Methods of calculation and estimation of demographic indicEs.

Methods of study OF morbidity.

Calculation and evaluation of disease.

 

Demography is the science about the population (from “demos” – people, “grapho” – to describe), or the statistics of population.

The statistical study of population is conducted in two basic directions:

1. Description of population on the set time (its quantity, composition, features of settling apart and others like that) – the so called statistics of population;

2. Description of processes of change of quantity of population – a dynamics or the motion of population. The last one in the last turn divides into the  mechanical motion of population ( the changes which take place under the act of migrations — migratory processes) and so called natural motion of population (the changes, that take place as a result of birth-rate and death rate and characterize the processes of recreation of population).

   

The indices of birth-rate, death rate, natural increase, average duration of life belong to the basic demographic indicators, and also one of age-old indices of death rate is the death rate of infants, that is children under the age of 1 year.

A birth-rate, as well as other demographic phenomena, is determined by statistical indices.

The general index of birth-rate settles accounts foremost. As well as most indices of natural increase, it is determined by the number of born in a calculation on a 1000 population:

 

But the process of recreation of population can be described more precisely, if to expect a birth-rate not among all population, but only among the women of fertile age (15-49 years). This index is named the special index of birth-rate (fertility, fecundity) and it is settled thus:

Except for the above-mentioned such special indices are used:

•  the total index of recreation of population – the number of the children born by a woman during the fertile period of her life (15-49 years);

•  the brutto-coefficient of recreation – the number of the girls born by a woman in age of 15-49 years;

•  the netto-coefficient, or the cleared index of recreation- the amount of the girls born in the middle by one woman for all reproductive period of her life, that attained age, which a woman at their birth was in.

One of major demographic indicators of public health is a death rate, which characterizes the health of population from the point of view of distribution of the most heavy pathology.

The general index of death rate characterizes the frequency of cases of death per year on  1000 population, that lives on the concrete territory. It is calculated this way:

 

The special indices of death rate are a death rate for the article (at men and women), after age (in separate age groups) and after reasons (from separate classes, groups and nosology forms of diseases).

A maternal death rate is the statistical concept related to the death of woman during pregnancy or during 42 days after its ending, regardless of duration and localization of pregnancy, from some reason related to pregnancy either by burdened by its conduct, but not from an accident or other casual reasons.

A late maternal death rate is related to the death of woman from direct or indirect obstetric reasons, later than in 42 days, but before one year upon termination of pregnancy.

Death rate of infants is one of age indices of the death rate. It characterizes the frequency of death of children of the first year of life.

The death rate of infants is selected from the problem of death rate as a result of its social significance.

The formula of calculation of level of death rate of infants after the WHO recommendations is such:

                                           

A death rate in the neonatal, early neonatal and post neonatal periods of life of child is separately selected.

A neonatal period begins from the birth of child and is closed in 28 complete days after the birth.

The neonatal death rate is the death rate among born living during the first 28 complete days of life – is determined after a formula:

An early neonatal period engulfs the first seven days or 168 o’clock of life. A death rate in an early neonatal period is determined so:

The period of life of a child after the first complete 28 days is named post neonatal (29 days-12 months). A death rate in this period is determined by a formula:

 

The level of perinatal death rate is determined by a formula:

Thus, first seven days of life are taken into account for the calculation of indices of death rate of infants and perinatal death rate.

1. Birth-rate

According to WHO, the criteria of live birth are: pregnancy term 22 weeks and more, weight 450 g and anymore, and also presence of palpitation. But in Ukraine there were established next criteria of live birth: pregnancy term 28 weeks and more, weight 1000 g and more, and also presence of palpitation and breathing.

Levels of birth-rate after WHO:

1.     Low level – to 15 ‰.

2.     Average level – 15 ‰ – 25‰.

3.     High level – 25‰ and anymore.

 The birth-rate level in Ukraine after 2006 р. was 9,0 ‰, which means that a birth-rate is at low level.

The greater part of the factors that influence on a birth-rate, greater part is instrumental in its diminishment. The following ones belong to these factors:

•   decrease of marriages number and increasing of divorces number;

•   active enlist of women to public life

•   disproportion in sexual population composition, irrespective of the reasons, that cause it. They are features of development of production relations, migratory  processes, consequences of wars;

•   employment of certain part of women in productions with the dangerous and harmful conditions of labors;

•   unsatisfactory state of women reproduction health;

•   economic situation in society.

It must be stressed that the main reason which stipulates the low levels and unaffordable tendency of birth – rate indexes’ is the negative influence of economic situation during last years in the country.

2. General death rate.

Levels of general death rate after WHO:

1.     Low level – to 9 ‰.

2.     Average level –  9 ‰.– 15 ‰

3.     High level – 15‰ and anymore.

The general death rate level in Ukraine after 2006 year was 16,6 ‰, which means  that  general death is at high level.

There is the average index of death rate in Europe – 10,5 ‰  (1995 year). And the lowest level is in Netherlands – 8,6 ‰ .

The indices of general death rate of both men and women in Ukraine are higher, than in marked such called “demographic standard” countries, death rate among the rural population is in 1,5 times higher than in a city. The men death rate in Ukraine can be defined as “over death rate”. Comparative with the developed countries of foreign it results in reduction of their life on 10-15 years.

According to separate reasons the general death rate structure among the population of Ukraine is stable enough. First place is taken by illnesses of the blood circulation system (60,5 %), on the second place are malignant new formations (13,5 %), on the third are accidents, poisonings and traumas (9,7), on fourth are illnesses of organs of breathing (6,9). Together they make from 85 to 95 % of all cases of death.

3. Infants death rate (death rate of children of the first year).

Levels of death rate of infants   for WHO:

1.     Low level – to 20 ‰.

2.     Average level – 20 ‰.– 50 ‰

 3. High level – 50 ‰ and anymore

The level of infants’ death rate in Ukraine after 2006 year was 9,99 ‰, that means  that  the infants death rate is at low level.

Infants death rate:

а) prenatal reasons – 38 %

б) congenital vices of development – 28 %

в) accidents, poisonings, traumas – 8 %

г) illnesses of breathing – 8 %

The death rate of children under one year age is one of the most sensible indicators  of socio-economic development level of society, which accumulates  the level of education and culture, environment state, efficiency of prophylactic measures, level of availability and quality of medical care, distributing of material and social welfares in society.

In the economic successful countries the infants death rate is 8-10 ‰. In developing countries, infants death rate far more higher: in African region it hesitates within the limits of 76-130 for 1000 new born, in India and Nepal – 100-110.

 

 

4. Average life duration is the meaumber of years that the generation (the persons of the same age) has to live on condition, that the coefficient of fatality rate is permanent. Men in Ukraine lives 63 years, women – 74 years (for comparison in Sweden men live on the average 77 years, women 82 years)

Description of basic types of population pathology at the end of the XX century

 

A demographic situation in Ukraine during the last decade is characterized as unsatisfactory, because of economic destabilization, decline of population standard life, degradation of social sphere, catastrophic worsening the environment state, sharpening of criminality situation.

It should be noted that the influence on a demographic situation is important part of the Ukrainian social policy, that why they are working on. Increasing of birth-rate and decreasing of population death rate and especially infants death rate, and also increasing of life- duration.

Chart showing average life span expectancy in various world countries

 

The demographic situation in Ukraine: present state, tendencies and predictions

The demographic situation in Ukraine is characterized by an accumulation of tendencies that are reaching crisis proportions. The population is decreasing, with an increase in the death rate among working-age people and a negative balance of external migration. Under these conditions, a deterioration in interethnic and interreligious relations in society is possible against a background of a worsening socioeconomic situation for most of the population.

In this article, the basic indices characterizing both the current state and the trends of the demographic situation in Ukraine will be presented and analyzed. These include both the population statistics and the factors and consequences that can be derived from those statistics.

One caution that needs to be taken into account regarding the statistics is the lack of a census on the background of active demographic processes, including migratory processes, for a considerable period of time. This gap is connected with several factors that followed the breakup of the USSR, the formation of independent states, and the transformation of their socioeconomic structure. This transformation included a reformation of the organs of state authority, among the functions, of which is registering various population flows. In addition, the systems for collecting and processing information were also reformed, which has both resulted in a level of incompleteness in the register of information and made the data difficult to compare.

As a result, only certain data for the year 2000 are used in this article, while the main data set used is limited to that for the year 1999.

The numbers and sociodemographic structure of the population

Dynamics of the population’s numbers

According to data from the census of 1989, the population of Ukraine numbered 51.7 million persons. At the beginning of 1993, it reached its highest level for the entire postwar period – 52.3 million persons. However, this increase in the population did not occur due to natural growth, but was a result of migration.

In general, the years 1991-93 were the period of the most active migratory processes among the republics of the former USSR, and this was particularly true for Ukraine. Many people were striving to return to their ethnic or historical homelands in order to receive citizenship there in connection with the breakup of the Soviet Union and the rise of independent national states on its former territory. In addition, certaiative peoples and ethnic groups that had earlier been forcibly deported from the territory of Ukraine were rehabilitated, and their rights were restored at the end of 1989. The descendants of these individuals got the opportunity to return to their historical homeland at the beginning of the 1990s. At a minimum, over the period 1990-99,1.6 million persons came to Ukraine from the countries of the former USSR to take up permanent residence. All these factors brought about significant migratory flows into Ukraine primarily over the course of the years 1990-93. A negative balance of external migration was first recorded in 1994, and at this point the growth of the population due to migration ceased.

The natural growth of the population had already revealed a tendency to fall off in 1991, when the death rate in Ukraine exceeded the birth rate for the first time in the postwar period-the coefficient of natural growth per 1000 persons in the population came to -0.8.6 The negative trend was reinforced in the following years, and in the year 2000 it reached a value of -7.5.7

As a result, after 1993 a reduction in the absolute numbers of Ukraine’s population began. Over the course of the years 1993-2000, the population of Ukraine dropped by 2.9 million persons, from 52.2 million persons to 49.3 million. Of that number, four-fifths of the losses have been due to natural population losses (an excess of the death rate over the birth rate) and one-fourth as a consequence of migratory processes (an excess of the level of emigration over the level of immigration).

Factors determining the dynamics of populatioumbers

The causes of reductions in populatioumbers are: a reduction in the birth rate, an increase in the death rate, the unsatisfactory state of the health of the population accompanying the low quality of and insufficient access to the health care system in the country, and an excess of the level of emigration over the level of immigration.

The birth rate.

