Health and Long-Term Living: Trends and Best Practices in Europe

1. Introduction

Whilst life expectancy at birth is increasing in the European Union (EU), health represents a key area of concern for European citizens. On the one hand, there are remarkable variations of life expectancy trends in the different Member States, which poses a great challenge for policy makers and for health systems to achieve equal health opportunities within all the European countries. On the other hand, the lengthening of life expectancy and the decrease of birth-rate are producing an increasingly ageing population which is normally associated with an increase in disability and chronic diseases and the consequent rise in the cost for health care, long-term care and pensions.
The demographic change seems to present two faces: a welcomed increase in life expectancy — the positive one — and an ageing society that poses a serious challenge to the financial sustainability of the EU Welfare system.

2. Health in the Pre-Enlarged European Union

Since the 1970s, life expectancy at birth has steadily increased by 3 months per year in high-income countries and it appears that this trend is not going to slow down (Oeppen, J. and Vaupel, J.W., 2002; Robine, J.M. et al., 2003). However, this phenomenon, which is clearly present in the EU countries over the period 1970-1995, is not shared by central and eastern European countries where life expectancy has been lower. The health report prepared by the Regional Office for Europe of the World Health Organization (WHO, 1997) emphasises the widening of the gap between EU and other European countries. More recently, an interesting report comparing health and health care systems in the countries of the so called ‘old Europe’ (EU 15) with those of the countries at that time candidate to accession was published (Thomson, S. et al., 2004). In terms of life expectancy at birth, trends were quite different during the period 1970-2000. Concerning men in EU 15 countries, Portugal has been at the bottom with life expectancy at 67.5 years in 1980 and 72.7 years in 2002, while Sweden has been at the top at 77.7 years in 2001. Concerning women, life expectancy has been lowest in Portugal and in Ireland (79.9 years in 2001), while it has been highest in France (83.2 years in 2001). In 2002, there is a general trend suggesting that the differences in life expectancy at birth within the EU 15 Member States are reducing.
Central and Eastern European countries share levels of life expectancy clearly lower than in Western Europe, a wider gender difference, and most of them experienced a mortality increase in the early 1990s. Trends in life expectancy in EU 15 since 1980 show a steady increase in all the Member States, while Latvia, Estonia, Lithuania, Romania and Bulgaria did not show any significant improvement. Central European countries show an increase in life expectancy in the period 1980-2002 for both male and female population but life expectancy in these countries remains lower than the average for the EU 15.
In 2001 a man in the EU 15 countries could expect to live about 7.5 years more than a Hungarian and about 11 years more than a Latvian.
By examining some key health indicators it appears that in 2001 infant deaths in Estonia, Hungary, Latvia, Lithuania, Poland, Romania and Bulgaria were almost 2-3 times higher than the average of the EU 15, while a similar ratio was seen for ischaemic heart disease mortality between the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Slovakia and the average rate of the EU 15 countries (WHO, 2004).
To investigate some of the factors underlying the health difference between old and new Member States some authors have studied avoidable mortality in the enlarged European Union (Newey, C. et al., 2004). The concept of avoidable mortality was originally developed by Rutstein and co-workers in 1976 as a measure of the quality of medical care. More recently, avoidable mortality has been related to causes that are responsive to medical intervention (treatable conditions) and those responsive to intersectoral policies (preventable conditions). In the report of Newey and co-workers 33 conditions were selected as treatable conditions — for example intestinal infections, perinatal mortality, appendicitis, Hodgkin’s disease, testis tumor —, 3 as preventable conditions — malignant neoplasm of trachea, bronchus and lung; liver cirrhosis; motor vehicle accidents — and ischaemic hearth disease was treated separately since it can be seen as an indicator of health care service but also of health policy.
It is not the task of this paper to analyse in detail the results of this research: we will sum up some data in order to underline the existence of remarkable differences.
At the beginning of the 1990s, treatable mortality rate was clearly higher in Romania and Bulgaria, followed by Central and Eastern Europe Countries: only Slovenia, Lithuania and Poland attained values similar to Portugal — the country among EU 15 with the worst incidence both regarding male and female population. Comparing the extremes, it results that in Romania there were 260 deaths for treatable conditions per 100.000 male population and 69 per 100.000 in Sweden. Among women, 221 per 100.000 female population in Romania and 66 per 100.000 in France.
Looking at changes in 2000-2002, Portugal, Austria and Finland showed a decline of almost a third either for men or for women, whereas in the EU 15 countries the improvement was smaller in the Netherlands, decreasing only by about a tenth for both men and women. Among candidate countries, the Czech Republic showed the deepest decline in treatable mortality; Estonia, Latvia and Lithuania a very low progress especially for men; Romania an increase at +5.48% for men.
Concerning preventable mortality, the highest level in 1990/91 was seen for Hungarian men, at 209 per 100.000 male inhabitants, relatively high in Romania, at 123 per 100.000 male inhabitants and the lowest for Swedish men, at 46 per 100.000 inhabitants. Among women, the death rate was 59 per 100.000 female population in Hungary and 44 in Romania; 35 per 100.000 female population in Slovenia and 31 in UK; 18 per 100.000 female population in Bulgaria and 15 in Spain. In 2000-2002, with the exception of Romania, declines from preventable conditions were seen in men but not in women and were prominent in Italy, Austria, Portugal, Finland and, among the candidate countries, the Czech Republic and Slovenia. Improvements were very small in Hungary and in Bulgaria and a worst rate was seen in Romania. As for female population, in 2000-2002 a widespread increase in preventable mortality was seen in all candidate countries — with the exception of Slovenia and Bulgaria — and in the Netherlands, Sweden and Finland.
In 1990-91 death rates for IHD were highest in all candidate countries with the exception of Slovenia and especially in Latvia, Estonia, Lithuania and Romania. Among the EU 15 countries, Ireland and Finland showed the highest mortality for IHD for both men and women. The lowest rate was seen in the Mediterranean countries. It has to be noted that female mortality rate was 2-3 times lower than male mortality rate. In 2000-2002 all the considered countries experienced a decline in IHD mortality with the exception of Romania: the improvement was particularly significant in the Czech Republic, UK, Ireland and Finland.
The analysis of avoidable mortality in the enlarged European Union Countries confirms the existence of a significant health divide between the old and the new Member States already seen when we have examined the extent of life expectancy in the different countries. The reasons for these differences are several: quality and development of health systems; availability of economic resources for an equal drug supply; the existence of intersectoral policy to implement good lifestyles; a decrease in car accidents; the prevention of diseases; the quality of social and economic environment that can contribute to high levels of stress; poverty and limited social support.
It clearly emerges that the challenge that the EU Member States Governments have to face to protect the health of their citizens is still remarkable and that many efforts still have to be made to reach acceptable levels of equity and to reduce inequalities.

