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Projected trends in health status and the health sector
in WHO European Region by 2020 First Meeting of the working group on
EURO's future
Copenhagen, 26-27 of September, 2005
Elena Varavikova, WHO HQ/EIP/SPO/QPS
In the 21st century Health is….
• Foreign policy
• Security policy
• Economic policy/Trade policy
• Demographic development
• Geopolitics
The growth of epidemics
• AIDS, SARS, Avian etc
• Global obesity/tobacco epidemics
• Increasing Global risk factors
• Unhealthy consumption
• The threat of bio terrorism
The lack of sustainable health systems
• Lack of health care coverage of the poor• Insufficient national capacities for public health
in rich and poor countries• The dramatic fall of investment in universal
health systems.• Lack of human resources //export and brain
drain
Systems default:
• Focus on disease
• A world of vertical programs and quick fix solutions
• A tendency to invest in technologies and drugs and not in social protection, health systems and people
Health and the European Union
• The health of most of the populations of the developed countries has never been better
• Professionally applied Public health measures
• Advanced medicine• Increased maternal literacy• Modern hygiene• Life-style changes
Current challenges for European Health System
• Rapid advancement in Technologies
• Rising expectations about health care
• Patient Safety
• Subsequent costs and quality of care
• Demographical challenges
(Aging; Migration; Low birth rate)
• Privatization of social services
• Macroeconomic context
Challenges for FSC
• Globalization
• Transition
• Population Challenge
• Social & Economic Challenge
• Ecological Challenge
• Political Challenge
Vision 2020
• Continuous Development and Progress
• A. EU• B Non EU
• Outstanding Challenges:
• Avian influenza• Manmade
catastrophe• Natural catastrophe
Recent trends in life expectancy at birth since 1970:Estonia, Hungary, Poland, Russia, and the UK
Recent trends in life expectancy at birth since 1970:Estonia, Hungary, Poland, Russia, and the UK
55
60
65
70
75
80
85
1970 1980 1990 2000
Year
Lif
e ex
pec
tan
cy in
yea
rs
UK Hungary Poland
Estonia Russia
55
60
65
70
75
80
85
1970 1980 1990 2000
Year
Lif
e ex
pec
tan
cy in
yea
rs
UK Hungary Poland
Estonia Russia
Emergence of a new East-East gap in the 1990s
e(0) in Russia, 2000: 59.2 (m) and 72.4 (f)
Long term trends in life expectancy at birth since 1890:France, Japan, Russia and the USA.
Long term trends in life expectancy at birth since 1890:France, Japan, Russia and the USA.
20
30
40
50
60
70
80
90
1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Lif
e ex
pec
tan
cy a
t b
irth
in y
ears
Russia
USA
Japan
France
MALES
20
30
40
50
60
70
80
90
1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000
Year
Lif
e ex
pec
tan
cy a
t b
irth
in y
ears
Russia
USA
Japan
France
FEMALES
Historical gap, its reduction in the 1950s and the new health crisis in 1965-2000
Population of Russia, projections, 1950-2050
• .
Trends in SDRs for avoidable causes of death since 1965: Russia, Baltic countries and the UK, both sexes, per 100000
0
100
200
300
400
500
600
700
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
All avoidable causes
0
50
100
150
200
250
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
All causes amenable by medical care
0
20
40
60
80
100
120
140
160
180
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Causes amenable to medical care: hypertensive disease and cerebrovascular disorders
0
2
4
6
8
10
12
14
16
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Tuberculosis
0
50
100
150
200
250
300
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Ischeamic heart disease
0
20
40
60
80
100
120
1965 1970 1975 1980 1985 1990 1995 2000
Year
Estonia Latvia Lithuania Russia United Kingdom
Causes amenable to health policy
Components of the life expectancy gap between Russia
and the UK in 1965-2000 according to potential impact of
medical care (either preventive or curative) and health policies
Components of the life expectancy gap between Russia
and the UK in 1965-2000 according to potential impact of
medical care (either preventive or curative) and health policies
The gap is mostly due to CVD and external causes. Stroke is included into group of causes amenable by medical care (blood pressure control). Liver cirrhosis, poisonings by alcohol and lung cancer can be reduced by health policies.