Over the period 1991-2000, the number of births per 1,000 persons in the population dropped by almost forty percent (from 12.7 in 1990 to 7.8 in 2000), and in absolute numbers by more than forty percent as well; while 657,200 persons were bora in 1990, 385,100 were bom in 2000. The reduction in the birth rate in rural areas of the country is reaching crisis proportions. According to data from the State Statistics Committee of Ukraine, out of the Ukraine’s 28,794 villages, not a single child was born in 12,673 of them in 1999. There are no children aged between six and fifteen in almost one thousand villages.

Against this background of a falling birth rate, the number of abortions remains stable and high. According to data from the Ministry of Health Care of Ukraine, 470,000 abortions were registered in the country in 1999.9 As a point of comparison, the number of births in 1999 came to 389,200 persons. For 320 of each 100,000 womeot giving birth as a result of abortion annually, the procedure ends in death.

Overall, the birth rate coefficient in Ukraine is one of the lowest among European countries (including the post-Communist countries). In the year 2000, the birth rate coefficient reached 7.8 in Ukraine. Lower figures were registered only in Bulgaria (7.7), Latvia (7.6), and Russia (7.6).

The death rate.

In contrast to the birth rate, the death rate in Ukraine is one of the highest in Europe. In 2000, the general coefficient of the death rate reached 15.3, compared to 10.6 in the countries of the European Union. Over the years 1991-2000, an increase of the death rate has been recorded in practically all age groups (with the exception of the age group 1-14), but the death rate is especially high among those of working age. The death rate index for working-age people grew by a factor of eight in the period 1991-2000, and the portion of the overall death rate reflecting people of working age reached almost twenty-five percent.

The high death rate among working-age men is an especially alarming phenomenon, capable of causing significant demographic deformations. This level is estimated to be the highest in the world. The death rate of men thus exceeds the death rate of women by two or three times in all age groups, but the difference is especially noticeable in the middle age groups of 30-45 years-that is, within the boundaries of the reproductive age.

Among the reasons for the high death rate among the working-age population since 1990, the most important is that of unnatural causes, including accidents, murders, and suicides. The main unnatural cause reflected in the death rate is suicide. The index of instances of suicide per 100,000 in the population is growing constantly: while in 1999 it came to 20.6, in 2000 it came to 29.4.

The population’s state of health, the quality of and access to health care. The indices of the state of health of Ukraine’s population are characterized by a steady worsening tendency. At the same time, the state of the health care system is also getting worse. The number of medical establishments is decreasing and the level of their financing by the state has fallen to a critical level. The transition of medicine towards a pay-for-care basis has significantly limited access to health care for the overwhelming majority of the population.

Up to 70 million instances of sickness are registered annually in Ukraine. According to data from the Ukrainian Institute for Public Health, only 4.4 percent of men and 2.9 percent of women of working age in the country have high indices of health and are in the so-called safety zone; 22.1 percent of men and 19.4 percent of women are in average health, while 73.5 percent of men and 77.7 percent of women have one degree or another of sickness. Coincidental with a general fall in the birth rate, the number of children with chronic illnesses and of children who are invalids is growing. Out of every hundred children born today in Ukraine, twenty-five are either born with pathologies or acquire them.

The so-called social illnesses-such as tuberculosis, syphilis, or HIV/AIDS- are spreading. The incidence of tuberculosis more than doubled over the period 1990-1999, and the death rate from this illness increased by almost two and a half times. About nine thousand people die from tuberculosis annually, more than 80 percent of them of working age (15 to 59). There is an increasing tendency for growth in the incidence of tuberculosis among children and, for the period 1995-1999, the corresponding index rose by 55 percent. The number of instances involving entire families, and also newborns, is increasing. Altogether, according to preliminary data, as of the beginning of 2001 about 625,000 persons were registered as being ill with this disease in Ukraine, a number that represents 1.4 percent of the country’s population and bears witness to the fact that Ukraine is experiencing an epidemic of tuberculosis.

Syphilis is encountered in Ukraine almost a hundred times more frequently than in the countries of Eastern and Central Europe. Over the period 1990-99, the number of instances of syphilis in the country increased by more than eighteen times (from 3,100 in 1990 to 56,800 in 1999). The fact that the disease is spreading among children and juveniles suggests that the outlook is bleak. The index of the number of illnesses per 100,000 in the population of that age has grown over the period 1994-99, among children by more than four times and among juveniles by almost 150 percent.

Ukraine, in the opinion of experts from UNAIDS and the WHO, has the “most dramatic” epidemic situation with regard to HIV/AIDS among the countries of the former USSR. As of the end of 2000, the number of officially registered cases of HIV infection came to about 36,000 persons. However, specialists assume that the number of persons ill with this disease in Ukraine is far higher than the officially registered number-perhaps around 285,000-and about 75 percent of those infected are young people in the age range 15-29.

Four regions (oblasts) in Ukraine (the Dnepropetrovsk, Donetsk, Nikolaev, and Odessa Regions) are experiencing an epidemic of HIV/AIDS. In these regions, the epidemic threshold established by the WHO is exceeded by three or four times at 70 instances of sickness per 100,000 persons in the population. The epidemiological situation is complicated by at least two factors, the influence of which could lead to a full-scale epidemic. First, the rate at which HIV/AIDS is spreading: Ukraine is the leader among European countries with about 500 new cases being registered monthly. By way of comparison, in Poland there are no more than 40 new cases per month. Second, the disease has gone beyond the limits of the group at risk and is hitting the general population, including children and young people.

On the whole, according to estimates made by specialists, if the tendencies for the spread of tuberculosis and HIV/AIDS are not overcome in the very nearest future, then in five to seven years one in every three inhabitants of Ukraine will be struck by one or the other of these diseases.

The worsening indices for the state of the population’s health notwithstanding, there is also a worsening in the quality of the country’s health care. In the index of outlays per inhabitant for health care, Ukraine occupies positioumber 111 among the 191 countries of the world, and positioumber eight among the countries of the CIS. In terms of level of achievement of the goals of health care, Ukraine occupies position number 60. Not only are outlays for health care per inhabitant in the country insufficient, they also demonstrate a tendency toward steady decline. In 1997, per capita health care outlays came to $47.30, while in 1998 they were $32.20, and in 2000, only $13.00. Overall, only 2.7 percent of GDP in Ukraine is directed at health care needs (the world standard being eight percent).

The growing proportion of pay-for-care medical services and their cost, which is incompatible with the average wage in the country, are progressively reducing the access to medical care for the overwhelming majority of the population. Instances of sick people dying because they are unable to pay for the necessary medical services or medicines are no longer a rarity. While he was Prime Minister of Ukraine, V.Iushchenko admitted that ten percent of Ukraine’s citizens do not have the possibility of availing themselves of medical aid. In the opinion of specialists, the real figure is far higher. This is confirmed by the results of a nationwide sociological poll conducted by UCEPS in February-March 2001, in which more than half the respondents (54.5 percent) reported that they had had to decline medical examination or aid due to a lack of means to pay for it.

A threatening situation has developed with regard to medical aid for children living in rural areas. According to data from the Ministry of Health Care of Ukraine, 95 percent of parents of rural children do not ask for medical aid due to the distance to medical establishments or due to an inability to pay.

The population’s socioeconomic situation.

The dynamics of the basic socioeconomic indices for 1990-2000 testify to a sharp decline in the quality of life for the overwhelming majority of the country’s population. The basic factors determining the economic situation of the population over the course of that period of time were a loss of savings brought about by the hyperinflation of 1991-93, the spread of unemployment, a decrease in monetary income (wages and pensions), and a depreciation in the value of that income as a consequence of inflation.

According to data from selective studies of the work force using the methodology of the International Association of Trade Unions, the level of unemployment came to 11.9 percent in 2000 among the economically active population aged 15-70. Among working age people, unemployment came to 12.5 percent. The level of registered unemployment was 4.2 percent of the working age population. However, according to expert estimates, taking hidden unemployment into account, the proportion of the economically active population without work reaches 35-40 percent. In this regard, closer inspection shows some extraordinarily negative signs of unemployment in Ukraine. Almost one third (30 percent) of the unemployed are young people aged 15-24. Unemployment is acquiring a nature associated with economic depression. In 1999, more than half the unemployed (56.3 percent) had not had work for more than a year, while the proportion of those who had not had work for more than three years increased from 1.3 percent in 1998 to 3.8 percent in 1999. The level of so-called family unemployment is growing, this phenomenon being especially characteristic of small towns and satellite towns to major industrial complexes.

At the same time, having work does not guarantee a good standard of living. In the first place, the wage level in Ukraine is critically low. The average monthly wage in 2000 came to 230 grivnas (US$42), and only covered 85 percent of the minimum subsistence level. In addition, arrears in wage payments are a chronic problem, in spite of some improvement in the situation in 2000. As of 1 January 2001 the total amount of arrears in payment of wages came to 4.9 billion grivnas (about US$9 million). As a result, there is a steady trend toward a reduction in the level of the income of the population. At present in Ukraine there are more than one million families in which the per capita income does not reach 50 grivnas (US$9) a month, while in more than one hundred thousand families it does not exceed 20 grivnas (US$3.60).

The existence of poverty and destitution was officially admitted in Ukraine only in 2000; at that time, 27.8 percent of the population (13.7 million persons) was considered to belong to the category of the impoverished, and 14.2 percent (almost 7 million persons), to the category of the destitute. Thus there are grounds for predicting that poverty will be a persistent and chronic problem. This is confirmed, in particular, by the poverty of families with children, and particularly of families with numerous children. In about 78 percent of families classified as impoverished, one of the adults has work. Where both parents have work, 26.1 percent of families with children are impoverished. If the current socioeconomic conditions persist, children from impoverished families will be unable to have quality health care and education, and consequently a vocation, and will be doomed to hereditary poverty. In addition, under conditions of spreading unemployment and poverty, the number of marriages is going down (the index of the number of marriages per 1,000 persons fell from 9.3 in 1990 to 5.5 in 2000). This leads, if not to a decrease in reproduction of the population, then to the growth of incomplete families and the spread of social orphans.

External migration of the population.

