperiaan.

Ellei —

Niin! Oli olemassa "ellei", julma ja jylhä vaihtoehto, huolimatta

presidentin melkein rukoilevista puheista, huolimatta useimpien
paremmasta ja jalostuneemmasta minästä, ja se oli verkalleen,
mutta varmasti tunkeutunut heidän tajuntaansa. Mirkovitsh oli
pakottanut heidät sitä ajattelemaan jo viisi päivää sitten, kun he
menestyksensä innostamina eivät olleet muistaneet muuta kuin
suurta päämääräänsä. Nyt kun heidän menestyksensä tuntui
olemattomalta, kun kaikki oli ehkä mennyt hunningolle, nyt he
ajattelivat jälleen vanhan toverinsa julmia sanoja, ja he alkoivat
himoita kostoa.

Puheenjohtaja oli pyytänyt heitä kokoontumaan taas tänä iltana, ja

kello kymmenen tienoissa he pujahtivat sisään innokkaina
kuulemaan uutisia.

"Onko mitään saatu tietää?" sanoi jokainen sisään tullessaan, ja

kun heille synkästi vastattiin kieltävästi, niin alettiin ottaa piippuja
esiin ja polteltiin äreän vaiteliaina.

Puheenjohtaja oli saapunut sulavakäytöksisenä ja hillittynä kuten

tavallista, mutta hänenkin kasvoillaan näkyi syvän huolestumisen
ilme, minkä hän nähtävästi yritti kätkeä nuoremmilta tovereiltaan.
Aina silloin tällöin hän katsoi tuskallisesti ovelle, mistä luultavasti
piankin kuuluisivat Mirkovitshin askeleet.

Viimeksimainittu ei vielä ollut saapunut. Eilen hän oli näyttänyt

yrmeämmältä ja jörömmältä kuin milloinkaan. Toisin kuin muut
veljeskunnan jäsenet ei hän näyttänyt mitenkään olevan huolissaan
Ivanin ja hänen mahdollisen kohtalonsa johdosta. Hänen
ajatuksensa kohdistuivat yhä tyytyväisempinä kauheaan
päämäärään, jonka hän toivoi piankin saavuttavansa. Hän ei vielä
ollut puhunut julki niitä ajatuksia, joiden hän jo tiesi kangastelevan
synkkinä kaikkien mielissä ja jotka olivat saaneet hänet täydellisesti
valtoihinsa. Mutta tänä iltana hän aikoi pyytää heidän
suostumustaan, ja hän huomasi astuessaan huoneeseen ja
nähdessään kaikkien katsannon, että hänen voittonsa olisi helppo.
Hän oli pitänyt huolta siitä, että siemen oli kylvetty ajoissa. Tänä
iltana hän aikoi korjata sadon.

Maria Stefanovna oli hänen mukanaan. Nyt he uskoivat hänelle

veljeskunnan salaisuudet. Hänen oopperanaamiaisissa niin
menestyksellisesti ja niin varovaisesti näyttelemänsä osa oli
todistanut heille, että hänenlaisensa nainen voi usein olla arvokas
apuri miesten toimissa.

Tyttö tuli sisään isänsä kanssa, ja tervehdittyään niitä, jotka olivat

hänelle kokouksen jäsenistä tutuimpia, hän myöskin sytytti lyhyen
savukkeen ja odotti, mitä kaikilla oli sanomista.

"Mirkovitsh, oletteko kuullut mitään Volenskista?" kysyi yht’aikaa

kymmenkunta ääntä.

"En", hän vastasi, "luulin, että puheenjohtajalla tai jollakulla

komitean jäsenellä olisi ollut tällä hetkellä häneltä jokin sanoma".
 Syntyi hiljaisuus. Sitten sanoi eräs juro ääni:

"Svietlitzki sanoo, että paavin lähettiläs ei ollenkaan mennyt

Pietariin, vaan että hän on oleskellut Tirolissa viime viikon."

"Mutta Ivanhan sanoi, että hän lähtisi hänen kanssaan seuraavana

päivänä, piinaviikon keskiviikkona."

"Varmaankin —"

"Ei!" keskeytti puheenjohtaja, "sitä ei tarvitse pelätä".

"Tarkoitatteko, että hän on joutunut poliisin kynsiin?"

"Se on mahdotonta", sanoi puheenjohtaja varmana, "sillä nyt

emme kaikki istuisi täällä rauhassa. Meitä kaikkia voitaisiin syyttää
rikoksesta, ja tällä hetkellä luullakseni useimmat meistä olisi vangittu.
Juuri se seikka, että me olemme kaikki vielä vapaita miehiä, osoittaa,
että paperimme ovat turvassa."

