DYING TOO YOUNG: CHALLENGES AND OPTIONS IN THE RUSSIAN FEDERATIONTHE WORLD BANK
Human Development Sector Unit Russia Country DepartmentEurope and Central Asia Region
Patricio Marquez December 2005
President Vladimir PutinState-of-the-Nation Address, Federal Assembly of the Russian Federation, April 25, 2005We cannot reconcile ourselves to the fact that the life expectancy of Russian women is nearly 10 years and of men nearly 16 years shorter than in Western Europe. Many of the current mortality factors can be remedied, and without particular expenseThe reasons are well known. And we should implement a whole range of measures to overcome this dreadful situation.
Presentation OverviewThe demographic decline and the health deficitDeterminants ConsequencesStrategies and interventions to prevent non-communicable diseases and injuries in RussiaActions to confront non-communicable diseases and injuriesExpected health improvements Potential economic benefitsConclusions and the way forward
Estimated Population Growth Rates, Russia, 198085 to 202025 Source: UN Population Projections, 2004 Revisions
Chart3
0.66
0.68
-0.02
-0.34
-0.57
-0.58
-0.6
-0.67
-0.73
Percent
Sheet6
Dependency Ratios
1995200020052010201520202025
Total50444037394449
Child32262018192020
Elderly18182018202429
Population 60+ and
Life Expectancy and Adult Mortality in Selected Countries, 20002001 Source: World Bank World Development Indicators
Mortality among the Working-Age Population in Russia Drives Fluctuations in Life Expectancy Source: WHO European Health for All Database
Life Expectancy at Birth: Russia and the EU, 19702000Source: WHO European Health for All Database
European Unionaverage
Russia
M+F combined
Healthy Life Expectancy (HALE) at Birth in Russia and Four European Countries, 2002 Source: WHO Health For All Database
Male Adult Mortality and Gross National Income per Capita in Selected Countries, 2000 Source: World Bank World Development Indicators. Note: PPP is purchasing power parity.
Chart1
5.3423342525.3423342526.0799331951
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5.9427993751
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5.29330482475.5214609179
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6.2005091744.6821312271
6.3868793194
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4.96981329965.1298987149
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5.18738580585.2933048247
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5.92157841965.5947113796
4.8362819075.4722706737
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4.73619844844.605170186
5.8721177895
5.30826769745.257495372
5.0225638656.5027900459
5.65599181086.1047932324
6.06842558825.3471075307
6.2045577626
5.70044357344.9052747784
6.26149168434.3870141762
5.39816270155.9532433343
4.62213742486.552507887
4.44265125655.3082676974
5.52146091795.429345629
5.44759906936.2499752423
5.13579843714.7095302013
5.55295958495.7104270174
4.68213122715.8777357818
5.429345629
4.5951198501
4.70048036585.1929568509
5.12989871495.4930614433
4.5849674787
5.29330482475.6347896032
6.35957386875.1590552992
5.59471137966.5132301109
5.47227067375.8377304472
5.22574667376.5439118456
4.6051701865.7493929859
5.87211778954.5538768916
5.2574953724.8828019226
6.50279004595.1873858058
6.10479323244.6821312271
5.34710753075.4161004022
6.1590953885
4.90527477846.09356977
4.3870141762
5.95324333434.6728288345
6.5525078875.2311086169
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5.429345629
6.24997524234.9767337424
4.70953020135.8833223885
5.71042701745.1532915945
5.87773578185.2470240722