Improvement of medical care itself (with IHD excluded) can remove about 15-20% of the gap.
5 5
6 0
6 5
7 0
7 5
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Y e a r
Life ex
pectan
cy
O t h e r
C a u s e s a m e n a b l e t o h e a l t h p o l i c y
T u b e r c u l o s i s
I s c h a e m i c h e a r t d i s e a s e
C a u s e s a m e n a b l e t o m e d i c a l c a r e
L i f e E x p e c r a n c y i n R u s s i a
L i f e E x p e c r a n c y i n U K
6 5
7 0
7 5
8 0
8 5
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
Y e a r
Life ex
pectan
cy
O t h e r
C a u s e s a m e n a b l e t o h e a l t h p o l i c y
T u b e r c u l o s i s
I s c h a e m i c h e a r t d i s e a s e
C a u s e s a m e n a b l e t o m e d i c a l c a r e
L i f e E x p e c r a n c y i n R u s s i a
L i f e E x p e c r a n c y i n U K
Alcohol Consumption in Russia
• Alcohol consumption plays a far greater role in the mortality crisis than had previously been thought.
• The decline in mortality in the mid-1980s (which co-incides with Gorbachev's anti-alcohol campaign) and the subsequent rise after 1988 parallels what is known about alcohol consumption in Russia. This has soared due to the upsurge of home brewing, the relatively cheap price of alcohol and the absence of any concerted attempt to counteract alcohol abuse.
• The direct effect of alcohol consumption on mortality is shown in the four-fold increase of deaths from alcohol-related conditions between 1988 and 1994.
• The indirect effects of alcohol are shown in the alarming increase in accidents and violence (a significant proportion of which may be alcohol-related).
• An important finding is that much of the increase in mortality from cardiovascular and respiratory disease among people of working age can be attributed to the effects of alcohol. (Acute episodes of very high levels of alcohol consumption can result in death from cardiac arrythmia and haemorrhagic stroke.)
CIA - Mapping the Global Future (2002)
• Russia’s energy resources will give a boost to economic growth, but Russia faces a severe demographic challenge resulting from low birth rates, poor medical care, and a potentially explosive AIDS situation. US Census Bureau projections show the working-age population likely to shrink dramatically by 2020. Russia’s present trajectory away from pluralism toward bureaucratic authoritarianism also decreases the chances it will be able to attract foreign investment outside the energy sector, limiting prospects for diversifying its economy. The problems along its southern borders—including Islamic extremism, terrorism, weak states with poor governance, and conflict—are likely to get worse over the next 15 years. Inside Russia, the autonomous republics in North Caucasus risk failure and will remain a source of endemic tension and conflict. While these social and political factors limit the extent to which Russia can be a major global player, in the complex world of 2020 Russia could be an important, if troubled, partner both for the established powers, such as the United States and Europe, and the rising powers of China and India. The potential also exists for Russia to enhance its leverage with others as a result of its position as a major oil and gas exporter.
Copyright ©2003 BMJ Publishing Group Ltd.
Men, T. et al. BMJ 2003;327:964
Fig 1 Age standardised mortality from all causes by region
Life expectancy at age 15 in Europe, men, 1970-2001.
40
45
50
55
60
65
1970 1975 1980 1985 1990 1995 2000
EUCEEFSURussia
Life expectancy at age 15 in Europe, women, 1970-2001.
