53036 Combating Ukraine's Health Crisis: Lessons from Europe Rekha Menon Ukraine has the Fastest Rate of Depopulation in Europe Key Messages Ukraine has experienced an Since independence, Ukraine has been in the midst of an unprecedented demographic decline since unprecedented demographic decline combined with a independence in 1991, resulting in an health crisis. Ukraine's population has been reduced by 12 overall reduction in population by about percent, or about 5.8 million people, from 52 million since 5.8 million people. independence in 1991 to 46.2 million in 2007. If current Ukrainian males are dying prematurely trends continue, the population of the country could decline and suffer some of the highest rates of by around 40 percent to 36.2 million by the year 2050. disability in ECA due to non- Below replacement fertility2 rates of 1.2 per woman, communicable (chronic) disease rates combined with high mortality rates especially among the during the most productive years of life. working age population, are rapidly changing the age structure of the population, with higher proportions Ukraine's health system is weak and concentrated in the mid- and older-age groups. unable to perform the most basic As seen in Figure 1, life expectancy in Ukraine is much functions. Additional capacity is below that of the rest of Europe, with greatest relative life necessary to adequately deal with highly expectancy loss at the working age, especially among preventable and treatable diseases. males. Reducing many non-communicable disease risk factors involves Figure 1: Life Expectancy and Healthy Life Expectancy improvements (for example, safer roads) in Ukraine and Selected European Countries, that are the jurisdiction of other sectors 2002 (in years) (for example, transportation). However, collaboration across sectors would be difficult and less effective in the absence of substantial reform of the health system. Introduction This Knowledge Brief synthesizes the important findings of a recent study.1 It spotlights key issues and challenges facing Ukraine's health sector and suggests strategies for improvement. To combat the current health crisis, Ukraine could look at the lessons learned by other European countries that have faced similar health crises. Source: WHO Statistical Information System (WHOSIS) 1 R. Menon. E. Ozaltin, S. Poniakina, B. Frogner and I. Oliynyk , An Avoidable 2 Replacement fertility is the total fertility rate at which newborn girls would have Tragedy: Combating Ukraine's Health Crisis, Lessons from Europe. World an average of exactly 1 daughter over their lifetimes. In more familiar terms, Bank. 2009. women have just enough babies to replace themselves. ECA Knowledge Brief Ukraine had a similar pattern of life expectancy as Eastern Similarly, the female-male differential in life expectancy in Europe until the late 1980s, after which a divergence was Ukraine flags some worrisome trends. The female-male observed: life expectancy declined in Ukraine and Russia differential in EU countries decreased by one year from while other formerly socialist countries such as the Czech 1989 to 2005, and was equal to 6.2 years by 2005. In Republic, Hungary, Slovenia, and Poland made big strides. comparison, the differential in Ukraine increased Currently, life expectancy in Ukraine appears to have considerably from 9 years in 1989 to almost 12 years in stagnated. Also, of the number of years lived, Ukrainians 2005 (Figure 2). Further, Ukrainian females' life spend an average of 13 percent of their lives in a state of expectancy is 8.2 years lower than the EU average, and 14 less than perfect health. In comparison, Poles are unhealthy years lower than that of Ukrainian males. for only about 8 percent of their lives, and Slovenians and Czechs 9 percent of their lives. Only Hungarians, at 11 percent, are close to Ukraine's level (Figure 1). Figure 2: Life Expectancy at Birth in Ukraine and Selected European Countries, 1970 to 2006 Source: HFA Database 2008 Table 1: Male Adult Mortality Rate and GNP per One third of Ukrainians die prematurely before the age Capita, Ukraine and Selected Countries of 65 years GNP per Male Adult Countries The probability of surviving to old age in Ukraine is low capita Mortality Rates compared with Central European countries, especially Benin 1250 349 among Ukrainian males. Ukrainian adult male deaths are at Togo 770 371 levels similar to those in countries with less than one-fifth Guinea 1130 380 the GNP per capita of Ukraine (Table 1). Haiti 1070 329 Ghana 1240 350 Non-communicable diseases (NCDs) account for the bulk Ukraine 6110 384 of deaths (82 percent) in Ukraine (Figure 3), with a heavy concentration among working age males. In addition, the Source: World Health Survey country also has the highest mortality rate from infectious Figure 3: Deaths in Ukraine, by Cause (2002) diseases in the entire WHO European region, followed by Russia and Eastern European countries. HIV/AIDS and Communicable, maternal, perinatal tuberculosis