Although domestic labour mobility is generally low, the worsening socioeconomic situation in the country, the spread of unemployment, and the low price of labour compels people to migrate from Ukraine temporarily in search of work or to leave Ukraine to take up permanent residence in countries with more favourable employment conditions. According to expert estimates, labour migration from the country comprises about five million persons per year. This migration is mainly illegal. For example, in 2000 45,000 inhabitants travelled abroad from the Chernovtsy Region of Ukraine alone for the purpose of illegally securing work. By contrast, only 33 persons were reported to have legally secured work in the near and far abroad. Moreover, in recent years labour migration has taken on criminal features. A rise in activity in trading in people has beeoted. Thus, from the beginning of 2001, in the Donetsk Region alone, the Criminal Investigations Administration uncovered four organized criminal groups engaged in the trade in human beings. Twelve Ukrainian citizens and six Turkish citizens were identified as a part of the groups. Twelve companies were also exposed which, under the guise of finding employment for citizens, were recruiting young women and girls to engage in the sex business and prostitution.

There have also been instances of Ukrainian citizens travelling abroad for the purpose of hiring themselves out to military and paramilitary units, including illegal groups. The Security Service of Ukraine Administration in the Ivano-Frankovsk Region has disseminated information that in recent times there has been a growth in the numbers of those who leave to serve in foreign military groups. Foreign radical political organizations and commercial structures are actively recruiting young Ukrainians into legal and illegal militarized formations. Ukrainians often wind up in the French Foreign Legion. In the course of the year 2000 alone, the special services have prevented eighteen instances of departure abroad by Ukrainian citizens who had decided to reinforce the ranks of foreign legionnaires. At the same time, it is known to the Security Service of Ukraine that a number of inhabitants of the Ivano-Frankovsk, Nadvirnian, Kalush, Kolomyia, Kosov, and Dolina Districts are serving in the French Foreign Legion. According to estimates by the Security Service of Ukraine Administration, this tendency will’ intensify given the existing socio-economic situation.

The number of citizens of Ukraine leaving to take up residence in foreign countries remains at a high level. In 1999, 110,600 persons left Ukraine, and 100,300 left in 2000. Permanent emigration from Ukraine involves a number of ethnic groups, most notably Jews, Germans, Czechs, Hungarians, and Greeks, but also, to a lesser extent, Ukrainians and Russians. Those who leave are usually of working-age with a high level of education. Between 1995-99, about 6,000 workers in the field of science and about 1000 from the arts and culture left Ukraine.

The trend of migration into Ukraine, as was already noted, has diminished (the number of immigrants decreased from 65,800 in 2000 to 53,700 persons in 1999), with migrants from third-world countries prevailing.

The high level of emigration combined with a decreasing number of immigrants is bringing about a negative balance of migration (in 1999 and 2000 it came to -0.9 per 1,000 persons in the population), and serves as one of the factors in the reduction of the total population in the country.

Consequences of negative trends in Ukraine’s demographic situation

The unfavorable socioeconomic situation and the constant threat of unemployment and destitution are powerful factors in spreading a socially depressed condition in society. This in turn has an extremely unfavorable influence on the demographic situation by reducing the birth rate and growth.

Aging of the population.

The population of Ukraine can be considered old both against the Rosset scale and using United Nations norms. Using the Rosset scale, the part of the population aged 60 and older stands at 20.5 percent. Using United Nations norms, the part of the population aged 65 and older comprises 13.8 percent. In developed countries, the aging of the population occurs due to a lowering of the death rate of working-age people and an increase in longevity. In Ukraine this process has been brought about by a headlong decrease in the birth rate and an increase in the death rate of the working-age population (mainly of men). If demographic tendencies do not change, by 2026 27 percent of Ukraine’s population will consist of people older than 60.

One widely accepted indicator used to compare standards of living in different countries is the expected longevity at birth. In Ukraine, the value of this index is decreasing. While the expected lifespan stood at 67.1 years for men and 75.4 for women in 1989, in 1999 it was 62.8 and 73.2, respectively. This is ten years less than for men in developed countries with a high level of aging, and five to eight years less for women.

The extremely high death rate for working-age men is also bringing about a distortion in the population structure by sex. In Ukraine, the noticeable excess of the number of women over the number of men begins in the age groups after thirty years of age. With each year, this point is dropping lower down the age pyramid, which will lead to a distortion in reproductive activity-a further drop in the birth rate, an increase in the number of births outside of wedlock, and accompanying increases in the number of incomplete families and social orphans.

Percent of population aged 60 and over, 2000-2025

Labour resources.

Over the period 1995-99, the labour force remained practically unchanged, staying at a level of thirty million persons. Out of every hundred persons employed in the economy, fifty are women, seventeen are young people aged 15-28, and fourteen are people receiving a pension due to age, disability, or other special conditions. However, the consequences of the depopulation described above will begin to manifest themselves as early as 2007-08, when those born in 1991-92 reach working age. At approximately that time the demographic load on the able-bodied population will begin to grow.

Predictions and scenarios for the development of the demographic situation in Ukraine

Specialists at the Council for the Study of Productive Forces at the National Academy of Sciences of Ukraine have worked out a forecast for the demographic development of the country to 2076.

One main hypothesis advanced is a palpable inflow into Ukraine of emigrants from Afro-Asian countries. It rests on an expected decrease in the population and a corresponding decrease in the work force as a consequence of the aging of the population. The aggravated problem of filling job slots will make the implementation of measures to attract immigrants from Asia and Africa into the country unavoidable. This is actually the sole source for satisfying the economy’s need for labour and supporting the necessary level of economic utilization of territory.

Two scenarios for the possible development of the demographic situation are laid out. The first assumes that there is a strengthening of positive trends in stabilizing the standard of living of the population and a transition to industrial growth in two or three years. The second assumes a further aggravation of negative trends in the socio-economic situation of the country.

Under the first scenario, the following developments are expected:

·                     A stabilization and gradual growth in the number of arrivals from Russia (up to 70-90 thousand persons annually in the years 2010-30; that is, at the level of 1996-1997) and from the countries of the Transcaucasus Region, with a lowering of the intensity of reverse flows.

·                     An intensification (in the next three or four years) of the return of eth nic Ukrainians and representatives of peoples deported earlier (primarily Crimean Tartars).

·                     The number of those arriving will exceed the number leaving as early as 2003. The balance of migration will grow gradually, and in 2015 will reach a surplus of 150,000 persons;

·                     At the same time, a sharp increase in arrivals from the countries of Asia and Africa may be expected. The number of immigrants from those countries may reach 300,000 persons in 2050 and 400,000 persons annually at the end of the forecast period. Migrants from those regions will arrive in Ukraine primarily to stay; only fifteen to twenty percent will return or migrate to third countries.

·                     The dimensions of departures for countries of the West will stabilize at a level of 43,000 to 47,000 persons annually in 2004-05, with a gradual decrease to 30,000 annually at the end of the forecast period. Beginning as soon as 2005-07, the main part of that flow will be made up of temporary labor migrants, while the permanent emigration to countries of the West will drop to zero.

·                     The intensity of migratory contacts with the countries of the former Soviet Union will drop sharply during the second half of the forecast period, and they will lose their status as Ukraine’s basic migratory partners.

If events develop according to this optimistic variant, the trend in the birth rate will change. The inflow of immigrants in the 2020s will also stimulate a rejuvenation and an increase in population, which as a result will reach approximately 52 million by 2060 and increase by another six million in the following fifteen years.

Under the second, and more negative, scenario, the following developments are expected:

·                     The size of the migratory inflow from Russia will be reduced from 47,000 persons in 1999 to 35,000 persons annually, beginning in 2001, and to ten to fifteen thousand persons at the end of the forecast period.

·                     The dimensions of arrivals from the European republics of the former Soviet Union will decrease from 5,700 to four and two thousand persons, respec tively.

·                     The scale of departures of ethnic Russians, Belorussians, and Moldovans for their historical homelands will increase to 100,000-105,000 persons aually beginning in 2002-03. In 1998, the figure was about 95,000, and in 1999, as a consequence of military operations in Chechnya, it was less than 60,000.

·                     The flow of permanent migration to countries of the West will expand sig nificantly. The number of departures for these countries will increase from 47,000-50,000 persons in 1995-99 to 60,000-80,000 over the course of the first decades of the twenty-first century, after which it will gradually decrease to 45,000 annually.

·                     The share of returning labor migrants in the general migratory flow is predicted to be at a level of 15-25 percent. It is assumed (based on the migration legislation principles of countries that may potentially receive Ukrainian workers) that the most common length of time for work abroad will be a three years, and that 40-50 percent of labor migrants will be re turning to Ukraine specifically after three years, while a further five to ten percent will return after a more lengthy period.

·                     The flow of arrivals from the countries of Asia and Africa, practically unchanged in 2001-04, will begin to grow in 2015-20. However, the level at which immigrants stay will be low during the initial stages of the increase, with up to a third of the flow returning home or emigrating to more prosperous third countries. The proportion of those settling and staying among the arrivals from the countries of the East is expected to increase after 2012. At that time, as a consequence of lengthy depopulation and intensive emigration, the numbers and density of Ukraine’s population will be seventeen to twenty percent lower than the current level (creating potential living space for immigrants from the East). Therefore, after 2030 the dimensions of migrant arrivals from these regions will be greater than under the optimistic scenario. The balance of migration of Ukraine’s population under the worst-case variant of development of events in 2005-13 will stabilize at a level close to the current one. Over the course of the years 2014-15, the value of the negative migratory balance will decrease sharply, and several years after that Ukraine will become a country of immigration.

Under this pessimistic scenario, the demographic crisis will become ever more acute, and the population will gradually decrease. In 2076 it will comprise 40,200,000 persons.

Ethnic makeup of the population and interethnic relations

Ukraine is a multiethnic and multi-religious state. More than one hundred ethnic peoples have traditionally resided on its territory. The titular ethnic group consists of Ukrainians, whose share in the total population comes to more than 70 percent. The second most numerous ethnic group are the Russians, who constitute more than twenty percent of the population. Crimean Tartars, Karaims, and Krymchaks claim the status of “native peoples” of Ukraine. Russians advince the demand that they be recognized as an “ethnic group that forms a state.”

General characteristics

The population of Ukraine, as of 1 January 2001, belongs to fifty-four religious denominations. Among these, the Orthodox (Ukrainians from all regions of Ukraine except the western regions, as well as Russians), along with Greek-rite Catholics (Ukrainians from Ukraine’s western regions), are predominant. Catholicism (mainly ethnic Poles), Judaism, Islam, and various Protestant denominations (including those which are ethnically defined, such as, for example, the Reformist Church of the ethnic Hungarians in Transcarpathia) are also widely represented.