55
60
65
70
1970 1975 1980 1985 1990 1995 2000
EUCEEFSURussia
Probability of men dying (per Probability of men dying (per 1000) between1000) between
15 and 59 15 and 59 yearsyears
295
226
147 144
10087
287
161 170143
428
365
0
50
100
150
200
250
300
350
400
450
Eastern/central Europe
Advanced industrialisedcountries
Developingcountries
Trends in selected causes of death for women aged 30-59 years in Russia 1965-1999
0
20
40
60
80
100
120
140
160
180
1965 1970 1975 1980 1985 1990 1995 2000
Year
SD
R p
er 1
0000
0
Accidents and violence
Ischaemic heart disease
Stomach cancer Breast cancer
Rheumatic heart disease
Rates of abortion in some European countries and the US
Country Year of most recent
available figures
Total number of legal
abortions
Abortion rate
Germany1 2000 134 609 8.0 per 1000 women aged 15-44
Finland2 2000 10 932 9.0 per 1000 women aged 15-49
Italy3 2002 126 164 9.3 per 1000 women aged 15-49
Denmark2 2000 15 681 12.5 per 1000 women aged 15-49
Iceland2 1999 947 13.4 per 1000 women aged 15-49
Norway2 2000 14 655 13.7 per 1000 women aged 15-49
Sweden2 2000 30 980 15.6 per 1000 women aged 15-49
US4 2001 853 485 16.0 per 1000 women aged 15-44
UK5 2004 185 400 17.8 per 1000 women aged 15-44 (age standardised to the European population)
Ukraine6 1999 495 800 45.4 per 1000 women aged 15-44
Maternal Mortality, Kazakhstan and others, 1970-2001
0
10
20
30
40
50
60
70
1970 1975 1980 1985 1990 1995 2000 2005
Israel
Kazakhstan
Russia
CEE average
CAR average
080100 +Maternal deaths per 100000 live births
Infant Mortality, Kazakhstan and others, 1970-Infant Mortality, Kazakhstan and others, 1970-20012001
5
10
15
20
25
30
35
40
45
1970 1975 1980 1985 1990 1995 2000 2005
Israel
Kazakhstan
Russia
CEE average
CAR average
070100 +Infant deaths per 1000 live births
Europe: Water; Food; Housing in 2020
• Water – the “Oil” of the 21st Century?
• Food - malnutrition
• Housing – 52%
European water treaty • Almost 140 million people in Europe (16%) do not have a
household connection to drinking water • Five million people (10%) do not have improved sanitation
(connection to a public sewer, connection to a septic system, pour flush latrine, simple pit latrine, or ventilated improved pit latrine)
• More than 41 million people (5%) lack access to a safe drinking water supply.
• Poor quality drinking water cause more than 13 000 deaths from diarrhoea among children aged 0 to 14 years (5.3% of all deaths in this age group) every year.
• Ress.P European water treaty hailed as a milestone for public health BMJ. 2005 Aug 13;331(7513):368.
The Privatization of Water • The four leading states of Western Europe all have different water
systems. However, all four now encourage privatization. In France and in the U.K., the process is far advanced, while in Germany and Italy, private participation is still incipient but growing. Service providers in all four countries have historically kept prices below market levels and now must face large price increases in order to upgrade their plants and distribution systems to accepted European standards. To pay for the necessary infrastructure, and not raise water tariffs through the roof, government providers would have to raise taxes, increase borrowing, or both, which few politicians dare to do nowadays. Therefore, they have turned to private companies and their shareholders. The new European standards have, perhaps inadvertently, made increased privatization of water and sewerage in Europe inevitable. The U.K. model, though slandered by many for political reasons, has met these higher investment needs most rapidly, albeit with higher prices, which have given rise to deep, if unwarranted, consumer distrust.
Climate change
• .
Copyright ©2005 BMJ Publishing Group Ltd.