account for 90 percent of all deaths from and nutritional Injuries communicable diseases in Ukraine. While infant mortality 12% conditions 6% rates are still high in the country compared with Central European nations, these are no longer the driving factor behind the high mortality rates in Ukraine due to the Noncommunicable priority placed on this topic since 1993. diseases 82% Source: WHO Global Burden of Disease (GBD) estimates, 2002 ECA Knowledge Brief Ten leading conditions are responsible for almost 72 About half of all deaths before the age of 75 in Ukraine percent of deaths in Ukraine.3 The same ten conditions could be avoided through adequate prevention and account for 65 percent of deaths in Russia, 54 percent in treatment Hungary, 53 percent in Czech Republic, 48 percent in Five major risk factors account for about half of the Poland, and 46 percent in Slovenia. These ten conditions DALYs in Ukraine and all other Easter European countries also account for almost half of total disability adjusted life in the study. High blood pressure is the biggest risk factor, years (DALYs) in Ukraine. Ischemic heart disease alone is with one-third of Ukrainians suffering from elevated blood responsible for almost 40 percent of all deaths in Ukraine pressure; unfortunately, most Ukrainians are unaware of and was the leading cause of DALYs at 13 percent in 2005. their hypertensive status. In addition, tobacco and alcohol Deaths from ischemic heart disease in Ukraine are consumption in the country is high. Almost two-thirds of approximately 40 to 50 percent of all deaths in the country Ukrainian males above age 15 are regular and daily - double the level observed in the Czech Republic and in smokers, the highest number for countries in WHO's Hungary (20 percent and 25 percent, respectively) and four European region. times higher than those observed in Slovenia. The risk of dying from circulatory system diseases (CSD) and cancer Many of the causes of premature death and disease in is also much higher in Ukraine than the EU average Ukraine are linked to risk-factors which are largely (Figures 4 and 5). modifiable and preventable. Major risk factors require Figure 4: Main Causes of Mortality by Age Group in changes in lifestyle behavior (such as, smoking, alcohol Ukraine in Comparison with EU (EU=100), males, 2005 and diet). Environmental conditions also play a key role in many diseases - including poisonings, injuries and the biggest killer in Ukraine, circulatory system diseases such as ischemic heart disease and stroke. Through adequate prevention programs targeted to modify behaviors and improve environmental conditions, along with effective treatment, about half of all deaths before the age of 75 in Ukraine could be avoided. Eighty percent of deaths among working-age males and about 30 percent of working-age females could have been treated adequately at the primary care level. Since NCD mortality and morbidity place a large share of Ukraine's disease burden, especially among the working age male population, it results in significant economic and social Figure 5: Main Causes of Mortality by Age Group in consequences. The declining health and significant Ukraine in Comparison with EU (EU=100), females, inequalities in health status across the population have been 2005 the result of imbalanced economic growth, political turbulence and a weakened health care system. Ukraine's health system is not geared to tackle the mortality crisis Despite the fact that most premature deaths in Ukraine are of a preventable or treatable nature and there is evidence that cost-effective targeted interventions can work, the Ukrainian health system is still designed for acute care episodic disease management and is not equipped to deal with this mortality crisis. A primary care oriented system would be ideal to deliver effective preventive interventions. Programs ongoing in other European countries show success in reducing premature mortality and morbidity through cost-effective interventions that are targeted to Source: MDB Database, 2008 reducing risk-factor prevalence. Many potential life years 3 and health life years can be gained by implementing any or In order of highest to lowest share, the ten conditions are: ischemic heart some of these interventions in Ukraine (examples in Table disease, cerebro-vascular disease (stroke), COPD, self-inflicted injuries, poisonings, other unintentional injuries, trachea, bronchus and lung cancers, 2). HIV/AIDS, cirrhosis of the liver, and stomach cancer. ECA Knowledge Brief Table 2: Key Cost Effective Interventions for NCD Prevention and Control in Ukraine INTERVENTIONS TOBACCO CONTROL Comprehensive bans on advertising. Increased tobacco taxes. Prominent health warning labels with pictures. Enforcement of comprehensive smoking bans and sales to minors. School-based health education. ALCOHOL CONTROL Counter-advertising. Increased alcohol taxes. Legislative interventions (mandatory warning labels, banning sales to minors, advertising