"Paperimme voivat kyllä olla, mutta kuinka ovat lähettiläämme

asiat?" puuttui puheeseen eräs veljistä.

"Tarkoitatteko, että hän ennen vangitsemistaan on ehkä hävittänyt

paperit?" sanoi toinen.

"Olen varma", sanoi eräs vanha mies, "että Ivan ennen luopuisi
hengestään kuin salaisuudestamme".

Huoneessa syntyi taas hiljaisuus. Mirkovitshin silmät kiersivät

pilkallisina, melkein halveksuvaisina miehestä mieheen. Maria
Stefanovna ei millään tavalla ottanut osaa näiden monien
otaksumien ja päätelmien tekemiseen. Hän istui tarkkaavaisesti
kuunnellen kaikkea, mitä hänen ympärillään puhuttiin, mutta hänen
silmänsä kohdistuivat aina silloin tällöin omituisen tuskaisesti ja
levottomasti hänen isäänsä, joka istui häntä vastapäätä.

"Eikö teistä tunnu omituiselta, hyvät ystävät", sanoi Mirkovitsh

viimein pilkallisesti, "että meidän on aivan mahdotonta, noin
kahdeksansadan mailin päästä, päättää mitään varmaa siitä, mitä on
Volenskille tapahtunut?"

Asia oli sillä tavalla, ja se tuntui omituiselta, ja kuitenkin tuotti

asiain selvitys hiukan tyydytystäkin, kun naapurin kanssa tehtiin
epämääräisiä olettamuksia ja kuultiin, minkälaisia olivat muiden
toverien ajatukset ja pelonaiheet, ja silloin tällöin saatiin rauhalliselta
puheenjohtajalta kuulla tyynnyttävä huomautus.

"Minä puolestani", sanoi Mirkovitsh, "ajattelen, että Volenskin

vaitiolo on kovin pahaenteistä. Ei olisi voinut olla mitään vaaraa
siinä, että hän olisi lähettänyt sähkösanoman puheenjohtajalle —
jonka tiedetään olevan hänen hyvän ystävänsä —, missä
sähkösanomassa hän olisi ilmoittanut saapumisestaan Pietariin. Jos
hän olisi päättänyt matkansa vaaroitta, niin aivan varmasti
puheenjohtaja olisi saanut siitä tiedon."

Puheenjohtaja katsoi tuskaisesti toveriinsa ja ojensi kätensä häntä

kohden, ikäänkuin hän olisi yrittänyt estää häntä jatkamasta, mitä
hänellä oli sanomista.

"Puhu, Mirkovitsh, sinullahan on jotakin mielessäsi", sanoi eräs

komitean jäsen, ja kaikilta suunnilta kuului: "Antaa kuulua!"

Maria Stefanovna samoin kuin puheenjohtajakin teki liikkeen,

ikäänkuin hän olisi tahtonut keskeyttää isänsä, mutta ehkä hän
huomasi sellaisen yrityksen hyödyttömyyden, sillä hän ryhtyi taas
polttamaan savukettaan ja istui tuskaisen odottavana kuten
ennenkin.

"Se, mitä minulla on sanottavana, kuten tiedätte, ei varmaankaan

ole monestakaan teistä hauskaa kuulla", sanoi Mirkovitsh, joka oli
nyt noussut seisoalleen ojentuen koko pituuteensa ja katsoi
kokoontuneisiin tovereihinsa ikäänkuin tornista hymyillen
halveksuvasti, kuten hänen tapansa oli. "Nähkääs, useimmat teistä
ovat onnettomuudekseen syntyneet herrasmiehinä. Mutta minä en
ole, ja sentähden minun paksuun, alhaiseen päähäni ei mahdu
mitään sellaisia tunteita, joita nimitätte jalostuneiksi. Hyvät ystävät,
vaikka lienettekin herrasmiehiä, älkää silti olko heikkoja ja
saamattomia kuten yhteiskuntaluokkaanne kuuluvat. Jumalan
tähden, katselkaa asioita, niinkuin ne ovat, ja koettakaa unhottaa
itsenne ja omat kiltit tunteenne maamme ja kansamme takia, joita
palvelemme. Ette tahtoneet kuulla minua aikaisemmin, vastoin
neuvoani käytitte mahtavaa, menestyksellistä suunnitelmaamme
vaivaiseen tarkoitukseen, toveriemme vankilasta vapauttamiseen.
Sanonpa teille", hän sanoi painavasti laskien voimakkaan nyrkkinsä
pöydälle, "että Venäjällä kaikki tahtovat kuolla hyvän asian puolesta.
He eivät kuten me rakasta elämää ja vapautta. He rakastavat ensin
aatetta eivätkä itseään ollenkaan. Miksi välittäisimme siitä, mitä on
tapahtunut Volenskille? Mitä merkitsee yksi mies, kun on
kysymyksessä miljoonien paras?"