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5.0998664278
5.19295685095.0159544556
5.49306144335.1532915945
6.5027900459
5.63478960325.4889377262
5.1590552992
6.51323011095.5947113796
5.83773044725.1984970313
6.54391184565.8721177895
5.74939298595.5909869805
4.55387689166.3750248198
4.88280192264.7361984484
5.18738580585.3981627015
4.68213122716.2461067655
5.41610040226.3403593037
6.15909538854.8040210447
6.093569775.4971682253
5.4930614433
4.67282883455.2430037208
5.23110861695.5053315359
5.39816270155.8318824773
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4.97673374246.4409465406
5.88332238854.5108595065
5.15329159454.5951198501
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5.0159544556
5.15329159456.1312264895
6.50279004595.4205349993
5.48893772625.342334252
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5.59471137965.3844950628
5.19849703136.4248690239
5.87211778954.9628446303
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4.73619844845.2203558251
5.39816270155.4806389233
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4.80402104474.6405373298
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5.1298987149
5.3844950628
6.4248690239
4.9628446303
4.6913478822
4.9904325868
5.2203558251
5.4806389233
5.1817835503
5.313205979
4.6405373298
5.0776706954
5.6276211137
6.5861716549
6.4769723629
GNI per capita PPP 2000 (in log)
Male adult mortality 2000 (in log)
ALB
ARM
AZE
BLR
BGR
HRV
CZE
EST
GEO
HUN
KAZ
KGZ
LVA
LTU
MKD
MDA
POL
ROM
RUSSIA
SVK
SVN
TJK
TKM
UKR
UZB
WDI adult mortality
Adult male mortalityAdult female mortalityGNI pc PPPAdult male mortalityAdult female mortalityGNI pc PPPAdult male mortalityAdult female mortalityGNI pc PPPAdult male mortalityAdult female mortalityGNI pc PPP
Figure 1.10.Male Adult Mortality and Gross National Income per Capita in Selected Countries, 2000
Adult male mortalityAdult female mortalityGNI pc PPP
Country CodeCountry Name200020002000ln GNIpc 2000ln Adu Male Mort 2000ln GNIpc 2000ln Adu Female Mort 2000
ALBAlbania209954,180ALB8.33815.34238.33814.5539
ARMArmenia2231062,490ARM7.82005.40727.82004.6634
AZEAzerbaijan2611502,430AZE7.79565.56457.79565.0106
BLRBelarus3811334,810BLR8.47855.94288.47854.8903
BIHBosnia and Herzegovina20093BIH5.29834.5326
BGRBulgaria2391036,070BGR8.71115.47658.71114.6347Y=8.8118 - 0.3915X; R2=0.6517
HRVCroatia1541178,880HRV9.09165.03709.09164.7622
CZECzech Republic1747513,620CZE9.51935.15919.51934.3175
ESTEstonia3161149,870EST9.19735.75579.19734.7362
GEOGeorgia2501331,950GEO7.57565.52157.57564.8903
HUNHungary29512311,930HUN9.38685.68709.38684.8122
KAZKazakhstan3662014,310KAZ8.36875.90268.36875.3033
KGZKyrgyz Republic3352991,460KGZ7.28625.81417.28625.7004
LVALatvia3281227,640LVA8.94125.79308.94124.8040
LTULithuania2861068,570LTU9.05605.65609.05604.6634
MKDMacedonia, FYR160896,490MKD8.77805.07528.77804.4886
MDAMoldova3251651,350MDA7.20795.78387.20795.1059
POLPoland226889,850POL9.19525.42059.19524.4773
ROMRomania2601175,670ROM8.64295.56078.64294.7622
RUSRussian Federation4281567,050RUS8.86086.05918.86085.0499
YUGSerbia and Montenegro180100YUG5.19304.6052
SVKSlovak Republic2168311,250SVK9.32815.37539.32814.4188
SVNSlovenia1707616,640SVN9.71965.13589.71964.3307
TJKTajikistan293204760TJK6.63335.68026.63335.3181
TKMTurkmenistan280.8157.23,440TKM8.14325.63768.14325.0575
UKRUkraine3651353,980UKR8.28905.89998.28904.9053
UZBUzbekistan2821761,490UZB7.30655.64197.30655.1705
AFGAfghanistan4373766.07995.9296
DZAAlgeria1551195,1508.54685.04348.54684.7791
ASMAmerican Samoa
ADOAndorra
AGOAngola4923861,5907.37156.19857.37155.9558