bans, etc.). School-based health education. Strict enforcement of drunk-driving laws, with clearly legislated maximum Blood Alcohol Concentration (BAC) levels. ROAD SAFETY Mandatory seatbelt enforcement. Strict enforcement of drunk-driving laws, with clearly legislated maximum BAC levels. Enforcement of speed limits. Safe driving lessons for youth. DIETARY CHANGE School-based health education. Information, Education and Communication (IEC) on the dangers of obesity and the benefits and elements of a healthy diet. Involvement of NGOs, community groups, etc., in activities promoting dietary change. Health worker training-- knowledge/skills to encourage dietary improvement. Taxation of harmful dietary inputs--sugar, fatty foods, alcohol, etc. PROMOTION OF School-based health education. IEC on physical activity/exercise. Promotion of sporting activities and clubs, especially those targeted at PHYSICAL ACTIVITY age/gender groups with low levels of physical activity. Health worker training--knowledge/skills to promote increased physical activity. SCREENING CERVICAL Consider more extensive screening, including IEC efforts, community/NGO participation. Ensure availability of trained/skilled clinical CANCER staff for diagnosis (including laboratory) and treatment of cases--and their ongoing training. Ensure presence of adequate laboratory facilities. SCREENING BREAST Screening, either via clinical examination or mammography. IEC efforts, community/NGO participation. Ensure availability of CANCER trained/skilled clinical staff for diagnosis and treatment of cases--and their ongoing training. Formation of support groups. SCREENING DIABETES Targeted screening of high-risk groups--those with conjoint risk factors (obesity, heart disease, hypertension, etc.), or those identified AND HYPERTENSION using risk factor questionnaires. IEC activities, public awareness campaigns. Periodic national screening campaigns. Ukraine's health system is complex, inefficient, highly rationalizing excess capacity at secondary and tertiary inequitable, and of low quality. Ukraine lacks a levels, and providing performance-based payments to comprehensive health reform implementation plan - though providers should be the focus of health system reform in several reforms have been proposed and some have even Ukraine. been legislated, most have not been implemented. Political instability, frequent changes of Government and of the Effective prevention mechanisms would require leadership of the Ministry of Health - with eight Ministers collaboration across sectors of Health since independence - have led to delays in Changes in the composition of the burden of disease institutional change in health care and the reorganization of require a multi-sectoral approach to disease prevention and primary health care. To addresses the health needs of the management. An integrated NCD control and prevention population which is becoming more NCD focused, strategy can help foster multi-sectoral collaboration. In the Ukraine's health system needs to be re-oriented from an short-term, there is a need to identify and implement acute care input-based model to a comprehensive disease priority cost-effective interventions (both within and management model that is more appropriate for NCD outside the health system) that target the major risk factors. prevention and control. These include interventions and policy options that target the major risk factors ­ such as alcohol and tobacco, road Unlike Ukraine, all Central European countries studied in safety, and diet/physical activity, within an integrated this report underwent comprehensive reforms in their strategy for NCD prevention. This requires the health systems, starting early in the transition process. development of integrated management structures that Reforms in Central European countries were guided by a bring together representatives from all areas of the health series of legislations, policies and strategic plans which system and beyond to ensure coordinated action for NCD were constantly adapted to changing needs. In all cases, prevention and control. The process should involve not effective government stewardship was critical to ensuring only the Government but also donors and NGOs--all of success in implementation of reforms. An important whom have a substantial role in NCD prevention and element of the reforms was defining the roles and control efforts. responsibilities of the various players in the health systems. About the Author Experience from Central European health reforms suggests Rekha Menon is a Senior Economist in the Human that removing rigidities in resource allocation, emphasizing Development Sector Unit at the Europe and Central Asia primary care, introducing referral care systems, Region of the World Bank. ECA Knowledge Brief is a regular series of notes highlighting recent analyses, good practices and lessons learned from the development work program of the World Bank's Europe and Central Asia Region http://www.worldbank.org/eca