The countries in the Region are undergoing an important demographic transition characterized by slower growth and increasing life expectancy of their populations. Compared with other WHO regions, Europe is considered to be at a stage of relative stability, in which fertility and mortality balance natural population growth. Nevertheless, certain conditions – including very low fertility levels, increasing ageing and immigration – are creating additional demographic pressure that requires attention and policies for managing the potential effects on health and welfare systems.
Population change and distribution
In 2007, the population of the 53 countries in the WHO European Region was 883.5 million, an increase of nearly 9 million (1%) since 2003 (4). Fertility continued to decline, with an average of 1.6 children per woman of childbearing age in 2007. Fertility varied among country groups, however, from 1.3 in EU12 countries to 2.4 in the CARK. Overall population growth in the Region is therefore slowing to an annual average of 0.1%, with 17 countries, mostly in the eastern part, already having a natural decline of 0.1% or more (Fig. 2.21). If current growth trends continue, population size, according to the medium fertility variant (129), is projected to increase slightly, peaking at 904.7 million by 2030 (an increase of 2%), and then to decline to 886.3 million by 2050.
In 2005, 70% of the population of the European Region lived in urban areas (130). This proportion is larger in the EU15 countries (76%) than in the CIS countries (64%) and CARK (41%). Urbanization is projected to continue at an annual rate of 0.2 percentage points until 2030, which will result in 80% of the population living in urban areas. In general, urban and rural areas differ according to population structure, educational levels, lifestyles, occupational backgrounds and exposure to environmental factors, all of which may affect populations’
health status and access to health care (131).
In the past two decades, the Region has undergone additional important changes in population due to migration, a trend that is expected to continue. Although precise information on migration flows is difficult to obtain because migration is sometimes illegal, nearly 1 million immigrants are estimated to reach the EU every year from neighbouring areas, especially higher-income countries (102,132). This population inflow has sustained nearly 70% of population growth and, to a lesser extent, employment levels. Although the long-term effects of immigration on population growth and structure are still uncertain, the health system and other social sectors will have to focus additional attention on the current and future needs of this population, which is usually characterized as younger, less affluent and having more illnesses and limited access to health care (131).
Fig. 2.21. Population growth, WHO European Region, 2006 or latest available year and projection for 2050
Note. MKD is the International Organization for Standardization (ISO) abbreviation for the former Yugoslav Republic of Macedonia.
Source: European Health for All database (4) and United Nations Population Division (129).
2006
Growth per 1000 population
– 10 – 5 0 5 10 15 20 25
Ukraine (2006)Russian Federation (2005)Belarus (2005)Bulgaria (2004)Latvia (2006)Serbia (2006)Lithuania (2005)Hungary (2005)Estonia (2005)Croatia (2006)Romania (2006)Republic of Moldova (2006)Germany (2004)Czech Republic (2005)Poland (2005)Italy (2006)Slovakia (2005)Bosnia and Herzegovina (2006)Slovenia (2006)Austria (2006)Greece (2006)Portugal (2004)Sweden (2004)Georgia (2006)Switzerland (2004)Denmark (2006)Malta (2005)Spain (2005)Belgium (2006)Finland (2005)MKD (2003)United Kingdom (2005)Montenegro (2005)San Marino (2005)Netherlands (2004)Norway (2005)Armenia (2003)Cyprus (2004)Luxembourg (2005)France (2004)Albania (2004)Ireland (2005)Iceland (2005)Kazakhstan (2006)Azerbaijan (2005)Turkey (2006)Kyrgyzstan (2005)Turkmenistan (1998)Uzbekistan (2005)Israel (2003)Tajikistan (2005)