Over the course of the years 1990-2000, as a consequence of the international migratory processes noted above, the correlation of ethnic groups and their absolute numbers in Ukraine have undergone changes. It will only be possible to establish what these changes are with a sufficient degree of reliability as a result of the forthcoming census.

The peculiarities of Ukraine’s historical development, namely the lengthy periods that some of its territories spent as parts of different empires and later as part of the USSR, brought about significant sociocultural differences not only between representatives of Ukraine’s various ethnic peoples, but also between regional groupings of the titular ethnic group. The latter manifests itself in several ways. Among Ukrainians, there are differences in the practice of using the Ukrainian and Russian languages in daily life, and in the attitude toward these languages and toward Russian and Russian-language culture. There are also differences in geocultural (and, accordingly, a geopolitical) orientation, either facing toward Russia or toward the countries of Europe.

The presence of ethnic peoples residing in compact groups on Ukraine’s territory (Hungarians, Romanians, Moldovans, and Bulgarians), the high degree of Russification of the southern and eastern regions of the country, and the differences in ethnocultural identification of the titular ethnic group result in a complex interethnic situation in several regions of Ukraine. This creates the potential for possible separatist manifestations.

Transcarpathia is one of the most variegated regions in an ethic sense; representatives of more than 90 ethnic peoples reside in the region’s territory, in particular a group of ethnic Hungarians numbering 160,000).Bessarabia (the southwestern part of Odessa Region) and Bukovina (Chernovtsy Region) are a territory where Romanians and Moldovans live in compact groups, to which certain circles in Romania lay claim, and which may become centers of Romanian separatism.

The southern regions of Ukraine (Nikolaev, Kherson, Zaporozhye, and Odessa Regions) and Eastern Ukraine (Kharkov, Lugansk, and Donetsk Regions) are presumed to be zones of action of the “Russian factor.” However, the interethnic and inter-religious situation in the Crimea is the most acute situation today.

The Crimea. According to data from the census of 1989, representatives of 89 ethnic groups were resident in the Crimea, out of a total of 132 such groups in Ukraine as a whole. Altogether, there were 2,256,000 persons in the Crimea, of whom Russians constituted 67 percent and Ukrainians 26 percent, while Be-lorassians, Crimean Tartars, Jews, Germans, Bulgarians, Greeks, Poles, Gypsies, and other ethnic groups together made up seven percent. The high degree of Russification of the Crimea is confirmed by the fact that 83 percent of the population (including 47 percent of the Ukrainians) considers Russian to be their native language.

Complex socio-demographic and political processes took place in the Crimea during the period from 1989-2000. The socio-demographic processes were brought about, first of all, by the mass return of Crimean Tartars to their historical homeland. The political processes were brought about by the breakup of the USSR and by the establishment of Ukraine’s independence and the autonomous republic of the Crimea (the ARC) – a territorial autonomous entitiy – as a part of Ukraine with ethnic Russians as the predominant group in the population.

Ethnic Ukrainians make up about 25 percent of the Crimea’s population, the majority of these Ukrainians being Russian-speakers. This situation demands that a rather balanced position be taken in the introduction of the Ukrainian language and the expansion of the presence of Ukrainian culture in the informational and educational field in the ARC. At the present time, the conditions in the autonomous entity for a more complete ethnocultural identification of the Ukrainians are inadequate. Only four Ukrainian schools (out of 583 in the ARC) and only two Ukrainian libraries are functioning at present; four Ukrainian-language printed publications are being published (out of 240 being published in the autonomous entity). Only fourteen congregations of the Ukrainian Orthodox Church of the Kiev patriarchy – the independent, ethnically-oriented church – are active.

Crimean Tartars are returning to the Crimea after their forcible deportation in 1944. About 300,000 Crimean Tartars, representing twelve percent of the Peninsula’s population, are resident in the autonomous entity at the present time. The Crimean Tartars speak the Crimean Tartar language (which belongs to the Turkic language group) and profess Sunni Islam. The ethnic group of Crimean Tartars in the ARC has organs of ethnic self-government; however, they are not recognized by Ukraine’s organs of governmental authority.

In August 1999, the “Arraid” Inter-regional Association of Public Organizations conducted a sociological study jointly with the Department of Psychology at Tauride University. According to this study, the Crimean Tartars are firmly oriented toward maintaining their ethnic and religious identity. According to data from the poll, 77 percent of Crimean Tartars would prefer a school for their children and grandchildren with instruction conducted in the Crimean Tartar language and providing conventional and religious education, while 18 percent prefer a school providing a primarily religious education. Only five percent of those polled would prefer a school without religious education. In another finding, the Crimean Tartars are inclined to make the Crimea in particular their permanent place of residence. The overwhelming majority (76 percent) of those polled declared that they have no desire to leave the Crimea for any other place at all.

Out of every three children bora in the Crimea today, two are Crimean Tartars. There are grounds to conclude that a significant demographic shift should be expected in the direction of an increase both of the absolute number of Crimean Tartars in the Crimea and of their share in the total population of the Autonomous entity as early as the next generation.

Ethnic Russians constitute about 60 percent of the total population in the Crimean peninsula. The overwhelming majority of these Russians profess Orthodoxy and belong to the Ukrainian Orthodox Church in canonical unity with the Moscow Patriarchy. The political, socioeconomic, and sociocultural interests of the Russians in the Crimea are actively supported by Russia, where by no means all political and social circles have resigned themselves to the “loss” of the Crimea.

Russian schools subordinate to the Ministry of Defense of Russia function on the territory of the Autonomous entity, while a branch of Moscow State University carries out recruitment of students. Competitions for student compositions about Russia, the Russian language, and Russian culture are organized actively, and scientific and scholarly conferences, festivals, and tours of performers are conducted with the participation of representatives from the Russian Federation.

As a result, the degree of Russification of the Autonomous entity remains very high; out of 583 general education schools in the Crimea, 570 are Russian-language schools. Teaching in Crimean institutes of higher education is conducted in Russian. The market for books in the Autonomous entity is 99.9 percent filled by Russian-language editions. All this testifies to the fact that the Russians in the Autonomous entity possess the ability to maintain their ethnic and religious identity. At the same time, the Russians are also oriented toward permanent residence in the Crimea. 76 percent of those polled answered that under no circumstances do they plan to leave the Crimea. Two percent could leave for other regions of Ukraine, thirteen percent for countries of the West, and not a single one of those polled expressed a desire to leave for Russia.

The predominance of ethnic Russians in the makeup of the Autonomous entity’s population, including the degree of the population’s general Russification, the non-acceptance by certain political circles in the Russian Federation of the Crimea’s detachment from Russia, and the maintenance of a Russian presence on the peninsula (including a military presence) have brought about (and are bringing about) significant separatist or pro-Russian sentiments among a significant portion of the Crimea’s population. There have been attempts to bring about the secession of the Autonomous entity from Ukraine.

On the other hand, some Crimean Tartars have put forward slogans about creating an ethnic Crimean Tartar autonomous entity, the restitution of property lost at the time of deportation, and full-fledged participation in processes of privatizing Crimean enterprises and sharing of land. In their claims, the Crimean Tartars rely on help from Turkey as a Muslim country in which, moreover, a rather sizeable Crimean Tartar diaspora operates.

It is along the line of the interrelations between the ethnic groups of Crimean Tartars and Russians in particular (more specifically, of the Russian-speaking socio-cultural group within the population of Crimea) that interethnic and inter-religious tension is to be observed. This tension is threatening to become acute under the influence of both internal and external factors.

In connection with this, it should be noted that there has been little desire among Crimean Tartars to create their own state. Only five percent of those polled expressed favor for such a prospect. The majority of respondents strive for the establishment in the Crimea of a territorial ethnic autonomous entity within Ukraine. Another 27 percent thinkt that the Crimea should remain an autonomous republic within Ukraine – that is, it should remain in its present status. These results suggest an absence of fertile ground for radical extremist and separatist tendencies among the Crimean Tartars.

What is alarming is the fact that a significant portion of the Crimean Tartars polled-35 percent-think-that their life is getting significantly worse with the passage of time, while another ten percent say it is worse, but not much. Only fourteen percent said their lives were getting better. 58 percent pointed to a worsening of living conditions in comparison with where they lived before, and the overwhelming majority (76 percent) stated that the average monthly income per family member among them was no more than fifty grivnas (US$10).

Statements like these have a real basis. Unemployment among the Crimean Tartars stands at 60 percent, as opposed to fifteen to twenty percent for the Crimea as a whole. Moreover, the prospects for satisfying the cultural and educational needs of the Crimean Tartars are doubtful. A problem exists with the level of representation for the Crimean Tartars in organs of government, which leads to the self-isolation of the Crimean Tartars and to interethnic alienation.

At the same time, the Russian population views the idea of extending privileges to the Crimean Tartars very critically. 47 percent of those polled think the granting of such privileges to be unfair, while only 27 percent are of the opposite opinion. However, judging by results of the poll, the standard of living of the Russians in the Crimea is significantly higher than the standard of living of the Crimean Tartars. Only fifteen percent of those polled said that the average monthly income per family member was no more than fifty grivnas, and unemployment among the Russians is only eight percent.

The Russians living in Crimea have a sharply negative attitude toward a potential status as a territorial ethnic autonomous entity within Ukraine. Not a single one of the Russians polled supported that status, but fifteen percent of the Russians polled think that the Crimea should become an autonomous republic within Russia, while another twenty-four percent think it should become an independent country. As was mentioned above, among the Crimean Tartars, only five percent think that Crimea should become an independent country.

Such moods are fertile soil for incitement of interethnic dissension, which is already manifesting itself today in the form of inter-religious conflicts. Such conflicts were noted in the summer of 2000, when the Spiritual Board of Crimean Muslims suspended its membership in the “Peace is God’s Gift” interfaith association to signify a protest against establishment of the Simferopol and Crimean eparchies of the Ukrainian Orthodox Church and against crosses for worshippers and display boards saying, “The Crimea is the cradle of Orthodoxy.” Crimean Tartars tore down such a cross in the village of Morskoe in October 2000. Clashes between them and the Orthodox population were avoided, thanks to the intervention of law enforcement agencies. Conflict between the Crimean eparchy of the Ukrainian Orthodox Church and the Crimean Tartars over a former monastery building was prevented in September 2001 only by the arrival of President of Ukraine Leonid Kuchma. However, the danger of conflicts of this kind remains and is becoming more acute, particularly in connection with accusations directed at the Crimean Tartars over their ties to Chechen militants, participation in military actions against Russia’s Federal troops in Chechnya, and so on.