Hän näytti nyt olevan haltioitunut, hän näytti ihannemaailman

profeetalta, jonka aate oli heidän kaikkien sydämissään, ja sen
olisivat jotkut heistä toteuttaneet hyvin hellävaroen, mutta tämä mies
tahtoi valloittaa utopiansa maan tulella ja miekalla.
 He tiesivät kaikki, mitä he kuulisivat hänen ehdottavan. He tiesivät,
mitä Mirkovitsh oli koko ajan tahtonut heidän tekevän. Monet heistä
olisivat mielellään tukkineet korvansa, jotta heidän ei olisi tarvinnut
kuulla pelättyä uhkavaatimusta, jota tämä voimakas mies
seuraavassa hetkessä heille tyrkyttäisi.

"Me olemme usein pitäneet täällä puheita", jatkoi Mirkovitsh taas,

"terästääksemme intoamme tyranneja vastaan, jotka pitävät
kämmenellään meidän ja kansalaistoveriemme kohtaloita. En ole
mikään puhuja. Puheet eivät luista minulta. Jotkut teistä, jotka
tänään näyttävät heikoimmilla, puhuivat silloin äänekkäimmin. Mutta
minä sanon teille, että meillä on oivallinen ase käsissämme heitä
vastaan, ja se ase tulee ennemmin tai myöhemmin vaivuttamaan
heidät voimattomina jalkojemme juureen, ja he pyytävät armoa, jota
he eivät milloinkaan ole meille suoneet.

"Se ase on pelko. Herättäkäämme heissä valtaavaa kauhua, hyvät

ystävät, muulla tavalla heihin ei voi iskeä. Kun voimme, niin
iskekäämme salakähmäisesti, aina nopeasti ja varmasti, niin että he
lähiaikoina piankin silmäilevät toisiaan kasvot kalpeina ja värisevin
huulin ja kuiskaavat, mitä he eivät uskalla sanoa kovaa: ’Ehkä
seuraavalla kerralla on minun vuoroni.' Sillä tavalla, vain sillä tavalla
meistä tulee heidän herrojaan, kun raukkamainen pelko panee
heidät matelemaan jalkojemme juuressa. Silloin me voimme sanella,
silloin me voimme hieroa kauppoja, ja mitä merkitsee sitä ennen
Dunajevski tai Volenski tai sadat muut? Mitä merkitsevät heidän
elämänsä, että me epäröisimme hetkeäkään käyttämästä asetta,
jonka omalla avullamme olemme itsellemme hankkineet?"

Hän istuutui taas, ja hänen puhettaan seurasi kuolettava

hiljaisuus. Läsnäolijain synkillä kasvoilla näkyi taas hehkuva
innostus, taaskin oli tuo rautaisen tahdon omaava mies saanut
heikommat toverinsa innostumaan, ja kun hänen pilkallinen
katseensa jälleen kiersi ympäri huonetta hän saattoi lukea edessään
olevien kasvoilta voimakkaan puheensa vaikutuksen. Hän luki sen
siitä, että tuskalliset katseet verkalleen hälvenivät, samoin
kauhunkuvat, joista ei puhuttu. Hän luki sen nuorista unelmoivista
silmistä, joissa taas paloi innostuksen hehku, urhoollisten tekojen
kaiho, hengen ja vapauden uhallakin.

"Mirkovitsh on oikeassa", sanoivat kaikki.

Ehkä jotkut heistä vieläkin värisivät ajatellessaan, mitä hänen

aikeensa merkitsivät Heumarktin vangille, mutta vain muutama niin
teki, ja kun puheenjohtajan tuskaiset ja Mirkovitshin riemuitsevat
silmät tarkastelivat kaikkien läsnäolevien kasvoja, niin he tunsivat,
että jos julman sosialistin ehdotuksesta äänestettäisiin, niin tulisi
monta hyväksyvää ääntä ja vain muutamia kieltäviä.