ATGAntigua and Barbuda1831339,6709.17685.20959.17684.8903
ARGArgentina1849211,8209.37755.21499.37754.5218
ABWAruba
AUSAustralia1005425,43010.14374.605210.14373.9890
AUTAustria1256027,57010.22454.828310.22454.0943
BHSBahamas, The26716116,0809.68535.58729.68535.0814
BHRBahrain1209315,2209.63044.78759.63044.5326
BGDBangladesh2622521,6107.38405.56837.38405.5294
BRBBarbados18011514,8709.60715.19309.60714.7449
BELBelgium1286726,99010.20324.852010.20324.2047
BLZBelize2001245,1308.54295.29838.54294.8203
BENBenin3843289706.87735.95066.87735.7930
BMUBermuda
BTNBhutan2682225.59105.4027
BOLBolivia2642192,3207.74935.57597.74935.3891
BWABotswana7036697,0408.85946.55548.85946.5058
BRABrazil2591367,1708.87775.55688.87774.9127
BRNBrunei144944.96984.5433
BFABurkina Faso5595071,0106.91776.32616.91776.2285
BDIBurundi6486035906.38016.47396.38016.4019
KHMCambodia3813221,7707.47875.94287.47875.7746
CMRCameroon4884401,7507.46746.19037.46746.0868
CANCanada1015727,18010.21024.615110.21024.0431
CPVCape Verde2101214,6008.43385.34718.43384.7958
CYMCayman Islands
CAFCentral African Republic6205731,1507.04756.42977.04756.3509
TCDChad4493618606.75696.10706.75695.8889
CHIChannel Islands119.845.64.78583.8199
CHLChile151678,8909.09275.01739.09274.2047
CHNChina1611103,8108.24545.08148.24544.7005
COLColombia2381155,9608.69285.47238.69284.7449
COMComoros3813251,6307.39635.94287.39635.7838
ZARCongo, Dem. Rep.5714936406.46156.34746.46156.2005
COGCongo, Rep.4754066806.52216.16336.52216.0064
CRICosta Rica131788,2109.01314.87529.01314.3567
CIVCote d'Ivoire5534941,4807.29986.31547.29986.2025
CUBCuba143944.96284.5433
CYPCyprus1165917,0709.74514.75369.74514.0775
DNKDenmark1298228,72010.26534.859810.26534.4067
DJIDjibouti5905411,9807.59096.38017.59096.2934
DMADominica1831055,2608.56795.20958.56794.6540
DOMDominican Republic2341465,8308.67085.45538.67084.9836
ECUEcuador1991203,0608.02625.29338.02624.7875
EGYEgypt, Arab Rep.2101473,5808.18315.34718.18314.9904
SLVEl Salvador2501484,6108.43605.52158.43604.9972
GNQEquatorial Guinea3392805,6508.63945.82608.63945.6348
ERIEritrea4934419406.84596.20056.84596.0890
ETHEthiopia5945357006.55116.38696.55116.2823
FROFaeroe Islands
FJIFiji2401804,7908.47435.48068.47435.1930
FINFinland1446124,83010.11984.969810.11984.1109
FRAFrance1446125,53010.14764.969810.14764.1109
PYFFrench Polynesia17998.65.18744.5911
GABGabon3803305,2908.57365.94028.57365.7991
GMBGambia, The3733201,6607.41465.92167.41465.7683
DEUGermany1266025,95010.16394.836310.16394.0943
GHAGhana3793261,9107.55495.93757.55495.7869
GRCGreece1144716,8609.73274.73629.73273.8501
GRLGreenland
GRDGrenada2021596,8108.82615.30838.82615.0689
GUMGuam151.882.65.02264.4140
GTMGuatemala2861823,9208.27385.65608.27385.2040
GINGuinea4323661,9207.56016.06847.56015.9026
GNBGuinea-Bissau4954277506.62016.20466.62016.0568
GUYGuyana2992093,7608.23225.70048.23225.3423
HTIHaiti5243731,6607.41466.26157.41465.9216
HNDHonduras2211572,4507.80385.39827.80385.0562
HKGHong Kong, China101.711252.426,31010.17774.622110.17773.9589
ISLIceland855127,96010.23854.442710.23853.9318
INDIndia2501912,4007.78325.52157.78325.2523
IDNIndonesia232.2180.22,8407.95165.44767.95165.1941
IRNIran, Islamic Rep.1701395,9408.68955.13588.68954.9345
IRQIraq2582085.55305.3375
IRLIreland1086225,97010.16474.682110.16474.1271
IMYIsle of Man
ISRIsrael995619,4909.87774.59519.87774.0254
ITAItaly1105324,73010.11584.700510.11583.9703
JAMJamaica1691273,5108.16345.12998.16344.8442
JPNJapan984426,30010.17734.585010.17733.7842
JORJordan1991443,9108.27135.29338.27134.9698
KENKenya5785299906.89776.35966.89776.2710
KIRKiribati2692085.59475.3375