According to the results of a sociological poll of the ARC’S population conducted by UCEPS in March 2001, the majority of those polled (61 percent) do not exclude the possibility that religious conflicts involving the use of force will arise in the Crimea, and just less than a third (27 percent) of the Crimea’s inhabitants are sure that such conflicts are impossible.

Predictions

Over the coming fifteen to twenty years, the demographic situation in the Crimea will change substantially. The proportion of the Crimean Tartar population in the general population will increase by means both of natural growth and the further immigration of Tartars from the Central Asian countries.

In 1995, it was assumed that 400-600,000 Crimean Tartars would return to the Crimea in the next five years. However, that did not happen, and only 50-60,000 actually returned.

In the event that a cardinal improvement in the socioeconomic situation does not occur, a sharp radicalization among the Crimean Tartars is possible. The assimilation of the Crimean Tartars should not be expected; rather, Crimea may evolve either in the direction of a Ukrainian Switzerland or in the direction of a Ukrainian Kosovo.

A poll by the Institute of Sociology of the National Academy of Sciences of Ukraine provided the following results:

Of the various groupings identified in Ukraine, Belorussians are the least inclined to maintain a unique culture, with only 29.9 percent expressing this intention. At the same time, representatives of other ethnic peoples (Poles, Bulgarians, Moldovans, and Jews) registered a rather high level of desire to preserve their cultural uniqueness. Those polled suggested that this desire was in reaction to attempts at forcible Ukrainization.

According to the results of investigations into the urge to leave for various historical homelands, Jews (52 percent) and Germans (45.7 percent) demonstrated the strongest tendency in this direction. The desire to emigrate was insignificant among Hungarians and Russians.

Trends among Russo-Ukrainian groupings

Three organizations have come forward with sharp criticism for the Ministry of Education of Ukraine: the Russian Movement, the Russo-Ukrainian Union, and “For a Unified Russia.” These organizations do not like “Kiev’s official policy of eliminating Russian-language education in Ukraine and encouraging assimilation of Russian and Russian-speaking citizens.” According to official data, over the last decade the Ukrainian government has changed the language of teaching from Russian to Ukrainian in 1300 schools. At the present time, teaching in the Ukrainian language is conducted in 90 percent of the country’s schools, although half the population considers Russian to be its native language.

Small but politically active structures exist: “The Civil Congress of Ukraine,” the Party of Slavic Unity, the “Union” party, the SLOn association, and the Party of Regional Rebirth of Ukraine (PRVU), among others. Here, regionalism or frank separatism, the battle for union with Russia or for a restoration of the USSR, are more likely to be colored by ethnocultural factors. Rather than these extreme goals, the real objectives are presumed to be securing the status for Russian as an official language and the retention of a high degree of Russification of public life, culture, and education in the country.

The demographic situation in Ukraine, which has acquired the features of an acute demographic crisis in recent years, became increasingly complicated in 1998. That was evidenced by the fact that a population of 50.5 million people in early 1998 had decreased to 50.1 million people by early 1999, as well as by the growing depopulation.

The population is decreasing annually because the number of deceased has exceeded that of newborns, by 39,000 in 1991, 100,000 in 1992 and 299,700 in 1995, including 166,800 in urban settlements and 133,900 in rural areas. Thus, 55% of the natural decrease of population occurred in urban settlements in 1998.

In 1998 the tendency towards a decrease of the total population continued. The urban population decreased by 254,100 people, while the rural population decreased by almost 400,000, approximately the same level as in recent years.

A decrease of the total population was observed in all regions. The most essential decrease of the total population occurred in such highly urbanized regions of Ukraine as Donetsk (56,500), Dniepropetrovsk (30,400), Kharkiv (26,500), the Autonomous Republic of the Crimea and the city of Sevastopol (28,600). The number of people in these regions mainly decreased at the expanse of urban population. These five regions make up 44.3% (174,000 people) of the total population decrease in 1998. The group of regions with a decrease of population also includes the regions of Odesa (19,200), Zaporizhzhia (18,700), Chernigiv (15,600), Vinnytsia (15,600) and Sumy (15,300).

These nine regions and the Autonomous Republic of the Crimea as a whole make up about 66% of the population decrease in Ukraine. The lowest population decrease in 1998 was observed in the regions of Zakarpattia (800 people), Rivne (1,900), Ivano-Frankivsk (3,000) and Chernivtsi (3,100 people); the natural increase was positive in the first two regions (1,500 and 4,000 people, respectively).

The decreasing population figures are a result of a further natural decrease of the population and negative indices of migration (both in urban settlements and rural areas). But the migration indices in rural areas are 6.4 times as low as in urban settlements.

Regional peculiarities of the demographic situation are formed as a result of interstate relations, the ethnic background of people in a certain region, the basic gene pool, moral and religious conditions, etc. Since the influence of these conditions has its distinctions in a concrete region, the state of the demographic process there gives a mosaic picture of reproduction of the population both in quantitative and qualitative respects.

A natural decrease of population has been recorded in all the regions of Ukraine except for Zakarpattia and Rivne regions. The decrease was highest in the regions of Chernigiv (10.8 people per 1,000), Sumy (9.2), Lugansk (8.9), Donetsk (8.7), Poltava (8.5), Kirovograd (8.3) and Cherkasy (8.2), and lowest in the regions of Ivano-Frankivsk (0.6), Chernivtsi (0.8) and Volyn (1.4).

The socio-economic crisis in Ukraine is the cause of the crisis situation in terms of population figures. Birth rates are still falling sharply. In 1998 the number of newborns (419,200) decreased by 23,400 as compared to 1997, and by 138,300 as compared to 1993. The birth rate coefficient in 1998 was 8.3 per 1,000 people. That is one of the lowest levels in Europe and in the world.

This index is even lower in the south-eastern (7.3%) and north-eastern (7.6%) regions of Ukraine. Only the western region is still characterized by a more or less considerable birth rate (11.7 in 1997, 11.3 in 1998). A relatively high birth rate level is observed in rural areas of Rivne (14.5%), Volyn (13.5%), Chernivtsi (12.9%), and Zakarpattia (12.8%) regions.

The total birth rate index has decreased to a level, which evidences a lack of population reproduction. The average number of children born by one woman was 1.1 in 1998 (1.0 in cities, 1.6 in villages).

A sharp deterioration of the situation of population mortality was observed in Ukraine in the 1990s, especially in the first years of the decade. The annual number of deaths increased by 163,000: from 630,000 in 1990 to 793,000 in 1995. As of 1996 one can observe a very slow decrease of the mortality coefficient, the total one from 15.2% to 14.3%, the standardized from 14.0% to 12.9%.

One can also observe a significant difference in various regions as to mortality coefficient. The highest levels were registered in the north-eastern (17.1%) and central (15.9%) regions, the lowest ones in the western region (12.1%).

The decreasing birth rates and rising mortality rates result in a deepening depopulation crisis. In 1998 the natural increase remained negative; the loss was 6.0% in Ukraine. The worst situation was observed in the north-eastern (- 9.5%) and south-eastern (-8.0%) regions.

Infant mortality in 1998 decreased to 12.8 per 1,000 babies born alive. It was the first decrease of the death rate of babies in the 1990s. As compared to 1997 infant mortality has decreased by 8.8%. A decrease of infant mortality was observed in all the regions of Ukraine; the rates of decrease were highest in the north-eastern (by 12%) and central (by 6%) regions.

Despite the considerable decrease, the coefficient of infant mortality remains the highest in the southern region (14.0%), its lowest level being observed in the central (11.1%) region. A considerable decrease of the death rate of newborn boys and a certain increase of the death rate of girls were observed in the southeastern region (Table 6.1).

Sharply decreasing birth rates cause the health of newborns to be of special concern. It depends essentially on the health of the parents and complications in the course of pregnancy and during delivery. An unfavourable ecological situation favours the expansion of chronic diseases which reaches the reproductive period and creates a closed cycle: a sick mother (father) – sick child – sick teenager – sick parents. The cycle term is 20-25 years, and with each such cycle the pathologic states of newborns become more severe.

Introduction of modern medical and organizational technologies in maternity and childhood protection services has, in spite of the unfavourable ecological situation and limited financing, resulted in a reassuring tendency in terms of neonatal (7.7 per 1,000 alive newborns in 1997 and 7.2 in 1998) and maternal mortality (30.9 and 29.5 per 100,000 of alive newborns, respectively).

The decrease of neonatal mortality took place against the background of a deterioration of the health of babies: while in 1995 only 211.8 of 1,000 newborns had birth defects, in 1998 this number reached 260.3. The acuteness of the prematurity problem is determined by the fact that the sickness rate of premature babies is 3.4 times and early neonatal mortality is 16.0 times as high as analogous indices for the mature.

Thus in all the areas of the central region the level of neonatal mortality and prematurity is the lowest (on average) in Ukraine, while in most regions of the southern and south-eastern regions the index of neonatal mortality remains high against a high level of prematurity.

In the south-eastern region, and in some areas of the western (Ivano-Frankivsk, Lviv, Ternopil) region the high level of neonatal mortality (lower prematurity than in Ukraine on average) is mainly determined by a high level of infant mortality from birth defects of development and states originating from the perinatal period.

The high levels of maternal and infant mortality are persisting in the regions hardest hit by the after-effects of the Chernobyl catastrophe. These are Kyiv, Zhitomyr and Chernigiv regions as well as the developed industrial complex (Zaporizhzhia, Kirovograd).

Constantly low levels of mortality were observed in the recent years only in Lugansk and Vinnytsia regions (Table 6.2).

An analysis of statistical data shows that there are regions in Ukraine where the demographic situation has acquired a special character. Among them:

The south-eastern region (Dniepropetrovsk, Donetsk, Lugansk and Kharkiv regions) with the highest population decrease, especially in the urban population. This decrease has been determined mainly by mortality exceeding natality as well as by the negative balance of population migration.

The capital region (Kyiv and district) with a considerable decrease of the urban population. The decrease of the urban population was observed side by side with that of the rural population.

The central region (Vinnytsia, Zhitomyr, Kirovograd, Poltava, Sumy, Khmelnitskyi, Cherkasy and Chernigiv regions) is characterized by a steadily increasing depopulation.

The southern region (AR of the Crimea, Mykolaiv, Odesa, Kherson regions) is also characterized by a decrease of population (both urban and rural).