Population growth (%)
–1 –0.5 0 0.5 1
BulgariaBosnia and HerzegovinaBelarusGeorgiaRepublic of MoldovaPolandRomaniaUkraineLithuaniaGermanyRussian FederationSlovakiaMKDCroatiaLatviaArmeniaPortugalSerbiaAlbaniaHungaryItalySloveniaEstoniaGreeceMaltaMontenegroAustriaNetherlandsDenmarkFinlandCzech RepublicAzerbaijan
BelgiumKazakhstanKyrgyzstanSpainIcelandTurkeySwitzerlandUzbekistanTurkmenistanSwedenUnited KingdomNorwayIrelandCyprusTajikistanIsraelLuxembourg –6.4–5.9–5.3–5.2–4.7–4.3–3.9–3.8–2.2–2.0–1.8–1.6–1.4–0.6–0.10.00.20.20.40.40.60.61.11.31.71.71.81.81.91.92.22.32.42.83.13.43.63.83.94.38.18.18.39.410.912.114.214.815.015.022.0
2050
France0 –0.95–0.92–0.91–0.84–0.81–0.68–0.68–0.67–0.6–0.56–0.51–0.49–0.49–0.46–0.44–0.39–0.39–0.3–0.29–0.28–0.28–0.22–0.2–0.2–0.19–0.19–0.13–0.11–0.1–0.09–0.08–0.07France
0.2
0.78 0.030.06
0.210.210.230.250.290.30.480.50.530.54 0.05
0.05 0.05
The increased longevity in the Region has been associated with reduced incidence of some chronic noncommunicable diseases, improved health care and rapidly declining fertility (as mentioned above, except in some countries) (133). Overall, the fertility rate is now well below the replacement level of 2.1 children per woman of childbearing age. Together, these factors have led to decreased growth and increased ageing. Today, less than 17% of the population of the Region is younger than 15 years and nearly 16% (about 138 million people) is older than 65 years (Fig. 2.22). The number of people older than 65, however, is growing more rapidly than the rest of the population. By 2050, more than 27% of the population (nearly 240 million people) is expected to be 65 years and older. Derived from the above figures, the total dependency ratio4 in the Region is expected to increase from 47% in 2007 to 74% in 2050 (128)
.
The ratio of males to females in the Region was close to 1.0 in 2006, but varies with age: from 1.1 for those under 15 years to 0.7 at 65 years and above and 0.4 at 85 years and above (or 2.5 women for each man). The ratios for the groups aged 0–14 and 65 years and more are projected to remain similar by 2050, but that for those aged 85 years and more is projected to increase to 0.5 (129).
The current situation and projected growth and ageing trends of the population often vary markedly across countries. For example, the population age structure in the CIS countries in 2005 shows a narrow base under the age of 10 years, followed by a sharp increase at age 15 and fluctuations among the working-age groups; the proportions of older age groups decrease rapidly at 70 years (Fig. 2.23). EU15 countries have a smoother transition. When the
4 The dependency ratio is the ratio of the total population aged 0–14 years and 65 years and more to the population aged 15–64 years – supposedly the economically active group. It is presented as the number of dependants per 100 people 15–64 years old.
Fig. 2.22. Percentage of the population aged 65 years and older by country group, WHO European Region, 1970–2005
Year
1970 1980 1990 2000 2010
Population (%)
0 5 10 15 20
European Region EU15 EU12 CIS CARK
Source: European Health for All database (4).
Fig. 2.23. Population age structure, CIS and EU15 countries, 2005 and 2050 (projected)
projections to 2050 are considered, the CIS countries have fewer older people: 20% aged 65 years and older, in marked contrast with the EU15 figure of nearly 30%. The male-to-female ratio in the EU15 countries in 2006 was an estimated 1.1 for people under 15 years and 0.8 for those aged 65 and older. In the CIS countries, these figures were 1.2 and 0.8, respectively.
