Morbidity and Mortality in Transition Countries in the European Context

European Population Forum 2004: Population Challenges and Policy Responses Ellen Nolte, Martin McKee and Anna Gilmore Morbidity and mortality in transition countries in the European context Background paper for the session on: Morbidity, mortality and reproductive health: facing challenges in transition countries. Disclaimer: This document has been reproduced without formal editing. The views expressed in it are those of the authors and do not necessarily reflect the views of the United Nations Economic Commission for Europe and the United Nations Population Fund. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the United Nations Economic Commission for Europe and the United Nations Population Fund concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers and boundaries. Morbidity and mortality in transition countries in the European context E Nolte, M McKee, A Gilmore European Centre on Health of Societies in Transition London School of Hygiene & Tropical Medicine, London, UK Background paper for the thematic session “Morbidity, mortality and reproductive health: Facing challenges in transition countries” at the European Population Forum 2004 Geneva, 12-14 January 2004 BACKGROUND After the fall of the Berlin Wall in November 1989, Europe’s political, economic and cultural borders shifted once again in the 20th century, with the break-up of the former communist bloc adding 22 new countries to the map of Europe. An immensely diverse region, Europe comprises some of the richest countries in the world alongside regions that have undergone dramatic political, social and economic changes during the last decade, a number of which having ended the 1990s with incomes close to those of the least developed countries. The economic disparities show a distinct geographical pattern, with national income per capita falling almost exponentially along the west-east axis. Thus, in Luxembourg, in 2001, GDP per capita was, at US$ 53,780 (PPP*), about 50 times that in Tajikistan (US$ 1,170) and at last 20 times that in the Caucasus region, Moldova, Uzbekistan or Kyrgyzstan. 1 The political and economic transition in the former communist countries of central and eastern Europe has been difficult for all countries affected, but, at the risk of oversimplification, can be described as a “tale of two regions” – central and eastern Europe on the one hand and the successor states of the former Soviet Union which are now member of the Commonwealth of Independent States (CIS)† on the other. Several countries in central and eastern Europe have made remarkable progress since the mid-1990s, with ten countries including the Baltic states on the verge of joining the European Union in 2004. In contrast, the countries emerging from the Soviet Union have been experiencing deep economic crises and a number of CIS countries including Russia and Ukraine saw an actual decline in the Human Development Index in the 1990s, reflecting failed economic growth and the inability to reduce income and human poverty. However, despite economic growth the more successful countries of central and eastern Europe, like those in western Europe, saw an increase in income inequalities, albeit of varying degree2, with an impact on levels of poverty. Thus, Poland experienced an increase in GDP per capita of 2.4% per year between 1987/88 and 1993/95, which was, however, accompanied by a 14% rise in levels of poverty.1 It has been estimated that poverty, defined as poverty line of US $2 per day, has almost trebled during the 1990s, to close to 100 million people or 25% of the population in central and eastern Europe and the CIS.1 This diversity in social and economic patterns across the European region is mirrored, to a considerable extent, in patterns of health that date back to the late 1960s, with a remarkably clear-cut division between pre-1990 political borders.3,4 Thus, during the last 30 years the health of the peoples of central and eastern Europe and the former Soviet Union (FSU) underwent changes that were very different from health patterns seen in their western neighbours. As a consequence, the 1990s have seen a dramatically increased gap in health status between countries in the European region. 