The western region (Volyn, Zakarpattia, Ivano-Frankivsk, Lviv, Rivne, Ternopil and Chernivtsi regions) is the most stable as to demographic development. It is still a region of natural reproduction.

The favourable age structure of the population is one of the factors causing a natural increase of the population in the western region. The youngest population and, therefore, the highest potential of demographic reproduction are characteristic of the region. Social and natural conditions for vital activities are the most important factors of reproduction. Living conditions for some people in certain regions of Ukraine have a negative effect on the quantitative indices of population reproduction. This mostly concerns the south-eastern region where considerable hyperurbanized areas with permanently high pollution of the atmospheric air, water, soil and food products affect public health, especially the health of children. A considerable spread of all diseases, especially those connected with the quality of the environment (malignant tumours, pregnancy pathologies, maternal anomalies, etc.) are characteristic of the region.

The same influence of unfavourable natural conditions is manifested in other highly urbanized regions of Ukraine. In the future such regions cannot be an essential source of population reproduction both because of the low natural increase, and because the physical state of the people has been weakened as a result of the natural and socio-economic conditions that have developed.

Considerable pollution by radioactive elements will also have a negative effect on population reproduction for a long period of time. Almost 2,350,000 people live in territories with different degrees of radioactive pollution. Various factors connected with this phenomenon determine the deterioration of reproduction indices. This mostly concerns areas of the central and capital regions, especially the Polissia parts of Kyiv and Zhitomyr regions, which have become areas of a demographic catastrophe.

The regional peculiarities of the demographic situation in Ukraine are caused by various reasons of social, economic and ecological character and this situation can be improved only with due regard to the fact that only the creation of favourable conditions for people’s vital activities will ensure positive progress in the demographic processes in Ukraine.

This part contains data of the All-Ukrainian census of the population at the data of 5 December 2001 about the number and structure of the permanent urban and rural population by sex, age groups and marital status. The part also contains the distribution of the population at the age of 100 and older by sex and age groups, and the distribution of the women by the age and the number of children in Ukraine and regions.

Future trends of demographic development (2000-2050)

A number of projections made in different Russian and Ukrainian institutions and by different authors and the UN prospects were examined. Projections made before mid-90th were more optimistic than ones made later. Almost all projections made in the end of the XXth century don’t assume Russian and Ukrainian population increase.

Populatioon-decrease can be ensured by such values of demographic characteristics that they are hardly attainable in the next decades.

Here we dwell upon the UN projections up to the year 2050 (UN World Population Prospects, the 2004 Revision). For each country medium, high and low variants are based on the same assumptions for LE and migration. For all variants TFRs for Ukraine are supposed to be lower than those for Russia, while values of LE – higher.

Annual net migration for Russia is set to be equal to 50 thousand, and –100 thousand for Ukraine.

Fig. 12 demonstrates total population size dynamics for Russia and Ukraine in 2000-2050 according to medium, high and low variants. For all scenarios total population will decrease (more rapidly for Ukraine), this decrease being determined by theassumptions made. Thus, according to the medium variant by the year 2050 Russia’s population can decrease by 24 % as compared with population size in 2000 (Ukraine’s – by 46 %).

Differences in fertility assumptions result in substantial differences in age structures both for Russia and Ukraine. Fig. 13a-13c demonstrate dynamics of proportions of children and the elderly for medium, high and low variants for Russia, Ukraine and the whole Europe. For all variants the gap between the proportions of children and the elderly is increasing, being higher for Ukraine. For the medium variant the difference between the proportions of the elderly and children in 2000 for Russia was 0.1% (2.9 % Ukraine, 2.8 % for Europe), by 20250 it can reach 14.5 % for Russia (25.6 % for Ukraine, 19 % for Europe).

Population age structures for Russia and Ukraine in 2025 and 2050 (medium variant) age given on Fig. 14 a, b showing further progress of population ageing. This process will develop according to all considered scenarios having profound and far-reaching consequences forcing Governments to reassess many established economic, social and political policies and programmes.

Results of the study may contribute to better understanding of demographic situation in Russia and Ukraine within the European context and will allow to use more widely the experience of each of these countries in elaboration of social policies.

CONCEPT OF HEALTH

Health is a common theme in most cultures. In fact, all communities have their concepts of health, as part of their culture. Among definitions stilt used, probably the oldest is that health is the “absence of disease”. In some cultures, health and harmony are considered equivalent, harmony being defined as “being at peace with the self, the community, god and cosmos”. The ancient Indians and Greeks shared this concept and attributed disease to disturbances in bodily equilibrium of what they called “humors”.

Modern medicine is often accused for its preoccupation with the study of disease, and neglect of the study of health. Consequently, our ignorance about health continues to be profound, as for example, the determinants of health are not yet clear; the current definitions of health are elusive; and there is no single yardstick for measuring health. There is thus a great scope for the study of the “epidemiology” of health.

Health continues to be a neglected entity despite tip service. At the individual level, it cannot be said that health occupies an important place; it is usually subjugated to other needs defined at more important, e.g., wealth, power, prestige, knowledge, security. Health is often taken for granted, and its value is not fully understood until it is lost. At the international level, health was “forgotten” when the covenant of the League of Nations was drafted after the First World War. Only at the last moment, was world health brought in. Health was again “forgotten” when the charter of the United Nations was drafted at the end of the Second World War. The matter of health had to be introduced ad hoc at the United Nations Conference at San Francisco in 1945.

However, during the past few decades, there has been a reawakening that health is a fundamental human right and a ^world-wide social goal; that it is essential to the satisfaction of basic humaeeds and to an improved quality of life; and, that it is to be attained by all people. In 1977, the 30th World Health Assembly decided that the main social target of governments and WHO in the coming decades should be “the attainment by “the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life”, for brevity, called “Health for All”. With the adoption of health as an integral part of socio-economic development by the United Nations in 1979, health, while being an end in itself, has also become a major instrument of overall socio-economic development and the creation of a new social order.

CHANGING CONCEPTS

An understanding of health is the basis of all health care. Health is not perceived the same way by all members of a community including various professional groups (e.g., biomedical scientists, social science specialists, health administrators, ecologists, etc) giving rise to confusion about the concept of health, in a world of continuous change, new concepts are bound to emerge based oew patterns of thought. Health has evolved over the centuries as a concept from an individual concern to a world-wide social goal and encompasses the whole quality of life. A brief account of the changing concepts of health is given below:

1. Biomedical concept

Traditionally, health has been viewed as an “absence of disease”, and if one was free from disease, then the person was considered healthy. This concept, known as the “biomedical concept” has the basis in the “germ theory of disease” which dominated medical thought at the turn of the 20th century. The medical profession viewed the human body as a machine, disease as a consequence of the breakdown of the machine and one of the doctor’s task as repair of the machine. Thus health, in this narrow view, became the ultimate goal of medicine.

The criticism that is levelled against the biomedical concept is that it has minimized the role of the environmental, social, psychological and cultural determinants of health. The biomedical model, for alt its spectacular success in treating disease, was found inadequate to solve some of the major health problems of mankind (e.g., malnutrition, chronic diseases, accidents, drug abuse, mental illness, environmental pollution, population explosion) by elaborating the medical technologies. Developments in medical and social sciences led to the conclusion that the biomedical concept of health was inadequate.

2. Ecological concept

Deficiencies in the biomedical concept gave rise to other concepts. The ecologists put forward an attractive hypothesis which viewed health as a dynamic equilibrium between man and his environment, and disease a maladjustment of the human organism to environment. Dubos defined health saying: “Health implies the relative absence of pain and discomfort and a continuous adaptation and adjustment to the environment to ensure optimal function”. Human ecological and cultural adaptations do determine not only the occurrence of disease but also the availability of food and the population explosion. The ecological concept raises two issues, viz. imperfect man and imperfect environment. History argues strongly that improvement in human adaptation to natural environments can lead to longer life expectancies and a better quality of life – even in the absence of modern health delivery services.

3. Psychosocial concepts

Contemporary developments in social sciences revealed that health is not only a biomedical phenomenon, but one which is influenced by social, psychological, cultural, economic and political factors of the people concerned. These factors must be taken into consideration in defining and measuring health. Thus health is both a biological and social phenomenon.

4. Holistic concept

The holistic model is a synthesis of all the above concepts. It recognizes the strength of social, economic, political and environmental influences on health. It has been variously described as a unified or multidimensional process involving the well-being of the whole person in the context of his environment. This view corresponds to the view held by the ancients that health implies a sound mind, in a sound body, in a sound family, in sound environment. The holistic approach implies that all sectors of society have an effect on health, in particular, agriculture, animal husbandry, food, industry, education, housing-, public works, communications and other sectors. The emphasis is on the promotion and protection of health.

DEFINITIONS OF HEALTH

“Health” is one of those terms which most people find it difficult to define although they are confident of its meaning. Therefore, many definitions of health have been offered from time to time, including the following:

a.   “the condition of being sound in body, mind or spirit, especially freedom from physical disease or pain” (Webster);

b.   “soundness, of body or mind; that condition in which its functions are duly and efficiently discharged” (Oxford English Dictionary);

c.   “a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic and environmental”;

d.   “a modus vivendi enabling imperfect men to achieve a rewarding and not too painful existence while they cope with an imperfect world”;

e.   “a state of relative equilibrium of body form and function which results from its successful dynamic adjustment to forces tending to disturb it. It is not passive interplay between body substance and forces impinging upon it but an active response of body forces working toward readjustment” (Perkins).

WHO definition

The widely accepted definition of health is that given by the World Health Organization (1948) in the preamble to its constitution, which is as follows:

“Health is a state of complete physical, mental and social wellbeing and not merely an absence of disease or infirmity”

In recent years, this statement has been amplified to include the ability to lead a “socially and economically productive life”.

The WHO definition of health has been criticised as being too broad. Some argue that health cannot be defined as a “state” at all, but must be seen as a process of continuous adjustment to the changing demands of living and of the changing meanings we give to life. It is a dynamic concept. !t helps people live well work well and enjoy themselves. The WHO definition of health is therefore considered by many as an Idealistic goal than a realistic proposition. It refers to a situation that may exist in some individuals but not in everyone all the time; it is not usually observed m groups of human beings and in communities. Some consider it irrelevant to everyday demands, as nobody qualifies as healthy, i.e., perfect biological, psychological and social functioning. That is, if we accept the WHO definition, we are all sick.

In spite of the above limitations, the concept of health as defined by WHO is broad and positive in its implications; it sets out the standard, the standard of “positive” health. It symbolized the aspirations of people and represents an overall objective or goal towards which nations should strive.

