The Impact of the COVID-19 Pandemic on the Financial Situation
of Hospitals in Europe
WOJCIECH NARUĆ
Institute of Economics and Finance,
University of Szczecin,
A. Mickiewicza 64, Szczecin,
POLAND
Abstract: Since 2020, the world has been facing a global pandemic of the infectious disease COVID-19 caused
by the coronavirus SARS-CoV-2. It has a negative impact not only on the economy of individual countries, but
also on the financial and property situation of business entities, and thus on the lives of hundreds of millions of
people around the world. The aim of this article is to present the results of the study and an assessment in terms
of the impact of the COVID-19 pandemic on the development of the financial situation of hospitals in Europe
after the first year of the pandemic in relation to the situation several years before the pandemic. The study
covered the period from 2017 to 2020. An economic analysis based on basic statistical characteristics was
conducted using the financial data of a survey population of 8,995 private and public hospital operating
companies in Europe, including 2,769 from Western Europe and 6,226 from Eastern Europe. The research
hypothesis was confirmed only for operating income (turnover), current ratio and solvency ratio, while it was
not confirmed for asset situation. For the other analyzed economic quantities, heterogeneous results were
obtained depending on the region of Europe in which the hospital is located.
Key-Words: functioning of public and private enterprises, finance company, financial liquidity, COVID-19
pandemic
Received: August 2, 2022. Revised: September 9, 2022. Accepted: September 27, 2022. Available online: October 21, 2022.
1 Introduction
For more than two years, the world has been facing
a global pandemic of the infectious disease COVID-
19 caused by the coronavirus SARS-CoV-2. Since
Chinese authorities informed the World Health
Organization (WHO) of the first case of pneumonia
(December 2019), the lives of millions of people
around the world have been significantly altered.
The coronavirus has spread rapidly around the
world, leading to the first pandemic of the 21st
century, [1]. The COVID-19 pandemic is considered
one of the most important and dangerous economic
and social events in decades. It has a negative
impact not only on the economies of individual
countries, but also on the financial situation of
business entities, and thus on the lives of hundreds
of millions of people around the world. Businesses
around the world have experienced the severe or
unsustainable negative impact of the pandemic, with
a reduction in the volume of orders received for
goods sold and increasing problems with payment
bottlenecks resulting in a deterioration or loss of
liquidity. Not all entities survived the first year of
the pandemic. In industries where this was possible,
employers introduced remote work and moved
processes to online platforms.
State administrations, following the guidelines
and recommendations of the WHO, were forced to
introduce a number of restrictions aimed at limiting
the spread of the virus. They have had to adapt to
the health, economic and social challenges created
by the pandemic, [1]. These circumstances have
contributed to the curtailment of many civil liberties
and freedoms related to broad economic, cultural
and social activities. Several studies conducted
during the first period of the pandemic in many
countries have shown that people were deeply
concerned about the impact of COVID-19, both
from a health and economic perspective, [3].
Unexpected changes in health care have occurred
and continue to evolve, [4]. The pandemic has had a
significant impact on restricting access to healthcare
services, as well as on the financial and asset
situation of hospitals.
In the first period of the COVID-19 pandemic,
many studies were published on the impact of the
pandemic on business. ‘The studies focused on
logistics blocks, labor shortages, and drops in
demand, business risk, corporate resiliency, or
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financial support and subsidies’, [1]. Unfortunately,
little research has been done on the impact of the
pandemic on the financial situation of hospitals.
And it was the pandemic that had a significant
impact on reduced access to health care services,
[6], as well as on the financial and asset situation of
hospitals.
With this in mind, the purpose of this article is to
present the results of the study and evaluate in terms
of the impact of the COVID-19 pandemic on
changes in the financial situation of hospitals in
Europe after the first year of the pandemic
compared to the situation several years before the
pandemic. The study covered the three years before
the pandemic (2017-2019) and the first full year
with the pandemic (2020). The study was conducted
using financial data obtained through the Orbis
database (Bureau van Dijk Electronic Publishing
Ltd., A Moody’s Analytics Company). The analysis
used financial data from a surveyed population of
8,995 private and public hospital operators in
Europe reporting separate financial statements;
among them 2,769 from Western Europe and 6,226
from Eastern Europe. The study included hospitals
that reported operating revenues of more than
€50,000 in the year prior to the pandemic, i.e. 2019.
It was hypothesized that the financial situation of
hospital operators in Europe deteriorated due to the
reduction in the range of the provided medical
services forced by the spread of the COVID-19
pandemic.
2 The Effects of the Pandemic in
Europe
The first confirmed cases of COVID-19 coronavirus
in Europe were reported to WHO and registered
with a date of 4/01/2020. They concerned Finland
and Germany. Further cases were confirmed in the
following European countries: Spain (11/01/2020),
France (25/01/2020), Italy (29/01/2020), Russia
(31/01/2020) and Sweden (31/01/2020). In the first
month of the pandemic in Europe, the first cases of
coronavirus appeared in 7 countries (11.3% of
European countries) and involved a total of 25
people. One month later, coronavirus was already
present in 26 European countries (41.9%) and
involved a total of 1 265 people. At the end of
March 2020, coronavirus cases were already
confirmed in 60 out of 62 European countries
(96.8%). The WHO includes 62 countries in the
Europe Region, not all of which are geographically
located on the European continent. In Europe,
391,884 people were affected by the COVID-19
coronavirus as of 31/03/2020, while at the end of
April there were already 1,372,517 Europeans.
The first confirmed fatal case of COVID-19
coronavirus in Europe was reported to WHO and
registered on 13/02/2020 and involved a resident of
Spain. Further fatal cases have been confirmed in
the following European countries: France
(15/02/2020), Germany (21/02/2020), Italy
(23/02/2020) and San Marino (29/02/2020). At the
end of February in Europe, the first fatal
coronavirus cases occurred in 5 countries (8.1% of
European countries) and involved a total of 26
people. By 29/02/2020, the share of deaths due to
COVID-19 infection was 2.1%. By the end of April
2020 - when fatal cases were already present in 56
of 62 European countries (90.3%) - the rate
exceeded 10.3%.