PRKKorea, Dem. Rep.2381925.47235.2575
KORKorea, Rep.1867115,1409.62515.22579.62514.2627
KWTKuwait1006818,6309.83254.60529.83254.2195
LAOLao PDR3552991,5107.31995.87217.31995.7004
LBNLebanon1921364,4508.40075.25758.40074.9127
LSOLesotho6676302,7307.91216.50287.91216.4457
LBRLiberia4483856.10485.9532
LBYLibya2101575.34715.0562
LIELiechtenstein
LUXLuxembourg1356450,94010.83844.905310.83844.1589
MACMacao, China80.451.619,1409.85954.38709.85953.9435
MDGMadagascar3853228106.69705.95326.69705.7746
MWIMalawi7016535906.38016.55256.38016.4816
MYSMalaysia2021138,2109.01315.30839.01314.7274
MDVMaldives2282265.42935.4205
MLIMali5184467306.59306.25006.59306.1003
MLTMalta1114617,3509.76134.70959.76133.8286
MHLMarshall Islands3022305.71045.4381
MRTMauritania3573021,6907.43255.87777.43255.7104
MUSMauritius2281099,5809.16745.42939.16744.6913
MYTMayotte
MEXMexico1801018,6909.06995.19309.06994.6151
FSMMicronesia, Fed. Sts.2431885.49315.2364
MCOMonaco
MNGMongolia2801991,6007.37785.63487.37785.2933
MARMorocco1741133,3908.12865.15918.12864.7274
MOZMozambique6746128206.70936.51326.70936.4167
MMRMyanmar3432455.83775.5013
NAMNamibia6956616,6208.79796.54398.79796.4938
NPLNepal3143141,3307.19295.74947.19295.7494
NLDNetherlands956427,34010.21614.553910.21614.1589
ANTNetherlands Antilles13266.84.88284.2017
NCLNew Caledonia17992.45.18744.5261
NZLNew Zealand1086918,7609.83954.68219.83954.2341
NICNicaragua2251612,3007.74075.41617.74075.0814
NERNiger4733087406.60676.15916.60675.7301
NGANigeria4433937906.67206.09366.67205.9738
MNPNorthern Mariana Islands
NORNorway1076134,79010.45714.672810.45714.1109
OMNOman18713512,0909.40015.23119.40014.9053
PAKPakistan2211981,8807.53905.39827.53905.2883
PLWPalau
PANPanama145935,9608.69284.97678.69284.5326
PNGPapua New Guinea3593292,3007.74075.88337.74075.7961
PRYParaguay1731294,6208.43815.15338.43814.8598
PERPeru1901394,6208.43815.24708.43814.9345
PHLPhilippines2491424,1708.33575.51758.33574.9558
PRTPortugal1646616,9309.73685.09999.73684.1897
PRIPuerto Rico150.85715,1309.62445.01609.62444.0431
QATQatar1731215.15334.7958
RWARwanda6675991,1007.00316.50287.00316.3953
WSMSamoa2421515,0908.53505.48898.53505.0173
SMRSan Marino
STPSao Tome and Principe2692265.59475.4205
SAUSaudi Arabia18111612,6109.44225.19859.44224.7536
SENSenegal3553031,4607.28625.87217.28625.7137
SYCSeychelles2681225.59104.8040
SLESierra Leone5875314506.10926.37506.10926.2748
SGPSingapore1146123,78010.07664.736210.07664.1109
SLBSolomon Islands2211541,8507.52295.39827.52295.0370
SOMSomalia5164526.24616.1137
ZAFSouth Africa5675029,2209.12916.34049.12916.2186
ESPSpain1224919,7609.89144.80409.89143.8918
LKASri Lanka2441243,4008.13155.49728.13154.8203
KNASt. Kitts and Nevis24314810,2809.23805.49319.23804.9972
LCASt. Lucia189.2376667117.31166675,2308.56225.24308.56224.7648
VCTSt. Vincent and the Grenadines2461654,9908.51525.50538.51525.1059
SDNSudan3412911,5607.35245.83197.35245.6733
SURSuriname2301385.43814.9273
SWZSwaziland6275874,5208.41636.44098.41636.3750
SWESweden9156.3333333324,34010.09994.510910.09994.0313
CHESwitzerland995830,91010.33884.595110.33884.0604
SYRSyrian Arab Republic1701323,1908.06785.13588.06784.8828
TZATanzania5695205106.23446.34396.23446.2538
THAThailand2451506,2708.74355.50138.74355.0106
TMPTimor-Leste
TGOTogo4604061,4007.24426.13127.24426.0064
TONTonga2261596,3408.75465.42058.75465.0689
TTOTrinidad and Tobago2091338,2909.02285.34239.02284.8903
TUNTunisia169995,9708.69455.12998.69454.5951
TURTurkey2181206,3008.74835.38458.74834.7875
UGAUganda6175671,2407.12296.42497.12296.3404
AREUnited Arab Emirates1439325,22010.13544.962810.13544.5326