Operational definition of health

The WHO definition of health is not an “operational” definition, i.e., it does not lend itself to direct measurement Studies of epidemiology of health have been hampered because of our inability to measure health and well-being directly. In this connection an “operational definition” has been devised by a WHO study group. In this definition, the concept of health is viewed as being of two orders. In a broad sense, health can be seen as “a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental”.

In a narrow sense – one more useful for measuring purposes – health means: (a) there is no obvious evidence of disease, and that a person is functioning normally, i.e., conforming withiormal limits of variation to the standards of health criteria generally accepted for one’s age, sex, community, and geographic region; and (b) the several organs of the body are functioning adequately in themselves and in relation to one another, which implies a kind of equilibrium or homeostasis – a condition relatively stable but which may vary as human beings adapt to internal and external stimuli.

New philosophy of health

In recent years, we have acquired a new philosophy of health, which may be stated as below:

– health is a fundamental human right

– health is the essence of productive life, and not the result of ever increasing expenditure on medical care

– health is intersectoral

– health is an integral part of development

– health is central to the concept of quality of life

– health involves individuals, state and international responsibility

– health and its maintenance is a major social investment

– health is world-wide social goal

DIMENSIONS OF HEALTH

Health is multidimensional. The WHO definition envisages three specific dimensions – the physical, the mental and the social. Many more may be cited, viz. spiritual, emotional, vocational and political dimensions. As the knowledge base grows, the list may be expanding. Although these dimensions function and interact with one another, each has its owature, and for descriptive purposes will be treated separately.

1. Physical Dimension

The physical dimension of health is probably the easiest to understand. The state of physical health implies the notion of “perfect functioning” of the body. It conceptualizes health biologically as a state in which every cell and every organ functioning at optimum capacity and in perfect harmony with the rest of the body. However, the term “optimum” is not definable.

The signs of physical health in an individual are: “a good complexion, a clean skin, bright eyes, lustrous hair with a body well clothed with firm flesh, not too fat, a sweet breath, a good appetite, sound sleep, regular activity of bowels and bladder and smooth, easy, coordinated bodily movements. All the organs of the body are of unexceptional size and functioormally: all the special senses are intact; the resting pulse rate, blood pressure and exercise tolerance are all within the range of “normality” for the individual’s age and sex. In the young and growing individual there is a steady gain in weight and in the future this weight remains more or less constant at a point about 5 lbs (2.3 kg) more or less than the individual’s weight at the age of 25 years. This state of normality has fairly wide limits. These limits are set by observation of a large number of “normal” people, who are free from-evident disease.

Evaluation of physical health:

Modern medicine has evolved tools and techniques which may be used in various combinations for the assessment of physical health. They include:

– self assessment of overall health

– inquiry into symptoms of ill health and risk factors

– inquiry into medications

– inquiry into levels of activity (e.g., number of days of restricted activity within a specified time, degree of fitness)

– inquiry into use of medical services (e.g., the number of visits to a physician, number of hospitalizations) in the recent past

– standardized questionnaires for cardiovascular diseases

– standardized questionnaires for respiratory diseases

– clinical examination

– nutrition and dietary assessment

– biochemical and laboratory investigations

At the community level, the state of health may be assessed by such indicators as death rate, infant mortality rate and expectation of life. Ideally, each piece of information should be individually useful and when combined should permit a more complete health profile of individuals and communities.

2. Mental dimension

Mental health is not mere absence of mental illness. Good mental health is the ability to respond to the many varied experiences of life with flexibility and a sense of purpose. More recently, mental health has been defined as “a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a coexistence between the realities of the self and that of other people and that of the environment”.

A few short decades ago, the mind and body were considered independent entities. Recently, however, researchers have discovered that psychological factors can induce all kinds of illness, not simply mental 6nes. They include conditions such as essential hypertension, peptic ulcer and bronchial asthma. Some major mental illnesses such as depression and schizophrenia have a biological component. The underlying Inference is that there is a behavioural, psychological or biological dysfunction and that the disturbance in the mental equilibrium is not merely in the relationship between the individual and society.

Although, mental health is an essential component of health, the scientific foundations of mental health are not yet clear. Therefore we do not have precise tools to assess the state of mental health unlike physical health. Psychologists have mentioned the following characteristics as attributes of a mentally healthy person:

a. a mentally healthy person is free from internal conflicts;

he is not at “war” with himself,

b. he is well-adjusted, i.e., he is able to get along well with others. He accepts criticism and is net easily upset,

c. he searches for identity

d. he has a strong sense of self-esteem

e. he knows himself: his needs, problems and goals-(this is known as self-actualization)

f. he has good self-control-balances rationality and emotionality

g. he faces problems and tries to solve them intelligently, i.e. coping with stress and anxiety.

Assessment of mental health at the population level may be made by administering mental status questionnaires by trained interviewers. The most commonly used questionnaires seek to determine the presence and extent of “organic disease” and of symptoms that could indicate psychiatric disorder; some personal assessment of mental well-being is also made. The most basic decision to be made in, assessing mental health is whether to assess mental functioning, i.e., the extent to which cognitive or affective impairments impede role performance and subjective life quality, or psychiatric diagnosis.

One of the keys to good health is a positive mental health. Unfortunately, our knowledge about mental health is far from complete.

3. Social dimension

Social well-being implies harmony and integration within the individual, between each individual and-other members of society and between individuals and the world in which they live. It has been defined as the “quantity and quality of an individual’s interpersonal ties and the extent of involvement with the community”.

The social dimension of health includes the levels of social skills one possesses, social functioning and the ability, to see oneself as a member of a larger society. In general, social health takes into account that every individual is part of a family and of wider community and focuses on social and economic conditions and well-being of the “whole person” in the context of his social network. Social health’ is rooted in “positive material environment” (focusing on financial and residential matters), and “positive human environment” which is concerned with the social network of the individual.

4. Spiritual dimension

Proponents of holistic health believe that the time has come to give serious consideration to the spiritual dimension and to the role this plays in health and disease. Spiritual health in this context, refers to that part of the individual which reaches out and strives for meaning and purpose in life. It is the intangible “something” that transcends physiology and psychology. As a relatively new concept, it seems to defy concrete definition. It includes integrity, principles and ethics, the purpose in life, commitment to some higher being and belief in concepts that are not subject to “state of the art” explanation.

5. Emotional dimension

Historically the mental and emotional dimensions have been seen as one element or as two closely related elements. However, as more research becomes available a definite difference is emerging. Mental health can be seen as “knowing” or “cognition” while emotional health relates to “feeling”. Experts in psychobiology have been relatively successful in isolating these two separate dimensions. With this new data, the mental and emotional aspects of humaess may .have to be viewed as two separate dimensions of human health.

6. Vocational dimension

The vocational aspect of life is a new dimension. It is part of human existence. When work is fully adapted to human goals, capacities and limitations, work often plays a role in promoting both physical and mental health. Physical work is usually associated with an improvement in physical capacity, while goal achievement and self-realization in work are a source of satisfaction and enhanced self-esteem.

The importance of this dimension is exposed when individuals suddenly lose their jobs or faced with mandatory retirement. For many individuals, the vocational dimension may be merely a source of income. To others, this dimension represents the -culmination of the efforts of other dimensions as they function together to produce what the individual considers life “success”.

7. Others

A few other dimensions have also been suggested such as:

– philosophical dimension

– cultural dimension

– socioeconomic dimension

– environmental dimension

– educational dimension

– nutritional dimension

– curative dimension

– preventive dimension

A glance at the above dimensions shows that there are many “non-medical” dimensions of health, e.g., social, cultural, educational, etc. These symbolize a huge range of factors to which other sectors besides health must contribute if all people are indeed to attain a level of health that will permit them to lead a socially and economically productive life.

HEALTH – A RELATIVE CONCEPT

An alternative approach to positive health conceptualizes health not as an ideal state, but as a biologically “normal” state, based on statistical averages. For example, a newborn baby in India weighs 2,8 kg on an average compared to 3.5 kg in the developed countries, and yet compares favourably in health. The height and weight standards vary from country to country and also between socio-economic groups. Many normal people show heart murmurs, enlarged tonsils and X-ray shadows in the chest and yet do not show signs of illhealth. Thus health is a relative concept and health standards vary among cultures social classes and age-groups. This implies that health in any society should be defined in terms of prevailing ecological conditions. That is, instead of setting universal health standards, each country will decide on its oworms for a given set of prevailing conditions and then look into ways to achieve that level.

CONCEPT OF WELLBEING

The WHO definition of health introduces the concept of “well-being”. The question then arises: what is meant by wellbeing? In point of fact, there is no satisfactory definition of the term “wellbeing”.

Recently, psychologists have pointed out that the “wellbeing” of an individual or group of individuals have objective and subjective components. The objective components relate to such concerns as are generally known by the term “standard of living” or “level of living”. The subjective component of well-being (as expressed by each individual) is referred to as “quality of life”. Let us consider these concepts separately.

1. Standard of living

The term “standard of living” refers to the usual scale of our expenditure, the goods we consume and the services we enjoy. It includes the level of education, employment status, dress, house, amusements and comforts of modern living.

A similar definition, corresponding to the above, was proposed by WHO: “Income and occupation, standards of housing, sanitation and nutrition, the level of provision of health, educational, recreational and other services may all be used individually as measures of socio-economic status, and collectively as an index of the “standard of living”.

There are vast inequalities in the standards of living of the people in different countries of the world. The extent of these differences are usually measured through the comparison of per capita GNP on which the standard of living primarily depends.

2. Level of living

The parallel term for standard of living used in United Nations documents is “level of living”. It consists of nine components: health, food consumption, education, occupation and working conditions, housing, social security, clothing, recreation and leisure and human rights. These objective characteristics are believed to influence human wellbeing. It is considered that health is the most important component of the level of living because its impairment always means impairment of the level of living.

3. Quality of life

Much has been said and written on the quality of life in recent years. It is the “subjective” component of wellbeing. “Quality of life” was defined by WHO as: “the condition of life resulting .from the combination of the effects of the complete range of factors such .as those determining health, happiness (including comfort in the physical environment and a satisfying occupation), education, social and intellectual attainments, freedom of action, justice and freedom of expression”.

A recent definition of quality of life is as follows: “a composite measure of physical, mental and social wellbeing as perceived by each individual or by group of individuals – that is to say, happiness, satisfaction and gratification as it is experienced in such life concerns as health, marriage, family work, financial situation, educational opportunities, self-esteem, creativity, belongingness, and trust in others”.