"Siis, hyvät ystävät", jatkoi roteva venäläinen laskien nyt valttinsa

pöydälle, "olen varma, että jos teiltä kysyttäisiin, niin ei teistä kukaan
tahtoisi, että suurenmoinen hankkeemme ajaisi häpeällisesti karille,
kun Venäjän poliisi vapauttaisi vankimme ja kaikki meidät
tuomittaisiin ilman, että olisimme saavuttaneet mitään, vaikka
olemme niin paljon uskaltaneet. Millä hetkellä tahansa, millä
minuutilla tahansa voimme kaikki olla kolmannen osaston kynsissä,
samalla kuin Nikolai Aleksandrovitsh poistuu talostani
vahingoittumatta. Jokaisena sekuntina vaaramme kasvavat ja
voitonmahdollisuutemme pienenevät. Ainakin jos sorrumme, sillä
tuntuu siltä, ettemme voi päästä pakenemaan ilmitulematta, niin
toimittakaamme jotakin, joka ikuisiksi ajoiksi tuottaa kunniaa
nimellemme jokaisen venäläisen isänmaanystävän silmissä."
 Siten vahvistettiin vangin tuomio; Keskustelu muodostui
vähäiseksi. Vastahakoisesti, mutta kuitenkin yksimielisesti he olivat
antaneet suostumuksensa pelkurimaiseen tekoon, jonka Mirkovitsh
niin mielellään tarjoutui suorittamaan heidän puolestaan. Muutamat
heistä pyysivät lykkäystä — yhden vuorokauden — jonka kuluessa
voisi sittenkin Volenskista tulla joitakin tietoja. Vanha sosialisti, joka
oli tyytyväinen päästessään tarkoitustensa perille, suostui mielellään
odottamaan seuraavaan päivään asti, ja lopullinen istunto määrättiin
sentähden seuraavaksi päiväksi ja samaksi ajaksi. Puheenjohtaja ei
ollut sanonut mitään. Hänen vaikutusvaltansa oli vähäinen julmaan
toveriinsa nähden. Tunteen vaihtelut, velvollisuus, josta erehdyttiin,
ja väärälle tolalle joutunut into olivat ratkaisseet nuoren tsaarin pojan
kohtalon.

Päättämättömyyden taakka tuntui häipyneen kaikkien hartioilta.

Vaikka he eivät tupakoineet eivätkä rupatelleet tapansa mukaan, niin
heidän synkkyytensä oli kokonaan vaihtunut ehdottomaan
päättäväisyyteen. Ei enää esitetty kysymyksiä eikä olettamuksia
Volenskin kohtalosta tai heidän omasta varmasta kohtalostaan.
Kerran oli mainittu sana "salamurha", ja sen olivat monet huulet
lausuneet väristen. Nyt sitä nimitettiin "mestaukseksi". Mirkovitsh oli
mielellään pyöveli. He olivat tuomareita, jotka olivat vanginneet ja
tuominneet vangin, aivan samoin kuin heidän tyranninsa tekivät
niihin miljooniin nähden, joita he hallitsivat.

Puolta tuntia myöhemmin he kaikki lähtivät maltillisina ja hiljaisina

ajatellen suurta huomispäivää. Ei kukaan ollut huomannut
paljonkaan Maria Stefanovnaa, jonka isot tummat silmät olivat
kiintyneet hänen isäänsä ikäänkuin lumottuina. Kun useimmat heistä
olivat menneet, hänkin poistui huoneesta odottamatta, seurasiko
Mirkovitsh häntä, kun hän riensi hänen ohitseen. Kadulla hän kutsui
ajurin, astui siihen yksin ja ajoi nopeasti Heumarktin suuntaan.
XV

Maria Stefanovnan asema suuressa sosialistisessa veljeskunnassa

oli omituinen. Vaikka hän olikin ainoa nainen niin monen miehen
joukossa, niin hän kuitenkin tiesi kaikki heidän salaisuutensa ja
hankkeensa, ja vaikka hän olikin nuori, niin hänen neuvonsa olivat
heitä usein auttaneet.

Hänen isänsä Mirkovitsh oli jo varhain totuttanut äidittömän

tyttärensä salaperäisiin tapoihinsa ja omituisin raskasmielisiin
puheisiinsa. Maria oli syntynyt ja kasvanut vihaamaan hallitusta, joka
istui Venäjän valtaistuimella, ja hän kuunteli isänsä useinkin
verenhimoisia tuumia aina vaiteliaan hyväksyväisenä, vaikka hän ei
aina ollutkaan aivan samaa mieltä.

Kun veljeskunta tarkasti mietittyään oli päättänyt uskoa hänelle

mitä tärkeimmän osan tsaarin pojan ryöstämisessä, niin hän tunsi
itsensä ylpeäksi ja onnelliseksi ajatellessaan, että hän ensi kertaa
olisi hyödyksi suurelle asialle, joka oli yhtä suuresti hänen
sydämellään kuin innostuneimmilla heistä. Kun Dunajevski ja hänen
toverinsa oli vangittu, niin kerrottiin tytölle kauheista kidutuksista,
joiden alaisiksi he joutuisivat, kun he olisivat Moskovassa
vankeudessa, ja myöhemmin, kun he saisivat vaeltaa rasittavan
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