5 This gap is reflected in, among other health indicators, life expectancy at birth. Figure 1 shows trends in life expectancy since 1980 in different European countries that have, for simplicity, been grouped into countries of the European Union (EU; 15 Member States as at 2000), central and eastern Europe (CEE; 12 * PPP (Purchasing Power Parity): A rate of exchange that accounts for price differences between countries, allowing international comparison of real output and incomes. At the PPP US$ rate as used here, PPP US$1 has the same purchasing power in the domestic economy as has $1 in the United States. † CIS refers to the 12 successor countries of the Soviet Union that now form the Commonwealth of Independent States and does therefore not include the three Baltic states Estonia, Latvia and Lithuania that were also part of the former Soviet Union (FSU); reference will be made to both. 2 countries‡), FSU and central Asia (CAR§). It shows that while life expectancy steadily increased in western Europe, it only slowly improved in the countries of central and eastern Europe, following years of stagnation throughout the 1980s. The successor countries of the Soviet Union, in contrast, saw a series of unexpected fluctuations in which life expectancy improved substantially in 1985 before falling back after 1987, accelerating downwards until 1994, followed by brief but considerable improvement until 1998 and then falling back again, the changes in the 1990s broadly mirroring the economic crises experienced. 80 85 men women EU 75 EU 80 70 CEE CEE 75 65 CAR FSU CAR FSU 70 Life expectancy at birth (years) Life expectancy at birth (years) 60 55 65 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Year Year Figure 1 Trends in life expectancy at birth in Europe, 1980-2000 [adapted from (6)] However, these general trends conceal a mortality pattern that differs between countries, especially regarding the diverse republics of the FSU. Within the European Union, whilst steadily improving in all Member States over the recent decades, there is still considerable variation in life expectancy at birth with, among men, Portugal continuously at the lower and Sweden at the upper end, at, respectively, 72.7 and 77.7 years in 20017 (Figure 2). 80 Sweden 85 France men women EU EU 75 80 70 Portugal Portugal 75 65 70 Life expectancy at birth (years) 60 Life expectancy at birth (years) 55 65 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Year Year Figure 2 Trends in life expectancy at birth in the Member States of the European Union, 1980-2000 [adapted from (6)] ‡ Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Hungary, Poland, Romania, Slovakia, Slovenia, TFYR Macedonia, Serbia and Montenegro § Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan 3 Among women, life expectancy at birth has also been lowest in Portugal, although alternating with Ireland and, in the 1990s also Denmark, and highest in France. In 2001, figures ranged between 79.2 years in Ireland and 82.9 in France.7 However, figure 2 also suggests that there is a general trend towards convergence in terms life expectancy at birth within the EU. south-east Europe 85 central Europe 85 women women E-Germany Slovakia 80 Slovenia 80 Albania Czech Rep. Poland Croatia Macedonia Bulgaria 75 75 Serb/Monten. E-Germany Hungary Slovenia Czech Rep. Romania Albania Macedonia 70 70 Serb/Monten. Bulgaria Slovakia Hungary Romania 65 65 Croatia Poland Life expectancy at birth (years) Life expectancy at birth (years) 60 60 men men 55 55 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 85 Baltic states 85 north west Europe women women 80 80 Lithuania Ukraine Estonia Belarus 75 75 Latvia Russia Moldova 70 Lithuania 70 Belarus Estonia Ukraine 65 65 Moldova Life expectancy at birth (years) Life expectancy at birth (years) 60 60 men Latvia men Russia 55 55 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Caucasus Central Asia 85 85 women women 80 Georgia 80 Armenia Kazakhstan 75 Azerbaijan 75 Kyrgyzstan Tajikistan Uzbekistan Georgia 70 70 Turkmenistan Armenia Azerbaijan Uzbekistan 65 65 Kyrgyzstan Life expectancy at birth (years) Life expectancy at birth (years) 60 60 Turkmenistan men Kazakhstan men Tajikistan 55 55 1980 1985 1990 1995 2000 1980 1985 1990 1995 2000 Figure 3 Trends in life expectancy at birth in selected countries of central and south- eastern Europe and the former Soviet Union, 1980-2000 [adapted from (6)] 4 In contrast, there is wide variation between the countries in transition. After a period of stagnating or even increasing mortality especially during the 1980s many countries in central and eastern Europe experienced a mortality crisis in the early 1990s after the fall of communism (Figure 3). In some countries, this worsening of mortality was short-lived and followed by improvements in health, which were rapid in some countries, such as east Germany, Poland and the Czech Republic, and delayed in others, such as Hungary. In contrast, there was a continuing steady deterioration in men in Bulgaria and Romania and no improvement in women until the late 1990s. In the FSU countries the path followed by each country was initially much more consistent, with a rapid fall in life expectancy until 1994. This was followed by a recovery which, in some such as Russia and Ukraine, peaked in 1998. One of the few exceptions to this pattern was Belarus, which after 1994 continued on a downward path albeit without the sudden declines experienced elsewhere.

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