During the first 2.5 years of the COVID-19
pandemic, the pattern of infections or deaths caused
by coronavirus varied from period to period and
location to location. Despite the vaccination
programs launched worldwide, the number of
confirmed coronavirus cases has been increasing in
consecutive years, although the rate of increase has
slowed markedly in recent months. In 2021, there
were 204.2 million confirmed cases worldwide,
which is 146.3% higher than in the preceding year.
At the beginning of October 2022, there were
already 328.7 million confirmed cases (all figures
given in this article for 2022 relate to the period up
to 04/10/2022) [Table 1]. This is an increase of
61.0% over the entire year of 2021.
Table 1. Confirmed cases of COVID-19 infection,
by WHO Region (in persons)
WHO Region
Cases of COVID-19
2022a)
2020
Global
328 740 513
82 880 441
Europe
152 316 331
27 212 761
46.3%
32.8%
Other regions
176 424 182
55 667 680
53.7%
67.2%
WHO Region
Cumulative data
2020-2022a)
2020-2021
Global
615 777 700
287 037 187
Europe
254 406 585
102 090 254
41.3%
35.6%
Other regions
361 371 115
184 946 933
58.7%
64.4%
Note: a) Figures as at 04/10/2022.
Source: Own study based on statistical data obtained
from covid19.who.int.
For Europe, the increase is greater than globally
[Table 1, 2]. In 2021, there were 74.9 million
confirmed cases, 175.2% more than the previous
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year. In contrast, until the beginning of October,
152.3 million confirmed cases have already been
reported. This is an increase of 103.4% over the
entire year of 2021. Data for each successive year of
the pandemic show that the proportion of confirmed
coronavirus cases in Europe compared to the rest of
the world increased from 32.8% in 2020 to 36.7% in
the following period and to 46.3% in 2022.
Table 2. Confirmed deaths of COVID-19 infection,
by WHO Region (in persons)
WHO Region
Deaths of COVID-19
2021
2020
Global
3 520 514
1 927 947
Europe
1 078 138
604 756
30.6%
31.4%
Other regions
2 442 376
1 323 191
69.4%
68.6%
WHO Region
Cumulative data
2020-2022a)
2020-2021
Global
6 527 192
5 448 461
Europe
2 095 729
1 682 894
32.1%
30.9%
Other regions
4 431 463
3 765 567
67.9%
69.1%
Note: a) Figures as at 04/10/2022.
Source: Own study based on statistical data obtained
from covid19.who.int.
Likewise, the situation in Europe is similar in terms
of fatalities, although a clear downward trend is
evident, thanks to the vaccination programs
launched in 2021 and continuing in the subsequent
period. The proportion of confirmed coronavirus
fatalities in Europe compared to the rest of the
world increases from 31.4% in 2020 to 38.3% in
2022, despite a slight decrease in 2021 [Table 2].
In 2021, 1.08 million confirmed cases were
recorded, which was 78.3% more than in the
preceding year. In contrast, 412.8 thousand
confirmed deaths were recorded until the beginning
of October. This is a decrease of 61.7% over the
entire year of 2021.
As at 04/10/2022, the cumulative number of
confirmed coronavirus cases worldwide is 615.8
million people, of which Europe accounts for 254.4
million people, or 41.3% of the total world
population. In contrast, the cumulative number of
confirmed coronavirus deaths worldwide as at
04/10/2022 is 6.5 million people of which Europe
accounts for 2.1 million people, that is 32.1% of the
total world population. Compared to the world
population, European countries perform better in the
treatment of coronavirus patients, as reflected by the
lower proportion of European countries in mortality
in relation to recorded cases of infection with the
virus. This is also confirmed by the data presented
in Table 3, which shows that the death rates in cases
of COVID-19 infection (both annual and
cumulative) are more favorable for Europe than for
the world as a whole and other regions.
Table 3. Participation deaths in cases of COVID-19
infection, by WHO Region
WHO
Region
Annual data
Cumulative data
2022a)
2021
2020
2020-22a)
2020-21
Global
0.3%
1.7%
2.3%
1.1%
1.9%
Europe
0.3%
1.4%
2.2%
0.8%
1.6%
Other regions
0.4%
1.9%
2.4%
1.2%
2.0%
Note: a) Figures as at 04/10/2022.
Source: Own study based on statistical data obtained
from covid19.who.int.
Since the end of March 2022, the number of new
cases and deaths of COVID-19 worldwide has been
steadily decreasing. This also applies to the
European region, [7][7]. This effect could have
been achieved much earlier, as evidenced by the
theoretical mathematical models presented in the
study conducted by G. Makanda, [8]. The European
Commission is coordinating a joint European
response to the coronavirus pandemic. It is taking
action to strengthen the public health sector and
mitigate the socio-economic impact of coronavirus
in the European Union, [9].
3 Methodology and Research Sample
The aim of the conducted research was to assess the
impact of the COVID-19 pandemic on the
development of the financial situation of hospitals in
Europe after the first year of the pandemic in
relation to the situation several years before the
pandemic. It was hypothesized that the financial
situation of hospital operating companies in Europe
deteriorated due to the reduction in the range of
medical services forced by the spread of COVID-19.
The study covered the three years before the
pandemic (2017-2019) and the first entire year with
the pandemic (2020). The study was conducted
using financial data obtained through the Orbis
database. The study material included businesses
involved in hospital activities in 44 European
countries classified in the Orbis database, including
23 from Western Europe and 21 from Eastern
Europe.
The Orbis database identified a general
population (N) of 57,722 entities from Europe
operating hospitals and preparing separate financial
statements. The research population was selected
from the hospitals that form the general population
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that: provided full or incomplete financial data for
2017-2019 and full financial data for 2020 and
reported operating revenues of more than €50,000 in
2019. The final study population was 8,995
hospitals, including 2,769 hospital operators in one
of 19 Western European (EC) countries and 6,226
hospital operators in one of 17 Eastern European
(CEE) countries. Due to the lack of complete
financial data for 2017-2020 on entities conducting
medical activities, 4 entities categorized as Western
European countries (Cyprus, Malta, Monaco,
Turkey) and 4 entities categorized as Eastern
European countries (Albania, Belarus, Kosovo,
Moldova) were not included in the study.
