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KYIV June 2009 Slide 2 Highest Population Decline In Europe with Working-age Cohorts Shrinking Fastest Slide 3 Ukraine vs Europe: Since 1980s, Sharp Decline in Life Expectancy Slide 4 Ukraine vs Europe: Second Worst Life Expectancy and Fewer Number of Years Lived in Full Health Life expectancy and Healthy life expectancy in Ukraine and selected European countries, in years, 2002 Slide 5 Ukraine vs Europe: Second Highest Mortality Among Working-age Population. Males are Most at Risk! Probability of dying between 15 to 60 years per 1000 population: Adult Mortality in Ukraine and Selected Countries CountriesBothFemalesMales Czech Republic10867148 Hungary177104249 Poland14579209 Russia300158432 Slovenia10456148 Ukraine264142384 Slide 6 Mortality Rates as High as in Low Income Countries Slide 7 Non-Communicable Diseases (NCD) are Major Killers in Ukraine Deaths by cause in Ukraine, 2002 Slide 8 Together With External Causes They are Responsible for Most of Premature Deaths Main causes of mortality by age group in Ukraine in comparison with EU (EU=100) MalesFemales Slide 9 and disabilities Ten leading conditions that reduce years of life in Ukraine Top Ten Causes of DALYs % share in total DALYs 1Ischemic heart disease12.65 2Cerebrovascular disease6.02 3Unipolar depressive disorders5.18 4Other unintentional injuries4.81 5HIV/AIDS3.62 6Self-inflicted injuries3.28 7Poisonings3.02 8Congenital anomalies2.94 9Nutritional deficiencies2.82 10Violence2.48 Disability- Adjusted Life- Years (DALY) is a health-gap measure summarising the number of years lost due to death and disease. Slide 10 Why These Health Patterns? Top Ten Risk Factors Responsible For 84% of Total Disease Burden Risk factors Ukraine Czech Republic HungaryPolandRussiaSlovenia 1 High blood pressure16.612.812.210.49.88.2 2 High cholesterol14.49.88.96.96.46.3 3 Tobacco12.815.520.916.611.013.7 4 Alcohol12.36.215.59.24.711.4 5 High BMI9.08.47.87.16.8 6 Low fruit and vegetable intake8.03.05.73.32.22.1 7 Physical inactivity5.64.13.93.12.92.8 8 Illicit drug use3.00.91.20.41.1 9 Unsafe sex1.61.21.01.31.00.8 10 Indoor smoke from solid fuel use 1.1 Combined84.461.975.9 59.1 45.253.2 Slide 11 Major causes of death: Cardiovascular diseases, cancer, liver diseases etc. Injuries, poisoning HIV/AIDS Reasons unhealthy lifestyles (alcohol, smoking, drug abuse, poor diet, lack of exercise) these five risk factors account for half of diseases burden Consequences aging, shrinking labor pool, high gender gap in life expectancy (widows and single women). Most of these deaths are either preventable or treatable Preventable public health, target risk factors, burden in all countries, cross-sectoral linkages important Treatable early detection and treament, quality of services Focus on quality of care From Challenges To Opportunities : Slide 12 Premature Deaths are Avoidable - but will require significant behavioral change ! Slide 13 Premature Deaths are Avoidable ! Prevention: Large Gains at a Small Cost Interventions Tobacco control Counter-advertising Increased tobacco taxes Legislative interventions (mandatory warning labels, banning sales to minors, advertising bans, etc.) School-based health education Border control of illegal tobacco imports Alcohol control Counter-advertising Increased alcohol taxes Legislative interventions (mandatory warning labels, banning sales to minors, advertising bans, etc.) School-based health education Strict drunk-driving laws Road SafetyMandatory seat belts Strict drunk driving laws Speed limits Safe driving lessons Preventing Deaths Through 3 Leading Risk Factors Slide 14 Health Crisis Response is Not Only MoH Business Ukraine needs an integrated, multi-sectoral approach to NCD prevention and control, including : educational efforts environmental regulatory efforts revenue regulatory efforts (e.g., taxes on harmful inputs) treatment efforts Slide 15 Premature Deaths are Avoidable ! Treatment: Focus on Primary Care Death rates from treatable mortality for 25-64 year olds in Ukraine Slide 16 Premature Deaths are Avoidable ! Evidence from Europe: Hungary Programming: early 1990s, five successive national health documents on health promotion, public health challenges, health policy investments, and the direction of long-term health policy; Implementation: led by the National Institute for Health Promotion within a comprehensive reform framework; Results: increase in LE by 3 years within a ten year period. Slide 17 Premature Deaths are Avoidable ! Evidence from Europe: Finland Programming: early 1970s, the North Karelia (NK) Project designed to reduce high mortality of heart disease, later rolled out for the whole country; Implementation: intervention through community organizations, involvement of key policy-makers, media and communication campaign to prevent risky lifestyles, and good M&E framework; Results over 25 years: mortality rate of heart disease fell by 73% in NK and by 65% in the whole country, lung cancer mortality reduced by 70% in NK and by 60% in Finland. Slide 18 Focus on Ukraine: Health Care Delivery has Changed Little since Independence Highly inefficient spending with lions share of Ukraines budget allocation going to hospitals and specialized facilities (86 %). Preventive and primary health care remains largely neglected. Rigid norms drive budgeting and allocation of resources at the local level High share of out-of-pocket payments (OOP) creates financial barriers in accessing health care Considerable overcapacity in the hospital sector Lack of an established and accountable physician gate- keeping mechanism. Utilization rates remain high, but quality of services received has declined dramatically. Slide 19 Health System Unable to Cope with New Challenges Unless Reforms are Initiated Key Reform Areas: Policy and regulations : comprehensive reform plan, clear definition of roles and responsibilities of players Financing : removing structural constraints in resource allocation and provider payment, introduction of performance-based provider payment mechanism Service Delivery : focus on primary care, introduction of referral, reduction of overcapacity, administrative decentralization Slide 20 It is not too late