GBRUnited Kingdom1096724,84010.12024.691310.12024.2047
USAUnited States1478434,69010.45424.990410.45424.4308
URYUruguay185898,7409.07575.22049.07574.4886
VUTVanuatu2401852,9407.98625.48067.98625.2204
VENVenezuela, RB178995,5808.62695.18188.62694.5951
VNMVietnam2031391,9907.59595.31327.59594.9345
VIRVirgin Islands (U.S.)103.6754.64054.3175
WBGWest Bank and Gaza160.41035.07774.6347
YEMYemen, Rep.2782267606.63335.62766.63335.4205
ZMBZambia7256877406.60676.58626.60676.5323
ZWEZimbabwe6506122,5007.82406.47707.82406.4167
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WDI adult mortality
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GNI per capita PPP 2000 (in log)
Male adult mortality 2000 (in log)
UZB
UKR
TKM
TJK
SVN
SVK
RUSSIA
ROM
POL
MDA
MKD
LTU
LVA
KGZ
KAZ
HUN
GEO
EST
CZE
HRV
BGR
BLR
AZE
ARM
ALB
Is Economic Growth Sustainable in Russia without Good Health in Russia?Source: World Bank World Development Indicators 2005/WHO/ERO HFA Database 2005.Note: When calculating GNI in U.S. dollars from GNI reported in national currencies, the World Bank follows the Atlasconversion method, using a three-year average of exchange rates to smooth the effects of transitory exchange ratefluctuations.
The Russian Population Structure:2005 and 2020 Source: UN Population Projections, 2004 Revisions
Chart1
-5.3779463564.513527404
-5.21538878354.393605946
-5.9453926975.0063914184
-9.06408982817.7896234993
-8.92109937087.847607501
-7.98639332917.1755202087
-7.61762846566.7511827419
-6.95987236226.1199478144
-8.11884764747.5128816731
-8.77810891368.4406257001
-7.58903037427.6314853129
-5.81895902956.2266910902
-2.68671543393.2471040945
-4.75480899496.5192467351
-2.44137391253.8651608397
-2.72735482716.9567623842
Percentage
Russia 2005
Sheet6
Dependency Ratios
1995200020052010201520202025
Total50444037394449
Child32262018192020
Elderly18182018202429
Population 60+ and
Deaths and DALYs Lost Attributable to the 10 Leading Diseases and Injuries in Russia, 2002 Source: WHO/EURO Health Database
Cause-Specific Adult Mortality Rates, Age 1564Deaths per 100,000 populationSource: WHO Mortality Database
Deaths and DALYs Lost Attributable to 10 Leading Risk Factors in Russia, 2002 Source: WHO/EURO Health Database.
RankRisk factorTotal Deaths %RankRisk factorTotal DALYs %1High blood pressure35.51Alcohol16.52High cholesterol23.02High blood pressure16.33Tobacco17.13Tobacco13.44Low fruit and vegetable intake12.94High cholesterol12.35High BMI12.55High BMI8.56Alcohol11.96Low fruit and vegetable intake7.07Physical inactivity9.07Physical inactivity4.68Urban outdoor air pollution1.28Illicit drugs2.29Lead1.29Lead1.110Illicit drugs0.910Unsafe sex1.0
Non-Communicable Diseases and Injuries Are the Leading Causes of Death and Ill Health in RussiaCardiovascular Disease: CVD death rate in Russia (2002) = 994 per 100,000 population (United States = 317, Portugal = 363, Brazil = 225)Traffic Injuries: Mortality due to traffic injuries in Russia = 20.6 deaths per 100,000 population (G-8 rate = 11) Suicide: Russias suicide rate is much higher than that of EU countries (when it peaked in 1994, suicide rate for Russian men aged 5054 was over six times that in the United States) Alcohol Abuse: Adult per capita alcohol consumption in 1999 was 10.7 liters per adult in Russia versus 8.6 liters in the United States and 9.7 liters in the United Kingdom Violence: In 1999, close to 30,000 persons died from homicide in Russia. Alcoholism is closely related to crime; the proportion of crimes committed by men and women while intoxicated in 2002 was about 30 percent and 12 percent, respectively.