The analysis of selected economic quantities was
carried out using statistical methods aimed at
summarizing the obtained set of data and drawing
basic conclusions about the general population.
These entities will be hereinafter referred to as the
"research sample" (n).
In order to ensure that the characteristics of the
general population are adequately reflected,
a minimum sample size has been established. Its
value is influenced by the size of the general
population, the assumed confidence level of the
estimate determined by taking a certain value of the
confidence coefficient, as well as the assumed
absolute precision of the estimate, considering the
maximum level of measurement, which is equal to
half the length of the entire confidence interval.
To determine the minimum research sample size
n, under the assumptions that:
• the selected general population has a size of
N=57,722,
• the value of the standardized random variable of
normal distribution N(0.1) assumes the level
µα=1.96, [10], [11],
• the precision of the estimation (maximum error)
was assumed to be d=3.55%,
the following formula was used, [12]:


󰇛󰇜 (1)
where:
nmin – minimum size of the research sample,
μα – the value of a random variable of normal
distribution N(0.1) when the confidence level
P=1-α is 0.95,
N – general population size,
d – accuracy of the estimate.
Performing calculations based on the presented
formula, the result of the minimum size of the
research sample was obtained, amounting to
nmin=753,41. This means that, with the assumptions
made, the survey should be carried out based on the
financial statements of at least 753 business units.
From the point of view of assessing the minimum
sample size, the research sample size of n=8,995
makes it possible to use the results of the study for
inference with translation to the entire general
population (N=57,722). The analyzed research
sample represented 15.6% of the general population.
If we compare cases of COVID-19 infection with
deaths of COVID-19 infection and with the
participation rate of deaths in cases of COVID-19
infection, we can see that Western Europe (WE)
differs significantly from Eastern Europe (CEE). As
this may also have an impact on the financial
situation of hospital operators, the study was carried
out considering the division of companies into those
with operations in Eastern and Western Europe.
Table 4. Confirmed cases of COVID-19 infection in
the countries of the research sample (in persons)
Region
Cases of COVID-19
2022a)
2021
2020
Europe
128 809 289
52 284 964
20 652 337
Eastern Europe
24 168 600
20 913 286
8 678 186
18.8%
40.0%
42.0%
Western Europe
104 640 689
31 371 678
11 974 151
81.2%
60.0%
58.0%
Region
Cumulative data
2020-2022a)
2020-2021
Europe
201 746 590
72 937 301
Eastern Europe
53 760 072
29 591 472
26.6%
40.6%
Western Europe
147 986 518
43 345 829
73.4%
59.4%
Note: a) Figures as at 04/10/2022.
Source: Own study based on statistical data obtained
from covid19.who.int.
According to Trading Economics, the population of
the research sample at the end of the first year of the
pandemic was 730.4 million people, including 425.0
million people from Western Europe (58.2%) and
305.4 million people from Eastern Europe (41.8%).
Comparing the figures for the population with those
presented in Table 4, it can be noted that they
coincide with the number of cases of coronavirus
confirmed for 2020-2021, as well as with the
fatalities confirmed for 2020. However, the trends
(in favor of Western European countries) for cases
and deaths of COVID-19 infection reverse in 2022
(for cases) and 2021 (for deaths) [Table 5]. The
indicated figures may suggest that Western
European countries from 2022 onwards have started
to do better in protecting themselves against the
incidence of coronavirus than is the case for Eastern
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European countries. In terms of deaths of COVID-
19, Western European countries compared to
Eastern European countries started doing better a
year earlier, i.e. from 2021 onwards. This may speak
unfavorably in terms of the performance of COVID-
19 control and prevention hospitals in Eastern
Europe.
Table 5. Confirmed deaths of COVID-19 infection
in the countries of the research sample (in persons)
Region
Deaths of COVID-19
2022a)
2021
2020
Europe
350 723
889 178
466 863
Eastern Europe
164 670
581 700
170 715
47.0%
65.4%
36.6%
Western Europe
186 053
307 478
296 148
53.0%
34.6%
63.4%
Region
Cumulative data
2020-2022a)
2020-2021
Europe
1 706 764
1 356 041
Eastern Europe
917 085
752 415
53.7%
55.5%
Western Europe
789 679
603 626
46.3%
44.5%
Note: a) Figures as at 04/10/2022.
Source: Own study based on statistical data obtained
from covid19.who.int.
The thesis presented above is also confirmed by the
participation deaths in cases of COVID-19
infection, which in 2021 and 2022 for Eastern
Europe is significantly worse than the level obtained
in Western Europe, except for the first year of the
pandemic [Table 6]. For the European area, this
indicator, after getting worse in 2021, improved
markedly in 2022.
Table 6. Participation deaths in cases of COVID-19
infection in the countries of the research sample
Region
Annual data
Cumulative data
2022a)
2021
2020
2020-22a)
2020-21
Europe
0.3%
1.7%
2.3%
0,8%
1.9%
Eastern Europe
0.7%
2.8%
2.0%
1,7%
2.5%
Western Europe
0.2%
1.0%
2.5%
0,5%
1.4%
Note: a) Figures as at 04/10/2022.
Source: Own study based on statistical data obtained
from covid19.who.int.
Operating revenue, liabilities, cash flow and profit
margin are commonly used as indicators which are
employed to assess financial performance,
especially in times of recession, [13]. To achieve the
objective of the research described in this article, the
following economic values characterizing private
and state-owned hospital companies in Eastern and
Western Europe were analyzed: operating revenue
(turnover), profit/loss before tax, cash flow, total
assets, profit margin (profit before tax / operating
revenue), ROE (profit/loss before tax / shareholder
funds), ROCE, current ratio (current assets / current
liabilities) and solvency ratio (shareholder funds /
total assets). In the case of ROCE, only 37.71% of
the research sample was collected for 2020, while in
the case of cash flow 58.99% of the research sample
was collected. Therefore, the analysis of economic
data for cash flow and ROCE was abandoned. The
focus was therefore on the analysis of the remaining
economic figures, for which between 98.62% and
99.98% of the research sample was obtained for
2020.
4 Presentation of Research Results
and Discussion
In the first year of the pandemic, a deceleration in
operating revenue (turnover) growth is noticeable
among hospital operating companies in Europe.