de Vries, E. et al. BMJ 2005;331:698
Age specific incidence of and mortality from cutaneous malignant melanoma in the Netherlands, 1950-2005
Benjamin Disraeli
What we anticipate - seldom occurs;
What we least expected generally happened
1: epidemic, 2: probable pandemic, 3: pandemic
Source: Potter, C.W: Textbook of Influenza by Nichols, Webster, Hay, Blackwell Science 1998
Recorded Influenza Pandemics
0
1
2
3
1883
30 years 10 10 37 years 10 20
2005
H1 H2 H3
H1
1893 1903 1913 1923 1933 1943 1953 1963 1973 1983 1993
*
1918-19
"Spanish Flu"
1957-58
"Asian Flu"
1968
"HK Flu"
Location of H5N1 Avian Influenza in the Russian Federation and suspected areas
(www.oie.int)
Aprx. 90.000 birds destroyed
Infections mainly seen in wild ducks and geese and widespread
Europe and Central Asia Regional Brief
Adults and children
living with HIV/AIDS
New infections
in 2004
Adult prevalence
rate* %
Deaths due to AIDS
in 2004
..1.4 million
(Range: 920,000 -
2.1 million)
..210,000(Range: 110,000-480,000)
..over 1%
..
..60,000(Range: 39,000-87,000)
AIDS in Europe and Central Asia
• .
Most TB cases are in India and China
10 000 to 99 999
100 000 to 999 999
1 000 000 or more
< 1 000
1 000 to 9 999
No Estimate
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2002
Trends in TB death registrations
0
200
400
600
800
1000
1200
1985 1990 1995 2000
Geo
met
ric
mea
n n
um
ber
of d
eath
s Former Soviet Union
Central Europe
Industrialized
Latin America
High rates of drug resistance mainly in former Soviet countries
0
5
10
15
20F
INLA
ND
FR
AN
CE
N'L
AN
DS
SC
OT
LAN
D
DE
NM
AR
K
SW
ED
EN
PO
LAN
D
SW
ITZ
LND
Bar
celo
na
EN
GLA
ND
GE
RM
AN
Y
CZ
EC
H
SLO
VA
KIA
NO
RW
AY
ITA
LY
LAT
VIA
Ivan
ovo
Tom
sk
ES
TO
NIA
MD
R c
ases
(%
)
Foreign-born make a large and growing contribution to TB in Europe
0
10
20
30
40
50
60
70
80
Portugal
Finla
nd
Greec
e
Irela
ndIta
ly
Austria
Germ
any
Belgiu
m
France UK
Nether
lands
Sweden
Norway
Luxem
bourg
Denm
ark
TB
ca
se
s a
mo
ng
fo
reig
ne
rs (
%)
0
50
100
150
200
1970 1980 1990 2000 2010
AlbaniaKazakhstanRepublic of MoldovaRussian FederationTFYR Macedonia
Tuberculosis incidence per 100000
0
5
10
15
20
25
30
1970 1980 1990 2000 2010
AlbaniaKazakhstanRepublic of MoldovaRussian FederationTFYR Macedonia
Diphtheria incidence per 100000
70% tobaccodeaths in 2020
70% tobacco consumption in 2000
70% of tobacco production in 1996
Tobacco and low and middle income countries
Current male smoking prevalence rates, by age group.
• .
Current female smoking prevalence rates, by age group.
• . • .
SDR, trachea/bronchus/lung cancer, 0-64 per 100000
Source: WHO/Europe, HFA Database, January 2005
Kazakhstan
Kyrgyzstan
Russian Federation
Tajikistan
Turkmenistan
Uzbekistan
EU
Current Tobacco Users (%), 13-15 yearsfrom Global Youth Tobacco Survey
< 15%15-25%> 25%Variable
Source: WHO/Europe, HFA Database, January 2005
Kazakhstan
Kyrgyzstan
Russian Federation
Tajikistan
Turkmenistan
Uzbekistan
EU
SDR, diseases of circulatory system, 0-64 per 1000000
Stroke Mortality, Kazakhstan and others, 1970-2001
0
50
100
150
200
250
300
350
1970 1975 1980 1985 1990 1995 2000 2005
Israel
Kazakhstan
Russia
CEE average
CAR average
090302 +SDR,cerebrovascular disease,all ages/100000
The public health implications of world trade negotiations
• Trade ministries from the World Trade Organization's (WTO's) 144 member states are presently deciding which public services to open to foreign competition under the complex liberalisation rules of the general agreement on trade in services (GATS).
• …..national autonomy over health policy is not preserved under GATS, and that accordingly, there is a role for international standards that protect public services from the adverse effect of trade and market forces.