The Preventable Risk Factors for NCDs and InjuriesTobacco Consumption: Russia has one of the worlds highest rates of smoking among men. While smoking prevalence among men decreased slightly to 61 percent in 2004, the prevalence of smoking among women increased from 7.3 percent in 1992 to 15 percent in 2004. Drug Use: At the beginning of 2005, drugs users were estimated to number 500,000. High Cholesterol: About 60 percent of Russian adults have higher than recommended cholesterol levels, and about 20 percent are at high risk and in need of medical attention.Psychosocial Stress: Stress resulting from the economic transition and reduction in the social safety net manifests as depression and anxiety and can lead to incapacity, suicide, and other violence-related injuries.Low Socioeconomic Status: People of lower socioeconomic status have higher mortality and are more likely to report bad health than people of higher status.
Consequences of the Demographic Decline and The Health DeficitImpact on labor: Fewer workers; high absenteeism due to ill health; and job lossesDestabilization of families: The death of a household member affects other household members welfare and behavior, including alcohol abuseGrowing regional disparities: Disparities in life expectancy in different regions and among social and ethnic groups could exacerbate existing differences and may give rise to social and political challenges, especially in a country as vast as RussiaChronic illness has negatively affected household incomes, particularly during 19982002, when it is estimated that chronic illness contributed to an annual loss of 5.6 percent of per capita incomeHigh medical treatment costs on the economy
Impact Of NCDs and Injuries on Health Care Costs and the Economy Source: Frid 2005.
Distribution of Risk Factors in a PopulationSource: Rose 1992, as shown in North Karelia Project Presentation, National Public Health Institute, 2005
Strategies and Interventions to Prevent Non-communicable Diseases and Injuries Policies, Strategies, and Capacity-building at the Federal Level:Develop legal, policy, and strategy support for priority population-based subprogramsBuild institutional capacity to implement priority subprogramsAssure federal oversight and accountability
Priority Subprograms in the Regions:Population-based Primary Prevention Interventions: Alcohol, Tobacco, Changes in Diet, and Promotion of Physical ActivitySecondary Prevention: Hypertension, Cholesterol, Diabetes ControlRegional support subprograms for implementing the national mortality reduction programImproved road safety and emergency medical services
What Health Improvements Could Result from an Intensified Program of Action?Estimated Improvements in Life Expectancy if Mortality Rates Are Reduced by 20 and 40 Percent, Russian Males, 2000
Source: Authors calculations
What Health Improvements Could Result from an Intensified Program of Action?Estimated Improvements in Life Expectancy if Mortality Rates Are Reduced by 20 and 40 Percent, Russian Females, 2000
Source: Authors calculations
Main FindingsThe static economic benefits of gradually bringing the adult NCD- and injury-mortality rates down to the European Union (EU-15) rates by 2025 are estimated at 3.6 to 7.1 percent of the 2002 Russian GDP When a broader concept than GDP per capita is considered, the welfare benefits from achieving EU-15 rates by 2025 are estimated to be as high as 29 percent of the 2002 Russian GDP The impact of improving adult health on economic growth rates is significant and grows over time: while in 2005 the difference in the per capita GDP between the status quo scenario and the most optimistic scenario is US$105$324, by 2025 this difference grows to US$2,856$9,243
What Are the Potential Economic Benefits of Mortality Reduction in Russia? Russian GDP per Capita Forecasts in the Three Scenarios1996 constant U.S. dollarsSource: Suhrcke at al. 2005
ConclusionsRussia is experiencing a major and complex demographic and health crisis characterized by premature mortality; ill health and disability among young adults; and a reduction in population size, coupled with the aging of its population. Poor adult health negatively affects economic well-being at the individual and household level; if effective action were taken in Russia, improved health would play an important role in economic growthMost non-communicable diseases and injuries could be prevented and controlled through a comprehensive national program operating at the federal, regional, and municipal levels, adapting best practices that have proven effective internationally The time has come to acknowledge the breadth of social and economic factors that affect health, including the responsibility of individuals for their own health and government responsibility for creating an enabling environment for its population to make healthier choices