This applies both to the total turnover generated by
the research sample, as well as to the median and
bottom quartile (Q1) comprising 75.0% of the
research sample. Turnover generated by the top
25.0% of companies in the top quartile (Q3) shows a
positive rate of change compared with previous
years [Table 7].
Table 7. Operating revenue (turnover) of the
research sample in Europe (k EUR)
Description
2020
2019
2018
2017
Total
110 418 588
110 474 013
96 982 452
91 082 822
Maximum value
2 400 557
2 527 132
2 339 626
2 297 988
Upper quartile
4 800
4 724
5 388
6 172
Median
797
823
622
752
Lower quartile
184
213
140
140
Minimum value
-2
50
0
0
Range
2 400 559
2 527 082
2 339 626
2 297 988
Arithmetic mean
12 404
12 282
12 408
13 334
Standard deviation
65 957
66 444
62 356
66 498
Eastern Europe
Median
510
558
361
367
Arithmetic mean
3 321
3 418
3 054
3 077
Standard deviation
12 695
18 400
12 700
10 968
Western Europe
Median
5 954
5 655
5 947
6 336
Arithmetic mean
33 435
32 212
31 536
32 065
Standard deviation
115 845
114 060
104 724
108 341
Source: Own study based on statistical data obtained
from orbiseurope.bvdinfo.com.
The reduction in overall revenue levels - noticeable
particularly in Eastern Europe - was primarily due to
the cessation of scheduled admissions and surgical
procedures, except for patients with immediate life-
threatening conditions. This was due to the need to
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attend to patients infected with the SARS-CoV-2
coronavirus. Hospitals limited or suspended services
performed on a scheduled basis for diagnostics and
diagnostic, therapeutic and surgical procedures, as
well as outpatient specialty care services. The
COVID-19 pandemic has intensified the
organizational and financial problems that hospitals,
especially those in the Eastern European region,
have been facing for many years. Problems in
hospitals during the pandemic became apparent in
the form of a lack of vacancies for Covid patients
and those suffering from other diseases, a shortage
of medical equipment (including respirators), an
inadequate number of intensive care stations,
occurring shortages of personal protective
equipment, i.e. suits or masks, and shortages of staff
or personnel capable of treating the sickest patients.
A significant spread between the maximum and
minimum value of €2.400 billion in 2020 and
€2.391 billion in 2017-2019 (arithmetic mean) is
noticeable over the study period. The large spread
was influenced by a hospital operating in Norway,
from a group of hospitals that in 2020 generated
17.7% of the operating revenues of the Western
European research sample and 14.4% of the
operating revenues of the European research
sample.
Fig. 1: Turnover of the research sample in Europe:
median and total turnover
Source: Own study.
The median turnover of companies from Europe in
2020 also records a decrease with respect to the
2019 value. The median dynamic for this period for
Europe is 96.9% and is the same as for Eastern
European companies, for which the dynamic is
91.3%. The situation looks different for companies
in Western Europe. In their case, the median
dynamic maintained their trend from previous years
and amounted to 93.9% (2018/17), 95.1% (2019/18)
and 105.3% (2020/19). The median of the research
sample from Western Europe has also been
significantly higher throughout the period under
analysis than for companies from the rest of Europe
[Figure 1]. In the first year of the pandemic, the gap
widened further by €348 k for 2019.
The part of the study population that generated
total turnover in 2020-2017 higher than the median
total turnover of the entire study population
included 6 entities from Eastern Europe (33.33%),
among which hospitals from Poland, Romania and
the Czech Republic had the highest total turnover.
The list of entities generating the highest total
turnover opens with rich Western European
economies like Norway, France and Belgium, while
it closes with the economies of small European
countries like Montenegro, Serbia and Iceland
[Figure 2].
Fig. 2: Turnover by country of the research sample
in Europe: total turnover and median of total
turnover
Source: Own study.
In the last four years, the share of operating income
generated by Western European companies has
exceeded 80% in each year. In the pre-pandemic
period, a slight decreasing trend is noticeable, which
in turn slowed down in the first year of the
pandemic.
Due to the reduction of existing medical
operations to the bare minimum or the temporary
suspension of scheduled medical services, during
the first period of the pandemic, hospital managers
were concerned that these changes would
significantly affect revenue reduction and increase
operating costs. Concerns were justified, because as
a consequence, the changes could contribute to a
deterioration in the profitability of hospital
functioning and an increase in their debts, thereby
increasing the number of bankruptcies of the
hospital services providers.
The COVID-19 pandemic can certainly be
counted among the events that lead to a systematic
decline in sales profitability, [14][14]. Therefore,
the total profit/loss before tax is an important
economic indicator reflecting changes in the
business environment. When analyzing the total
profit/loss before tax obtained by the research
-500
500
1 500
2 500
3 500
4 500
5 500
6 500
0
10 000 000
20 000 000
30 000 000
40 000 000
50 000 000
60 000 000
70 000 000
80 000 000
90 000 000
2020 2019 2018 2017
CEE (total) WE (total) CEE (median) WE (median)
[k EUR]
[k EUR]
0
2 000 000
4 000 000
6 000 000
8 000 000
10 000 000
12 000 000
14 000 000
16 000 000
NO
FR
BE
IT
CH
PL
DE
PT
AT
ES
GB
NL
RU
CZ
UA
BG
SE
LT
SK
LV
LU
IE
BA
GR
RO
FI
EE
HU
DK
MK
HR
SI
LI
ME
RS
IS
2020 2019-2017 (arithmetic mean) 2020 (mediana)
[k EUR]
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sample in Europe, it is important to note its
significant decrease in the first year of the pandemic
to the previous year. Year-on-year profitability was
reduced by €691,934 k, with a growth rate of only
52.9% (2020/19) [Table 8]. However, it is
interesting to note that it is the companies
generating 80% of turnover, i.e. those from Western
Europe, that have contributed to creating this
situation, inherent in both total profitability and
median profitability [Figure 3].
Fig. 3: Profitability of the research sample in
Europe: median profit/loss before tax and median
profit margin
Source: Own study.