3. EU Initiatives

According to the principle of subsidiarity (Delors, J., 1991) the EU does not have competence in the management and in the organisation of the health services of the different Member States, but the Union has competence in the field of prevention and health promotion. Within the EU, there is a Health Action Programme with its three fields of activities on health information, health determinants and health emergencies, which can have an important impact on avoidable mortality, especially on the preventable one. Information and education induce better life styles, health determinants can promote health and prevent diseases and mortality across all policies and activities, health emergencies have the objective of enhancing the capability of responding rapidly in a co-ordinated fashion to threats to health.
The first Programme of Community action in the field of public health (2003-2008) financed over 300 projects and other actions with the aim of contributing to ensuring a high level of human health protection through the promotion of an integrated and intersectoral health strategy and to enhance co-operation between Member States in the area of health. It is of interest to underline that very recently the European Council of Ministers agreed that the second EU Programme of Community Action in the Field of Health (2008-2013) will come into force from 1 January 2008. The objectives of the programme are: a) to improve citizen’s health security; b) to promote health including the reduction of health inequalities; c) to generate and disseminate health information and knowledge.
The concern to reduce health inequalities — be they the diverse life expectancy at birth or the different rate of avoidable mortality in the EU Member States — seems to be present in the EU strategies and the Second Programme of Community Action in the Field of Health — which includes a main action concerning the reduction of health inequalities in the EU — is considered an effective tool.

Angelo Carenzi: President EIPA-CEFASS (EU Training Centre Social Affairs and Public Health Care), Milan.

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