THE 2010 EUROPE & EURASIA HEALTH VULNERABILITY ANALYSIS SIXTH REPORT | MARCH 2010 Table of Contents Acknowledgments . 5 Acronyms. 7 Executive Summary . 9 Introduction. 12 Methodology . 14 Health Vulnerability Index . 17 Population Growth and Fertility . 21 Life Expectancy. 25 Adult Mortality . 28 Under-5 Mortality . 33 Tuberculosis. 35 HIV/AIDS. 40 Health Expenditures. 44 Conclusions: Health Vulnerabilities in the E&E Region . 49 References . 55 Annexes . 59 A. Health Vulnerability Index Indicator Selection . .59 B. Regional Vulnerability and Indicator Maps . .60 C. Country Radar Graphs for E&E Countries and EU-27 . .64 The 2010 Europe and Eurasia Health Vulnerability Analysis 3 4 The 2010 Europe and Eurasia Health Vulnerability Analysis Acknowledgments The Bureau for Europe and Eurasia (E&E) Health Team would like to acknowledge the following USAID staff whose input was invaluable to the production of The 2010 Europe and Eurasia Health Vulnerability Analysis: Sandra Bird, Susanna Baker, Lyndsey Garcia, Carolyn Mohan, Samantha Huffman, Jessica Forrest, Forest Duncan, Paul Holmes, and other E&E Bureau staff.We would also like to thank the summer interns Patricia High, Stacey Brilliant,Amy Bates, Ramona Carey, Lauren Smith, and Sarah Guagliardo, whose excellent work on the E&E health vulnerability analyses in years past continues to contribute to our annual analysis of the region. This year’s report was a collaborative effort. Soumya Alva, Eckhard Kleinau, and Kathy Rowan from the Analysis, Information Management & Communications (AIM) Activity and summer interns Yireh Rivera Mercado and Eliseo Rodriguez were the primary analysts and authors.A very special thank you goes out to Susanna Baker, Lyndsey Garcia, and Paul Holmes, who supervised the team and provided invaluable input throughout the process. Finally, the AIM team worked diligently to edit, improve, and finalize the report for distribution to colleagues in Washington, D.C., and throughout the E&E region. The 2010 Europe and Eurasia Health Vulnerability Analysis 5 6 The 2010 Europe and Eurasia Health Vulnerability Analysis Acronyms AIDS Acquired Immune Deficiency Syndrome AMR Adult Mortality Rate ARV Antiretroviral CAR Central Asian Republics DOTS Directly Observed Treatment, Short Course E&E Europe and Eurasia EU European Union EU-27 The 27 countries in the European Union in 2007 GDP Gross Domestic Product HALE Health-Adjusted Life Expectancy HIV Human Immunodeficiency Virus IDU Injecting Drug Use, Injecting Drug User LSHTM London School of Hygiene & Tropical Medicine MDG Millennium Development Goal MDR-TB Multidrug-Resistant Tuberculosis MMR Maternal Mortality Ratio MSM Men Who Have Sex with Men NCDI Noncommunicable Disease and Injury NT Northern Tier PRB Population Reference Bureau RUMB Russia, Ukraine, Moldova, Belarus SE Southeastern Europe SS+ Sputum Smear-Positive TB Tuberculosis U5MR Under-5 Mortality Rate UNAIDS Joint United Nations Program on HIV/AIDS UNFPA United Nations Population Fund The 2010 Europe and Eurasia Health Vulnerability Analysis 7 UNGASS United Nations General Assembly Special Session UNICEF United Nations Children’s Fund UNODC United Nations Office on Drugs and Crime UNPD United Nations Population Division USAID United States Agency for International Development USG United States Government WDI World Development Indicator WHO World Health Organization WHOSIS World Health Organization Statistical Information System XDR-TB Extensively Drug-Resistant Tuberculosis 8 The 2010 Europe and Eurasia Health Vulnerability Analysis Executive Summary The 2010 Europe and Eurasia Health Vulnerability Analysis iden­ and explains the rationale for choosing them.The report ana­ tifies those countries in the Europe and Eurasia (E&E) region lyzes recent health trends in E&E using these indicators, mak­ of the United States Agency for International Development ing comparisons with E&E’s former “Northern Tier” subregion (USAID) where health status is the poorest and where the (comprising the Czech Republic, Hungary, Poland, Slovakia, and transition to democracy and free market economies may be Slovenia) and the 27 members of the European Union in most vulnerable because of health factors.Tracking the 2007 (EU-27) to see how well E&E countries and subregions region’s health vulnerabilities informs our understanding of are progressing relative to these “ideals” for the region. the social conditions of its countries and the economic and democratic transitions taking place within the region. Poor Overall, the 2010 analysis finds the five most vulnerable health diminishes society’s productive capacity, deteriorates countries in terms of health to be Turkmenistan, Kazakhstan, the strength of civil society, and tarnishes people’s perceptions Tajikistan, Russia, and