• Skilled workforce migration
Poverty reduction, 1990-98MDG goal: halving poverty by 2015
50
75
100
125
1990 1998
Eastern Europe/Central Asia
Sub-SaharanAfrica
South Asia
Middle East &North Africa
target
Latin America
East Asia
poverty incidence 1990 =100
Trends in probability of survival in Russian men by education (relatives’ study)
0.4
0.45
0.5
0.55
0.6
0.65
0.7
Calendar year
45 p
20
university elementary
45 p20 = probability of living to 65 yrs when aged 20 yrs Murphy et al, submitted
WHS People(%) who noted worsening attitude to
them on the part of the medical personnel for one of the following reasons:
groupsgroups Outpatient Outpatient clinicclinic
Inpatient Inpatient Hospital Hospital
-sexsex 0,20,2 0,70,7
-ageage >> 60 6060 60 ++
6,86,82,02,0
12,612,6
8,88,82,62,6
15,815,8
-lack of moneylack of money 9,29,2 15,115,1
-ethnic groupethnic group russianrussian titletitle ethnic groupethnic group otherother
0,30,30,20,2--
2,22,2
0,50,50,20,21,01,08,78,7
WHS
Angina pectoris in the able-bodied age (%)Angina pectoris in the able-bodied age (%)
Positions urban rural
Prevalence 6,6 13,1
Visited in the last 12 months 74,5 60,9
Not get all the medicines in the last 12 months
38,9 60,9
Could not afford 48,6 35,7
WHS Have not got (or have not fully got) medicines Have not got (or have not fully got) medicines
prescribed by the medical personnel (%)prescribed by the medical personnel (%)- for adult 37,7
- for children 24,5
Reasons for adult for children
- Could not afford 52,0 46,3
- Already had some of the medicines at home
18,3 27,8
- Could not find all medicines 8,0 11,2
- Did not believe all the medications were needed
9,5 7,4
WHS
Comparative estimate of population distribution (%) in the
relative body mass (BMI) for the ages of 20 to 74 BMI Russia USA*
men women men women
> 18,49 0,6 2,4 1,1 3,5
18,5 – 24,99
48,5 42,0 37,9 45,3
25 > 50,8 55,6 61,0 51,2
30 > 6,5 16,3 12,8 17,1*Health USA, 2000
4.9
5.3
7.8
3.63.7
1.2
7.7
Prevalence of diabetes among the adult population
P. Home, 2001, Athens, Greece
Russia 2.5%
from the World Health Survey in Russia - 2.9%
The Paradigm Shift in Health Research
Approach Biomedical deterministic research
Participatory social/ community research
Focus Individual Community
Dimesions Physical / pathological Psycho- social, cultural, economic, political
Technology Drugs / vaccines Education and social processes
Type of service
Providing/ Dependanse creating / Social marketing
Enabling / EmpoweringAutonomy Building
Link with people
Patient as passive beneficiary
Community as active Participant
Research Molecular biologyPharmaco – therapeuticsClinical Epidemiology
Socio – epidemiologySocial determinantsHealth SystemsSocial Policy
Towards a Fresh Vision
• Focusing on the Goal: Sustainable Improvement of Health status in WHO European Region in 2020
• Understanding potentials and limitations of the role of WHO in the process
• Responding to the needs of adequate development
Strengthening public health: vision for EURO
• Improved Public health research, training and standards of practice - a priority
• Broad view of public health (trauma, poverty)
• Adequately resources
• Strong and respected leadership, advocacy
• Appropriate information and surveillance systems (measurements, methods)
• Acting nationally and globally
Conclusions• The societal transformation has had a
major impact on peoples lives and health• Central Europe is doing better than some
FSC• The aggregate trends related to social
factors and will continue• Mortality reversal (Russia)• Emerging negative trends in mortality of
Russian women• LE will continue to deteriorate in Russia
To the positive attitude:
• Business carried on as usual during alteration on the map of Europe
Winston Churchill,
Speech, 9 November, 1914