Profitability of Western European entities decreased
by €889,669 k in 2020/19 (with a dynamic of 6.4%),
while Eastern European entities recorded an
increase in profitability of €197,735 k in the same
period (with a dynamic of 138.2%). As the survey
results presented here indicate, concerns about the
deterioration of the profitability of hospital
performance were confirmed only for entities
belonging to the Western European population.
Table 8. Profit/loss before tax of the research
sample in Europe (k EUR)
Description
2020
2019
2018
2017
Total
775 802
1 467 737
605 439
956 578
Maximum value
90 993
169 167
83 915
87 293
Upper quartile
197
150
142
176
Median
30
28
21
24
Lower quartile
0
-1
-1
-1
Minimum value
-367 570
-399 098
-518 913
-465 559
Range
458 563
568 265
602 827
552 851
Arithmetic mean
87
164
78
140
Standard deviation
5 462
6 174
7 020
6 578
Eastern Europe
Median
23
18
14
14
Arithmetic mean
115
83
33
61
Standard deviation
905
1 764
683
718
Source: Own study based on statistical data obtained
from orbiseurope.bvdinfo.com.
Analyzing the situation in terms of the statistical
characteristics selected for the research, it can be
noted that only a group of 25.0% of the research
sample from Western Europe included in the set of
the lower quartile (Q1) showed a loss before tax, for
which the dynamic in the period 2020/19 amounted
to (-)413.3%, with dynamic of 79.5% for the median
and 92.4% for the upper quartile (Q3). The spread
narrowed over the period, affected by a reduction in
both maximum and minimum values [Table 9].
The profitability of Eastern European entities has
been steadily increasing from 2018 onwards, both
from the point of view of total profitability (from
€266,874 k in 2017 to €715,298 k in 2020) and its
median (from €14 k in 2017 to €23 k in 2020). Also,
in the quartile sets (Q1 and Q3), a similar trend can
be observed, which was not stopped in the first year
of the pandemic, as it happened for hospitals from
the western region of Europe. However, for the
European sample, when analyzing the median and
the upper quartile, a positive dynamic can be
observed indicating an 8.1% increase in profitability
for the median and a 31.6% increase for the upper
quartile.
Table 9. Profit/loss before tax of the research
sample in Western Europe (k EUR)
Description
2020
2019
2018
2017
Total
60 504
950 174
433 986
689 703
Maximum value
90 993
169 167
83 915
87 293
Upper quartile
672
728
726
773
Median
71
89
94
120
Lower quartile
-14
3
0
0
Minimum value
-367 570
-399 098
-518 913
-465 559
Range
458 563
568 265
602 827
552 851
Arithmetic mean
23
348
170
287
Standard deviation
9 853
10 856
12 226
11 033
Source: Own study based on statistical data obtained
from orbiseurope.bvdinfo.com.
Similar trends - as indicated for profit/loss before
tax - can be noticed in profit margin [Figure 2].
Despite the pandemic, the median profit margin
improved by 0.96 p.p. in 2020/19 (with a growth
rate of 121.5%), driven by Eastern European
companies recording a 1.72 p.p. increase in profit
margin (with a growth rate of 141.0%). Over the
same period, hospitals from Western Europe
recorded a decrease in profit margin of 0.90 p.p.
(with a dynamic of 82.4%) [Table 10].
4,0
4,2
4,4
4,6
4,8
5,0
5,2
5,4
5,6
5,8
6,0
0
20
40
60
80
100
120
2020 2019 2018 2017
CEE (profit/loss) WE (profit/loss) CEE (profit margin) WE (profit margin)
[k EUR]
[%]
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Table 10. Profit margin of the research sample in
Europe (%)
Description
2020
2019
2018
2017
Median
5.4
4.5
4.7
4.9
Arithmetic mean
9.2
9.0
8.7
8.8
Standard deviation
23.0
22.7
22.9
22.6
Eastern Europe
Median
5.9
4.2
4.7
5.0
Arithmetic mean
8.9
8.0
7.8
8.2
Standard deviation
22.3
21.5
22.2
22.7
Western Europe
Median
4.2
5.1
4.9
4.7
Arithmetic mean
9.7
11.3
10.5
9.9
Standard deviation
24.5
25.2
24.0
22.4
Source: Own study.
Looking at total assets, no significant impact of the
pandemic in the first year of its occurrence was
observed in either entire Europe or its individual
regions compared to the previous three years. The
steady increase in the level of total assets of the
research sample was maintained with a dynamic of
105.9% for Europe and Western Europe and 105.8%
for Eastern Europe. In contrast, a slight reduction in
the rate of asset growth is noticeable. The dynamic in
2020/19 decreased compared to previous periods by
5.3 p.p. (2019/18) and by 0.5 p.p. (2018/17) [Table
11].
Table 11. Total assets of the research sample in
Europe (k EUR)
Description
2020
2019
2018
2017
Total
125 498 165
118 497 013
106 546 736
100 158 511
Maximum value
2 199 302
2 307 709
2 152 169
2 084 476
Median
539
509
406
479
Minimum value
0
0
-2
-15
Range
2 199 302
2 307 709
2 152 171
2 084 491
Arithmetic mean
13 955
13 177
12 621
13 977
Standard deviation
76 161
72 718
66 993
70 519
Eastern Europe
Median
287
277
199
182
Arithmetic mean
3 011
2 846
2 571
2 747
Standard deviation
14 190
13 273
11 206
11 335
Western Europe
Median
5 908
5 020
5 145
5 633
Arithmetic mean
38 554
36 421
34 757
35 065
Standard deviation
132 347
126 543
115 706
115 726
Source: Own study based on statistical data obtained
from orbiseurope.bvdinfo.com.
Over the entire period covered by this study, more
than 85% of hospital assets are in Western European
companies. This trend was not disrupted by the
emergence of the pandemic. This is primarily due to
the wealth of hospital entities in this part of Europe,
which in turn is a result of the wealth of national
economies, the ownership structure of hospitals and
the expenditures allocated to their operation and
development.