Challenges and implications for the future
The ageing of the population of the Region during the past decade (with an increase of 13% in the number of people 65 years and older) reflects longer life expectancy at birth of 2.5 years since 1990 (3% increase) and improved overall living and health conditions. Nevertheless, the increase in the older population may have negative effects. During the coming years, population ageing, low fertility and delays in the onset of chronic noncommunicable diseases will change or increase the demands on countries’ health systems. Since the health trends among older people are complex, how ageing will affect health systems and population health in general is still very uncertain (134). For example, an estimated 20% of the population in the EU reported a long-term illness or disability, but the highest and the lowest country proportions differed threefold (135). Evidence indicates that the proportion of older people with a disability in the EU is decreasing, but the absolute numbers will increase since the older population will grow. Meanwhile, the prevalence of most chronic conditions continues to rise with age, and nearly 75% of people 65 years and older will die from cardiovascular diseases or cancer in most countries in the Region.
These trends at the country level also apply within countries, thus compounding the interpretations and predictions. Possible scenarios have been outlined considering broad
changes in illness, disability and vulnerability that determine the quality of life. A first scenario comprises people living longer but with chronic diseases or their consequences, thus accumulating poor health, which in turn increases the demand for health services. A second scenario, generally accepted to be more likely, envisions a decline in the severity of disabling conditions during working age accompanied by an increase in mild disability.
Since morbidity may be compressed – squeezing the burden of disease and disability into the final few years of life by delaying the onset of disease – this may not affect the overall demand for health services. A final and more optimistic alternative is that improved population lifestyles and delayed illness and disability would create conditions for reducing the demand for health services: validating the hypothesis of compressed morbidity, which would save costs for the health system.
Despite the decrease in chronic diseases, the economic burden of increased ageing on health systems may result in some countries doubling their current expenditure because of increasing health care costs (133,136,137). Nevertheless, although aggregate costs for the older population may be higher, this is not true for the individual; for the same condition, older people incur lower health care costs than younger ones, partly because they receive less intensive treatment (138). In addition, the imminence of death, not necessarily ageing, has been suggested to drive health expenditure. Again, the available evidence (or its measurement) is still too contradictory to allow any accurate predictions.
A decline in the economically active population, with total dependency ratios projected to increase to nearly three quarters of the population by 2050, may affect the funding and sustainability of the health and welfare systems in many countries. According to the European Commission, ageing will reduce the economically active population, thus causing the annual GDP growth rate in EU countries to decline from 2.4% in 2004–2010 to 1.2%
in 2030–2050. In addition, public spending related to pensions and services for the older population is expected to increase by 3–4 percentage points of GDP between 2004 and 2050 (134).
Several policy approaches have been proposed to reduce the impact of ageing on the health system, from health-system-specific interventions to wider social and economic policies.
The former include:
• emphasizing the prevention of the most important chronic diseases and risk factors by following healthy lifestyles, at least from early mid-life, if not over the whole life-course;
• targeting health care interventions to postpone the onset of cardiovascular diseases, obesity, hypertension and dementia;
• promoting self-care and improving long-term care with more efficient use of resources, including formal and informal care; and
• involving older people directly in more decisions and activities (including economic choices) that affect their care (132,134,139).
In addition, special attention should be paid to gender and to lower-income groups.
Currently, nearly 40% more women than men live to be 65 years or older and three times as many, 85 years and older. Further, poor and older people have a 30–65% higher risk of almost all chronic diseases than affluent and younger people (135). As noted above, women also experience longer life with poorer health than men, especially because of multiple conditions, thus requiring more integrated care approaches. In addition, as women tend to have poorer access to health services than men, greater access needs to be facilitated.
Social and economic policies suggested to limit the impact of ageing on society include:
increasing overall employment, deferring the age of mandatory retirement and improving older people’s participation in the workforce, increasing tax receipts by increasing economic growth and reducing public-sector expenditure now to cover increases in future expenditure (140). Facilitating older people’s participation in employment will require upgrading skills and retraining (141). No single policy or set of policies will suffice for the whole European Region, and decisions will have to be adjusted to respond to different circumstances.