Hospitals financial performance across European countries: a scoping review protocol


  • The review process will apply a rigorous and standardised methodological approach.

  • Broad inclusion criteria (quantitative and qualitative empirical studies as well as theoretical papers, technical reports) guarantee a comprehensive approach.

  • Quality assessment and the risk of bias of the included studies will not be conducted.

  • Only publications in English will be considered.


Hospitals constitute the cornerstone of health systems across European countries and absorb a significant share of total health expenditures. In 2020, among the 31 European countries for which data are available, hospital expenditures as a share of total current health expenditures ranged from 28.8% in Germany to more than 48.0% in Romania, and were above 35% in 25 countries.1 The strong position of hospital sector underlines the role of hospital financial sustainability as an important determinant of healthcare provision security. During the recent COVID-19 pandemic, hospitals stood at the front line of health system response and the need to support their financial sustainability has grown in importance.2

Yet, hospitals are unique organisations that operate in a heavily regulated environment.3 They function under constant pressure to contain cost while simultaneously striving to improve quality of care provision. The issue of measuring, monitoring and supporting their financial sustainability is much more complex than in the case of organisations in other sectors. Across European health systems, hospitals function in a diversity of legal forms and governance frameworks: (1) public versus private ownership; (2) for-profit versus non-profit business model; (3) corporations versus foundations versus trusts versus consortia versus other organisational forms dedicated solely for healthcare providers.3 Hospitals as organisations are characterised by high resistance to change, while public hospitals are especially problematic in implementing reforms due to determinants related to structural dysfunctionalities and bureaucracy issues.4 5 In Europe, public hospital care provision prevails in terms of both—hospitals ownership and sources of funding. In 2020, among 25 European countries for which data are available: in 23 the number of beds in publicly owned hospitals constituted majority of the total number of hospital beds in a country. In the same year, the average for European Union-27, share of ‘government and compulsory contributory health financing schemes’ in funding hospitals was 94%.1 Public hospitals across European countries often hold a special statute of ‘public services producers’, which is related to the obligation to provide services, regardless of their ability to cover the operational/production costs.6

The issue of hospitals’ financial sustainability constitutes a complex concept, both in terms of measurement techniques and determining factors. Hospital financial performance can be measured by diverse indicators, such as those related to profitability, liquidity, or composite measures (combining multiple indicators).7 8 In terms of the factors influencing hospitals’ financial performance, there are several literature reviews,9–11 with the vast majority of studies focusing on the US market (where hospitals function in substantially different governance model than in Europe). The US-based studies indicate that a variety of factors (including hospital size, affiliation, payer mix or market concentration) can impact hospital financial standing. International research evidence also suggests a positive association between hospital financial performance and quality of care.12 Yet, the empirical studies are also mostly focused on the US market.12

At the same time, the available fragmented data indicate that hospitals in many European countries continuously face financial deficits/ insolvency problems:

  • The analysis based on a sample of approx. 1500 hospitals from 8 European countries showed that in 2011, 1 in 5 hospitals could be considered high risk in terms of their probability of financial default.13

  • In the UK in 2015, hospitals recorded a financial deficit of £2.45 billion, while the number of hospitals in the red (insolvent) increased in comparison to previous years.14

  • in Poland in 2018, the majority of public hospitals (52%; 416 out of 805) generated financial losses, while 40% (324 out of 805) hospitals had overdue liabilities.15

  • In Portugal in 2018, half of the state-owned hospitals were technically bankrupt (total value of liabilities exceeded total value of assets), while the general difficult financial situation of public hospitals remained constant despite government led debt-relief initiatives.16

  • In Hungary in 2018, the state-run hospitals generated almost US$192 million in debt, which was paid by the government, only to generate new debts in the upcoming years (reoccurring hospital debt remains the major problem resulting in postponing necessary care provision, including diagnostic examinations, surgeries).17

  • Between 2008 and 2019, sectoral reforms aimed at improving hospitals financial standing were conducted in five (Croatia, Bulgaria, Poland, Hungary, Slovakia) out of 11 analysed Central and Eastern European countries.18

The challenges facing the financial sustainability of hospital sectors across Europe were recently emphasised by the experiences of both the COVID pandemic and the 2022 energy price increase and inflation.19 To the authors’ best knowledge, no comparative analysis of hospital financial performance across European countries exists. The proposed review will therefore fill in an important research gap and build a knowledge base on the topic of assessing and monitoring the financial sustainability of hospitals in Europe.


The general objective is to identify, synthetise and map the existing evidence on hospital financial performance across European countries. The review will help to answer the following research questions: (1) when/where/what research was conducted?; (2) how was the hospital financial performance measured?; (3) what is the evidence on factors that influence hospitals financial standing?