A significant difference between the value of
assets of Eastern and Western European hospitals
can also be seen on the median side. In Western
Europe, the median amounted to €5,908 thousand in
2020, which was €642 thousand higher than the
mean median achieved in 2017-2019 by hospitals in
that part of Europe. It is noteworthy that the median
has changed its unfavorable trend observed in the
years preceding the pandemic. In 2018/17, the
median worsened by €489 thousand, while in 2019
it deteriorated by another €125 thousand with
respect to the previous period. In contrast, in the
first year of the pandemic, the median recorded
a significant increase of €888 thousand compared to
2019.
In Eastern Europe, the median was only
€287,000 in 2020, which was €68,000 higher than
the mean median achieved in 2017-2019 by
hospitals in this part of Europe. The favorable
upward trend of the median in the years preceding
the pandemic and in the first year of the pandemic
was maintained. The median value recorded an
increase of €199,000 in 2018/17, of €277,000 in
2019/18 and of another €287,000 in 2020 compared
to the previous period. It can be noted that the
pandemic has positively affected the median value
of the assets of the study population. In addition to
the change in the amount of profit generated, this
has to do with the need to subsidize hospitals due to
the pandemic in the form of money, as well as in the
form of numerous donations of medical equipment
necessary to save the lives of those infected with the
coronavirus.
The part of the study population characterized by
higher total assets in 2020-2017 in relation to the
median total assets of the entire study population
included 5 entities from Eastern Europe (27.78%),
among which hospitals from Poland, Romania and
the Czech Republic had the highest asset values (as
was the case with the total turnover generated). The
list of entities with the highest total assets opens
with rich Western European economies like
Norway, the UK and Belgium, while it closes with
the economies of small European countries like
Liechtenstein, Serbia and Iceland [Figure 4].
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Fig. 4: Total assets by country of the research
sample in Europe: total assets and median of total
assets
Source: Own study.
Over the study period, a significant gap between the
maximum and minimum value of €2.199 billion in
2020 and €2.181 billion in 2017-2019 (arithmetic
mean) is noticeable. This was driven by Western
European hospitals, whose maximum and minimum
asset levels shaped the results of the entire study
population. For Eastern European hospitals, the gap
between the maximum and minimum was only
€0.402 billion in 2020 and €0.310 billion in 2017-
2019 (arithmetic mean).
As liquidity may be particularly sensitive to the
financial situation caused by Covid-19, the behavior
of the current ratio (CR) was analyzed, [15]. In the
first year of the COVID-19 pandemic, companies
recorded a slight deterioration in their current ratio
in relation to 2019 by 0.024 [Table 12]. In previous
periods, European hospitals were characterized by
an improvement in their current financial liquidity
(year-on-year) illustrated by an increase in the CR
ratio of 0.175 in the period 2018/17, 0.014 in the
period 2019/18. The decreasing trend of the current
financial liquidity ratio is indicative of a
deteriorating ability to settle short-term liabilities.
Despite the decline in the CR ratio, it is still
maintained at an optimal level, i.e. between 1.5 and
2.0.
Table 12. Current ratio of the research sample in Europe
Description
2020
2019
2018
2017
Median
1.59
1.62
1.60
1.43
Arithmetic mean
4.96
5.40
5.03
4.26
Standard deviation
10.88
11.69
10.90
9.70
Eastern Europe
Median
1.60
1.64
1.64
1.36
Arithmetic mean
5.48
6.21
5.65
4.54
Standard deviation
11.78
12.96
11.89
10.10
Western Europe
Median
1.58
1.58
1.54
1.50
Arithmetic mean
3.82
3.66
3.72
3.74
Standard deviation
8.49
8.03
8.30
8.88
Source: Own study.
Similar trends can be observed in the western and
eastern parts of Europe. However, Eastern European
hospitals have a higher level of current ratio than
Western European entities. The difference is small,
but it has persisted over the last three years [Figure
5] and the COVID-19 pandemic has not affected
this dependency, which is mainly due to the higher
level of short-term liabilities of Western European
hospitals. The above thesis is confirmed by the
results from the assessment of the level of solvency
ratio, where hospitals from Eastern Europe are also
characterized by greater financial security [Table
13].
Fig. 5: Assets, liquidity and solvency of the research
sample in Europe: median total assets and median
current ratio
Source: Own study.
Table 13. Solvency ratio (asset based) of the research
sample in Europe (%)
Description
2020
2019
2018
2017
Median
56.2
58.5
56.8
51.2
Arithmetic mean
49.9
51.3
49.2
45.1
Standard deviation
38.9
40.5
42.0
41.4
Eastern Europe
Median
62.8
66.0
63.5
55.8
Arithmetic mean
53.3
54.7
51.9
46.2
Standard deviation
40.1
42.7
44.6
45.2
Western Europe
Median
43.5
45.8
45.2
45.5
Arithmetic mean
42.6
44.2
43.5
43.2
Standard deviation
35.0
34.3
35.2
33.8
Source: Own study.
In the first year of the COVID-19 pandemic, the
solvency ratio worsened compared to the previous
year in both Eastern and Western European
companies [Figure 6]. The deterioration in the ratio
was 3.29 p.p. for Eastern European hospitals and
2.32 p.p. for Western European hospitals, with a
negative change calculated over the entire study
sample of 2.29 p.p.
0
2 000 000
4 000 000
6 000 000
8 000 000
10 000 000
12 000 000
14 000 000
16 000 000
NO
GB
BE
IT
FR
CH
ES
DE
AT
PL
PT
RU
NL
CZ
UA
BG
GR
SE
BA
SK
LV
LT
IE
LU
RO
MK
HU
EE
ME
FI
DK
SI
HR
LI
RS
IS
2020 2019-2017 (arithmetic mean) 2020 (mediana)
[k EUR]
1,20
1,25
1,30
1,35
1,40
1,45
1,50
1,55
1,60
1,65
1,70
0
1 000
2 000
3 000
4 000
5 000
6 000
2020 2019 2018 2017
CEE (total assets) WE (total assets)
CEE (current ratio) WE (current ratio)
[k EUR]
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Fig. 6: Assets, liquidity and solvency of the research
sample in Europe: median total assets and median
solvency ratio
Source: Own study.