Kyrgyzstan. Excluding the CAR coun­ of the benefits of democracy and free market economies. tries, the five most vulnerable E&E countries are Russia, Poor health is, therefore, not only a threat in its own right; Ukraine,Azerbaijan, Moldova, and Georgia. it is also a threat to economic and democratic progress. The primary findings of the analysis and conclusions line up The analysis also highlights health issues that may warrant with the six indicators of the Health Vulnerability Index and special or increased attention by United States Government the demographic changes that are taking place in the E&E (USG) policymakers.The seminal analysis of this type was region.The seven key vulnerabilities plus a final recommenda­ conducted in 2003.This is the sixth report that provides tion for improved health data collection are as follows: USG policymakers and USAID health staff in E&E countries and Washington, D.C., with an overview of health status and Changing Demographics in the E&E Region – vulnerability in the region.Today, it is all the more important A Shrinking and Aging Population to understand the impact of the current global economic cri­ Many countries in the E&E region are undergoing an impor­ sis on the health spending of both donors and countries tant demographic transition characterized mostly by increas­ themselves and the quality of health in E&E countries. Given ing life expectancy of their populations, although several the growth in infectious diseases alongside high levels of continue to experience slow or even negative growth. adult mortality, the impact of the economic crisis is of Compared with Western European countries, Eastern increasing concern. European countries show varying signs of vulnerability in which fertility, premature mortality and disabilities, and This analysis shows the general health picture across 29 E&E migration patterns are not in balance, resulting in shrinking countries, 14 of which – Albania,Armenia,Azerbaijan, Belarus, and increasingly aging populations. Older populations Georgia, Kosovo, Moldova, Russia, Ukraine, and the five encounter long-term illness or disability, and as the older Central Asian republics (CAR)* of Kazakhstan, Kyrgyzstan, population grows so does the number of people afflicted by Tajikistan,Turkmenistan, and Uzbekistan – currently receive these conditions.With shrinking populations, over time USAID health funding.The analysis is based on readily acces­ there are fewer economically active people to support a sible data that are regularly provided by international organi­ growing number of older dependents in future years.This zations, thus permitting comparisons among countries, and is transition creates a need for migrant labor as well as addi­ most useful for comparing subregions within E&E.This tional demographic and economic pressures that require enables the E&E Bureau and USAID Missions to raise aware­ attention and policies for managing potential effects on ness of major health issues relevant to the region. health and welfare systems. The foundation of this analysis is a Health Vulnerability Index * To provide context and continuity of comparison with previous reports, this that ranks the health status of E&E countries using aggregated E&E health analysis continues to include the CAR, although in 2009 these countries were put in USAID’s Asia region under the responsibility of the data for six indicators.Annex A defines these six indicators USAID Asia Bureau. The 2010 Europe and Eurasia Health Vulnerability Analysis 9 Uneven Gains in Life Expectancy Noncommunicable diseases produce the largest burden of The health status of the population in the E&E region has mortality in the E&E region, accounting for more than 93 mostly improved in the past decade, as indicated by longer percent of the 5.5 million estimated deaths between 2003 life expectancy at birth. Nevertheless, important differences and 2007. Cardiovascular diseases, cancer (malignant neo­ in the degree and pace of improvement exist among subre­ plasms), external causes of injury and poisoning, and diges­ gions and countries. Moreover, growing inequality in longevi­ tive diseases are the four major causes of death in the ty is associated with gender and with social, economic, and region.The direct, indirect, and intangible costs of illness lifestyle factors. Gender gaps in life expectancy in the E&E place burdens on individuals, families, and societies, especially subregions have increased in recent decades because of in shrinking and aging populations. changes in the risk-taking behaviors of men and women and their uptake of preventive and curative health services, Substantial Drop in Under-5 Mortality which in turn have responded to socioeconomic shifts. in Most Countries Under-5