Methods and analysis

The scoping review will follow the standardised methodological guidelines20 21 and include six consecutive stages: (1) defining the research question, (2) identifying relevant literature, (3) studies’ selection, (4) data extraction, (5) collating, summarising and reporting the results and (6) the consultation process and engagement of knowledge users. The project will be registered through the Open Science Framework22 and realised in 2024. The reporting will use the PRISMA extension for Scoping Reviews checklist.23

Stage 1: defining the research questions

The following specific review questions (RQ) were formulated:

RQ1: What types of studies are available?

RQ2: What is the main focus of available publications?

RQ3: How was hospital financial performance measured?

RQ4: What were the results?

RQ5: What limitations were stated?

Stage 2: identifying relevant literature

The following databases will be searched: (1) Medline via PubMed, (2) Web of Science Core Collection, (4) Scopus and (4) ProQuest Central. An initial scan demonstrated that these databases are most likely to identify publications that are related to the focus of this scoping review. Google Engine search will also be conducted. Finally, the references list of relevant papers will be visually scanned to identify further studies of interest.

The search strategy will combine terms from three topics: (1) hospital and (2) financial performance and (3) European country (table 1). As financial performance constitutes a multidimensional concepts, the keyword formulation is challenging. The search strategy will address this issue by being iteratively developed and tested in each database.

Table 1

Search terms for the databases

Terms will be searched as keywords in title and/or abstract, with a publication date limit since 2010. The geographical scope will cover 40 European countries (only 4 small countries with populations below 40 000 inhabitants will be excluded from key words list).

Stage 3: studies selection

The search results will be downloaded and imported into dedicated software (eg, Mendeley or Rayyan) which will be used for the study selection process. The selection will consist of two stages of screening: (1)title and abstract and (2) full-text screening. The following procedure will be applied for both stages of screening: two researchers (authors of this protocol) will screen a random 10% sample of the records and compare and discuss their results until a consensus is reached. If the agreement between them is sufficiently high (at least 80% raw agreement), the remaining records will be screened by one researcher. If the agreement is below 80%, another 10% sample will be screened by the same two researchers and the process will be repeated. The full text articles will be assessed to determine whether they meet the following inclusion criteria:

  • the focus is on hospital setting in a European country.

  • The focus is on hospital financial performance.

  • It is a peer-reviewed empirical study, theoretical paper or technical report (conference abstract will not be included).

  • The full text is available in English.

Stage 4: data extraction

A data extraction template will be developed by the research team—in the form of a Microsoft Office Excel spreadsheet. Table 2 presents the general overview of the data collection table. Each section of the data extraction will be related to a specific research question with assigned codes for further analysis (where appropriate). Depending on the number and type of included studies, a separate extraction table will be developed for empirical studies and other types of publications. The process will be iterative, with data from the first five studies extracted independently by two researchers (the authors of this protocol) and then compared. If needed, the data extraction instrument will be adjusted (piloting of the extraction sheet). Subsequently, data from a random sample of 10% of the studies will be extracted and compared independently by the same two researchers. Any discrepancies will be further discussed to ensure consistency. If the agreement between the two researchers is sufficiently high (at least 80% raw agreement), data of the remaining studies will be extracted by one researcher. If the agreement is below 80%, the process will be repeated until the threshold of 80% will be reached.

Table 2

Overview of the data extraction and coding table

Stage 5: collating, summarising and reporting the results

Both quantitative and qualitative (thematic analysis) methods will be used for data analysis. Table 2 presents examples of the coding themes. In the case of the included publication research design, a standard category will be used for empirical studies (quantitative, qualitative, mix). Similarly, for the financial performance measures, the standard ratio analysis divides the indicators into four main categories: profitability, liquidity, debt management and asset management.24 Also, composite measures8 category will be used if needed. Regarding the main focus of the included publications, an inductive thematic analysis will be used. We anticipate that some of the categories for the publications content may be related to: (1) measuring and/or comparing hospitals financial performance; (2) factors influencing hospital financial performance; (3) association between hospital financial performance and other hospital level outcomes and (4) other (eg, the effectiveness of government-led policies aimed to improve hospitals financial performance). During the analysis, the research team will discuss and revise the coding template as necessary. Since we aim to synthesise and describe the coverage of the evidence, we will not assess the studies’ quality.20

Stage 6: the consultation process and engagement of knowledge users

The consultation process can help provide additional insights, tailor and refine the preliminary results based on stakeholder needs.25 The preliminary review findings will be shared with relevant stakeholders (policy-makers and hospital managers, eg, during relevant national or international conferences, workshops) to provide better understanding and improve validity of the results. These can help define most relevant study implications and support the process of knowledge transfer into practice.

Patient and public involvement

In the design, writing or editing of this scoping review protocol neither patients nor the general public were involved.

Ethics statements

Patient consent for publication

This post was originally published on