How, then, has the ROE developed? Table 14
presents the assets of the research sample. The
extracted data shows that the assets of the research
sample from Western Europe are characterized by
high levels in relation to companies from Eastern
Europe. Comparing the median assets of the study
sample in 2020, they were more than 20 times
higher in hospitals from Western Europe than from
Eastern Europe. In relation to 2019, the spread
between the assets of the two areas of Europe has
widened. The level of assets of the Western
European research sample, their capital structure
and thus the level of shareholder funds made it
difficult for companies from this region of Europe to
achieve a high ROE, particularly in relation to
companies from Eastern Europe, which have several
times lower shareholder funds [Figure 7].
Fig. 7: ROE, shareholder funds and profit margin of
the research sample in Europe: median ROE and
shareholder funds
Source: Own study.
The European research sample is characterized by
a high - given the industry in which it operates -
ROE, which ranged from 16.6% to 18.4% during
the research period. A significant difference can be
observed between the two European regions.
Hospitals in Eastern Europe had a higher ROE in
each year of the study than those in Western Europe.
The differences in ROE between European regions
in the pre-pandemic period were 12.5 p.p. (2017),
8.9 p.p. (2018), 2.4 p.p. (2019) and had a clear
downward trend (year-on-year) [Table 14]. In 2020,
the ROE gap widened and reached 11.1 p.p.
Table 14. ROE of the research sample in Europe (%)
Description
2020
2019
2018
2017
Median
17.2
16.6
18.4
18.1
Arithmetic mean
32.9
38.6
38.8
38.8
Standard deviation
103.4
107.8
110.8
111.0
Eastern Europe
Median
22.0
17.5
22.7
25.2
Arithmetic mean
42.2
43.9
47.8
51.2
Standard deviation
112.4
115.3
121.9
128.7
Western Europe
Median
10.8
15.1
13.8
12.7
Arithmetic mean
12.8
27.7
22.9
20.0
Standard deviation
77.3
89.4
85.5
72.9
Source: Own study.
For Eastern European hospitals, the first year of the
COVID-19 pandemic did not negatively affect
return on equity, which improved from 17.5% to
22.0% compared to 2019. The opposite situation
occurred in hospitals from Western Europe. In this
case, the first year of the pandemic had a negative
impact on the return on equity. These entities in the
period 2017-2019 improved ROE (year-on-year) by
1.1 p.p. (2018/17) and 1.3 p.p. (2019/18). However,
in 2020, the level of ROE was lowered from the
15.1% obtained in 2019 to 10.8%.
Fig. 8: ROE, shareholder funds and profit margin of
the research sample in Europe: median ROE and
profit margin
Source: Own study.
Profit margin is characterized by similar trends as
ROE, as can clearly be seen in Figure 8. Analyzing
the results obtained, it can be noted that the period
of the first year of the pandemic significantly
changed the profit margin trend, which could be
observed in the last years preceding the pandemic.
For the entire study population and the population
including Eastern Europe, the profit margin had
40,0
45,0
50,0
55,0
60,0
65,0
70,0
0
1 000
2 000
3 000
4 000
5 000
6 000
2020 2019 2018 2017
CEE (total assets) WE (total assets)
CEE (solvency ratio) WE (solv ency ratio)
[k EUR]
[%]
10,0
12,0
14,0
16,0
18,0
20,0
22,0
24,0
26,0
0
100
200
300
400
500
600
700
800
900
1 000
2020 2019 2018 2017
CEE (Shareholder funds) WE (Sharehol der funds) CEE (ROE) WE (ROE)
[k EUR]
[%]
4,0
9,0
14,0
19,0
24,0
29,0
4,0
4,3
4,5
4,8
5,0
5,3
5,5
5,8
6,0
2020 2019 2018 2017
CEE (profit margin) WE (profit margin) CEE (ROE) WE (ROE)
[%]
[%]
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Volume 20, 2023
a downward trend (year-on-year) before the
pandemic period. Profit margin deteriorated by 0.19
p.p. (2018/17) and by 0.26 p.p. (2019/18) for the
entire study population, and by 0.37 p.p. (2018/17)
and by 0.47 p.p. (2019/18) for Eastern European
entities. In contrast, the profit margin improved
significantly in the first year of the pandemic, i.e. by
0.96 p.p. (2020/19) for the entire study population
and 1.72 p.p. for Eastern European entities.
The change in the trend of the profit margin
indicator is also noticeable in the second group of
the study population, i.e. Western European entities.
In this case, the change is the opposite. In the pre-
pandemic period, entities from this region of Europe
recorded an increase in the analyzed indicator (year-
on-year) by 0.16 p.p. (2018/17) and by 0.19 p.p.
(2019/18). In turn, after the first year of the
pandemic, the indicator deteriorated by 0.90 p.p.
(2020/19).
The change in the behavior of the profit margin
ratio was influenced by both the change in the
volume of operating revenue (turnover) and
profitability. Western European companies in the
first year of the pandemic recorded both an increase
in turnover and a decrease in profitability, which
ultimately must have had a negative impact on profit
margin. The opposite was true for entities in Eastern
Europe. In this part of the population, companies
recorded a decrease in turnover and an increase in
profitability, which in turn contributed to an
improvement in the profit margin ratio. Eastern
European entities managed to generate more profit
in the first year of the pandemic than in the period
preceding it, despite reduced turnover levels.
5 Conclusion
The COVID-19 pandemic forced hospital managers
in Europe to change their priorities and strategies.
As a consequence of the negative impact of the
coronavirus pandemic on national economies,
economic entities around the world experienced
severe or threatening to their stability negative
financial effects in the form of a reduction in the
volume of orders received for goods sold, an
increase in problems related to payment bottlenecks
affecting the deterioration or loss of financial
liquidity. The pandemic also had a significant
impact on reduced access to health care services, as
well as on the financial and asset situation of
hospitals.
The aim of this article was to present the
research results and evaluate in terms of the impact
of the COVID-19 pandemic on the development of
the financial situation of hospitals in Europe after
the first year of the pandemic with reference to the
situation several years before the pandemic. The
study covered the period 2017-2020. An economic
analysis was conducted relying on basic statistical
characteristics using financial data from a research
population of 8,995 private and public hospital
operating companies in Europe, including 2,769
from Western Europe and 6,226 from Eastern
Europe. From the point of view of assessing the
minimum sample size (nmin=753,41), the size of the
study population (n=8,995) allows the results of the
survey to be used for inference with translation to
the entire general population (N=57,722).
