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,

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