The hypothesis was adopted that the financial
situation of hospital operators in Europe has
deteriorated due to a reduction in the range of
medical services forced by the spread of
coronavirus. The research data was analyzed by
Eastern and Western Europe and assessed against
economic volumes represented by the research
sample from across Europe. Considering the above,
the research hypothesis was only confirmed in the
case of operating revenue, current ratio, and
solvency ratio.
In the first year of the pandemic, there is
a noticeable slowdown in the growth rate of total
operating revenue (turnover) of the research sample,
both in Eastern and Western Europe and at the level
of the European area. In the case of median
turnover, the deceleration of the growth rate is
characteristic only for Eastern Europe (-63.2 p.p.).
This resulted in a decrease in turnover in 2020
compared to 2019 generated by Eastern European
companies and an increase in turnover generated by
Western European companies.
In the first year of the COVID-19 pandemic,
hospitals from both Eastern and Western Europe
recorded a slight deterioration in current ratio. In the
last three years before the pandemic, hospitals in
Europe showed an improvement in their current
ratio (year-on-year). The decreasing trend of the
current ratio is indicative of a deteriorating ability to
meet short term liabilities. Despite the deterioration
of the current ratio, it is still maintained at an
optimal level, i.e. between 1.5 and 2.0. The solvency
ratio also deteriorated in the first year of the
COVID-19 pandemic in both Eastern and Western
European entities. For Eastern European hospitals
the deterioration of the ratio was 3.29 p.p. and for
Western European hospitals it was 2.32 p.p., with
a negative change calculated over the entire study
sample of 2.29 p.p.
The hypothesis was not confirmed in terms of the
asset situation. No significant impact of the
pandemic in the first year of its occurrence on the
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companies' asset levels was observed. The steady
increase in the level of total assets of the research
sample was maintained, with a slight reduction in
the rate of asset growth. The steady increase in the
level of total assets of the research sample was
maintained with a dynamic of 105.9% for Europe
and Western Europe and 105.8% for Eastern
Europe. In contrast, a slight reduction in the rate of
asset growth is noticeable. The dynamic in 2020/19
decreased compared to previous periods by 5.3 p.p.
(2019/18) and by 0.5 p.p. (2018/17).
For the other economic quantities analyzed, such
as profit/loss before tax, profit margin and ROE,
heterogeneous results were obtained, depending on
the region of Europe in which the hospital operates.
The results confirmed that for Eastern European
hospitals, the COVID-19 pandemic did not affect
the deterioration of total profit/loss before tax, profit
margin and ROE. The research sample from Eastern
Europe in the first year of the pandemic increased
total profit/loss before tax by €197,735 k, median
profit/loss before tax by €5.3 k, profit margin by
0.96 p.p. and ROE by 4.45 p.p. Meanwhile, the
Western European sample over the same period
decreased total profit/loss before tax by €889,669 k,
median profit/loss before tax by €18.2 k, profit
margin by 0.90 p.p. and ROE by 4.25 p.p.
Despite lower asset potential, the above-
mentioned economic figures for the first year of the
pandemic for Eastern European hospitals were
better than for the Western European part of the
research sample. Total profit/loss before tax was
higher by €654 794 k, profit margin higher by 1.72
p.p. and ROE by 11.1 p.p. For median profit/loss
before tax, hospitals from Western Europe showed
a higher profit margin.
Continuing research on the impact of the
COVID- 19 pandemic on the development of the
financial situation of hospitals in the subsequent
years of the pandemic, narrowing down the statistics
to the country level may allow hospital operators in
Europe to be better prepared to function not only in
a pandemic environment, but also in the various
crisis situations that are increasingly affecting
business entities and societies in Europe. Thereby, it
will be possible to minimize the negative impact of
crises not only on the economy of individual
countries, but also on the financial situation of
business entities, and thus on the lives of hundreds
of millions of people, if not around the world, then
at least in Europe.
Europe in the last decade or so has been
experiencing successive crises affecting the
financial and asset situation not only of economic
entities, but also of the inhabitants of the European
continent. The global financial crisis began in 2007,
was followed by the Greek financial crisis with the
threat of bankruptcy of the country, then the over-
liquidity of the financial sector was experienced in
many European countries and was followed by the
crisis caused by the SARS-CoV-2 coronavirus. The
world has not yet overcome the consequences of the
COVID-19 pandemic in its first period, and at the
beginning of 2022 a new crisis began in Europe
triggered by Russia's war with Ukraine, which is
already resulting in an increase in the price of
strategic raw materials, as well as a high increase in
inflation (inflationary crisis). As a consequence of
the inflationary crisis and the war in Ukraine,
a significant decrease in gross domestic product can
be expected in most European countries soon. These
are certainly not the last problems of the Old
Continent.
The financial crises of recent years affect the
financial and asset situation of economic entities
doing business in Europe, which is an interesting
research problem that can be considered in
subsequent scientific studies. The subject of further
research should be Eastern and Western European
entities doing business in key industries for
European economies and society, such as energy,
petrochemicals and fertilizer production. This is
particularly relevant to the situation in which
Europe finds itself at the end of 2022. Problems
with inflation and insufficient energy utilities are
just some of them. Europe, due to Russia-induced
restrictions on energy and petrochemical raw
materials, needs to ensure its security over a longer
time horizon, beyond the duration of hostilities in
Ukraine.
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E-ISSN: 2224-2899
192
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Sources of Funding for Research Presented in
a Scientific Article or Scientific Article Itself
The project is financed within the framework of the
program of the Minister of Science and Higher
Education under the name "Regional Excellence
Initiative" in the years 2019-2022; project number
001/RID/2018/19; the amount of financing PLN
10,684,000.00.
WSEAS TRANSACTIONS on BUSINESS and ECONOMICS
DOI: 10.37394/23207.2023.20.18
Wojciech Naruć
E-ISSN: 2224-2899
193
Volume 20, 2023
Conflict of Interest
The authors have no conflicts of interest to declare
that are relevant to the content of this article.
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