Thus, a distinction is drawn between the concept of “level of living” consisting of objective criteria and of “quality of life” comprising the individual’s own subjective evaluation of these. The quality of life can be evaluated by assessing a person’s subjective, feelings of happiness or unhappiness about the various life concerns.

People are now demanding a better quality of life. Therefore, governments all over the world are increasingly concerned about improving the quality of life of their people by reducing morbidity and mortality, providing primary health care and enhancing physical, mental and social well-being. It is conceded that a rise in the standard of living of the people is not enough to achieve satisfaction or happiness. Improvement of quality of life must also be added, and this means increased emphasis on social policy and on reformulation of societal goals to make life more livable for all those who survive.

Physical quality of life index

As things stand at present, this important concept of quality of life is difficult to define and even more difficult to measure. Various attempts have been made to reach one composite index from a number of health indicators. The “Physical quality of life index” is one such index. It consolidates three indicators, viz. infant mortality, life expectancy at age one, and literacy. These three components measure the results rather than inputs. As such they lend themselves to international and national comparison.

For each component, the performance of individual countries is placed on a scale of 0 to 100, where 0 represents an absolutely defined “worst” performance, and 100 represents an absolutely defined “best” performance. The composite index is calculated by averaging the three indicators, giving equal weight to each of them. The resulting PQLI thus also is scaled 0 to 100.

It may be mentioned that PQLI has not taken per capita GNP into consideration, showing thereby that “money is not everything”. For example, the oil-rich countries of Middle East with high per capita incomes have in fact not very high PQLIs. At the other extreme, Sri Lanka and Kerala state in India have low per capita incomes with high PQLIs. In short, PQLI does not measure economic growth; it measures the results of social, economic and political policies. It is intended to complement, not replace GNP. The ultimate objective is to attain a PQLI of 100.

Human Development Index

Human development index (HDI) is defined as “a composite index combining indicators representing three dimensions -longevity (life expectancy at birth); knowledge (adult literacy rate and mean years of schooling); and income (real GDP per capita in purchasing power – parity dollars)”.

Thus the concept of HDI reflects achievements in .the most basic human capabilities, viz., leading a long life, being knowledgeable and enjoying a decent standard of living. Hence, three variables has been chosen to represent those dimensions. The HDI is a more comprehensive measure than per capita income. Income is ‘only a means to human development, not an end. Nor is it, a sum total of human lives. Thus by focusing on areas beyond income and treating income as a proxy for a decent standard of living, the HDI provides a more comprehensive picture of human life than income does.

The HDI values ranges between 0 to 1. The HDI value for a country shows the distance that it has already traveled towards maximum possible value to 1, and also allows comparisons with other countries.

To construct the index, fixed minimum and maximum values have been established for each of these indicators, (say x₁).

– Life expectancy at birth: 25 years and 85 years

– Adult literacy rate: 0 per cent and 100 per cent

– Combined gross enrolment ratio: 0 per cent and 100 per cent

– Real GDP per capita (PPP$): $ 100 and  $ 40,000 (PPP $)

For any component of the HDI, individual indices can be computed according the general, formula:

Disparities between regions can be significant with some regions having more ground to cover in making the shortfall than others. The link between the economic prosperity and human, development is neither automatic nor obvious. Two countries with similar income per capita can have very different HDI values and countries having similar HDI can have very different income levels.

The concept of Gender – Related Development index (GDI) and Gender Empowerment Measure (GEM) were introduced during the year 1995. These terms are composite measures reflecting gender inequalities in human development. While GDI reflects achievements in. the basic human development adjusted for gender inequalities, GEM measures gender inequalities in economic and political opportunities. During the year 1997 another term Human Poverty Index (HPI) was introduced while the HDI measures average achievements in basic dimensions of human development, the HPI measures deprivation in those dimensions.

SPECTRUM OF HEALTH

Health and disease lie along a continuum, and there is no single cut-off point. The lowest point on the health-disease spectrum is death and the highest point corresponds to the WHO definition of positive health (Fig.2). It is thus obvious that health fluctuates within a range of optimum well-being to various levels of dysfunction, including the state of total dysfunction, namely the death. The transition from optimum health to illhealth is often gradual, and where one state ends and the other beams is a matter of judgment.

The spectral concept of health emphasizes that the health of any individual is not static; it is a dynamic phenomenon and a process of continuous change, subject to frequent subtle variations. What is considered maximum health today may be minimum tomorrow? That is, a person may function at maximum levels of health today, and diminished levels of health tomorrow. It implies that health is a state not to be attained once and for all, but ever to be renewed. There are degrees or “levels of health” as there are degrees or severity of illness. As long as we are alive there is some degree of health in us.

Positive health

Better health

Freedom from sickness

 

Unrecognised sickness

Mild sickness

Severe sickness

Death

FIG. 2. The Health Sickness Spectrum

DETERMINANTS OF HEALTH

Health is multifactorial. The factors which influence health lie both within the individual and externally in the society in which he or she lives. It is a truism to say that what man is and to what diseases he may fall victim depends on a .combination of two sets of factors – his genetic factors and the environmental factors to which he is exposed. These factors interact and these interactions may be health-promoting or deleterious. Thus, conceptually, the health of individuals and whole communities may be considered to be the result of many interactions. Only a brief indication of the more important determinants or variables are shown in fig. 3.

1.     Biological determinants

The physical and mental traits of every human being are to some extent determined by the nature of his genes at the moment of conception. The genetic make-up is unique in that it cannot be altered after conception. A number of diseases are now known to be of genetic origin, e.g., chromosomal anomalies, errors of metabolism, mental retardation, some types of diabetes, etc. The state of health therefore depends partly on the genetic constitution of man. Nowadays, medical genetics offers hope for prevention and treatment of a wide spectrum of diseases, thus the prospect of better medicine and longer healthier life. A vast field of knowledge has yet to be exploited. It plays a particularly important role in genetic screening and gene therapy.

Fig. 3. Determinants of health

Thus, from the genetic stand-point, health may be defined as that “state of the individual which is based upon the absence from the genetic constitution of such genes as correspond to characters that take the form of serious defect and derangement and to the absence of any aberration in respect of the total amount of chromosome material in the karyotype or stated in positive terms, from the presence in the genetic constitution of the genes that correspond to the normal characterization and to the presence of a normal karyotype”.

The “positive health” advocated by WHO implies that a person should be able to express as completely as possible the potentialities of his genetic heritage. This is possible only when the person is allowed to live in healthy relationship with his environment – an environment that transforms genetic potentialities into phenotypic realities.

2. Behavioral and socio-cultural conditions

The term “lifestyle” is rather a diffuse concept often used to denote “the way people live”, reflecting a whole range of social values, attitudes and activities. It is composed of cultural and behavioral patterns and lifelong personal habits (e.g., sticking, alcoholism) that have developed through processes of socialization. Lifestyles are learnt through social interaction with parents, peer groups, friends and siblings and through school and mass media.

Health requires the promotion of healthy lifestyle. In the last 20 years, a considerable body of evidence has accumulated which indicates that there is an association between health and lifestyle of individuals. Many current-day health problems especially in the developed countries (e.g., coronary heart disease, obesity, lung cancer, drug addiction) are associated with lifestyle changes. In developing countries such as India where traditional lifestyles still persist, risks of illness and death are connected with lack of sanitation, poor nutrition, personal hygiene, elementary human habits, customs and cultural patterns.

It may be noted that not all lifestyle factors are harmful. There are many that can actually promote health. Examples include adequate nutrition, enough sleep, sufficient physical activity, etc. In short, the achievement of optimum health demands adoption of healthy lifestyles. Health is both a consequence of an individual’s lifestyle and a factor in determining it.

3. Environment

It was Hippocrates who first related disease to environment, e.g., climate, water, air, etc. Centuries later, Pettenkofer in Germany revived the concept of disease-environment association.

Environment is classified as “internal” and “external”. The Internal environment of man pertains to “each and every component part, every tissue, organ and organ-system and their harmonious functioning within the system”. Internal environment is the domain of internal medicine. The external or macro-environment consists of those things to which man is exposed after conception. It is defined as “all that which is external to the individual human host”. It can be divided into physical, biological and psychosocial components, any or all of which can affect the health of man and his susceptibility to illness. Some epidemiologists have used the term “microenvironment” (or domestic environment) to personal environment which includes the individual’s way of living and lifestyle, e.g., eating habits, other personal habits (e.g., smoking or drinking), use of drugs, etc. It is also customary to speak about occupational environment, socioeconomic environment and moral environment.

It is an established fact that environment has a direct impact on the physical, mental and social well-being of those living in it. The environmental factors range from housing, water supply, psychosocial stress and family structure through social and economic support systems, to the organization of health and social welfare services in the community.

The environmental components (physical, biological and. psychological) are not water-tight compartments. They are so inextricably linked with one another that it is realistic and fruitful to view the human environment in toto when we consider the •influence of environment on the health status of the population. If the environment is favorable to the individual, he can make full use of his physical and mental capabilities. Protection and promotion of family and environmental health is one of the major issues in the world today.

4. Socio-economic conditions

Socioeconomic conditions have long been known to influence human health. For the majority of the world’s people, health status is determined primarily by their level of socioeconomic development, e.g., per capita GNP, education, nutrition, employment, housing, the political system of the country, etc. Those of major importance are:

(I)               Economic status: The per capita GNP is the most widely accepted measure of general economic performance. There can be no doubt that in many developing countries, .it is the economic progress that has been the major factor in reducing morbidity, increasing life expectancy and improving the quality of life (Table 3). The economic status determines the purchasing power, standard of living, quality .of life, family size and the pattern of disease and deviant behavior in the community. It is also an important factor in seeking health care. Ironically, affluence may also be a contributory cause of illness as exemplified by the high rates of coronary heart disease, diabetes and obesity in the upper socioeconomic groups.

(II) Education: A second major factor influencing health status is education (especially female education). The world map of illiteracy closely coincides with the maps of poverty, malnutrition, illhealth, high infant and child mortality rates. Studies indicate that education, to some extent, compensates the effects of poverty on health, irrespective of the availability of health facilities. The small state of Kerala in India Is a striking example. Kerala has an estimated infant mortality rate of 14 compared to 71 for all-India in 1999. A major factor in the low infant mortality of Kerala is its highest female literacy rate of 87.86 per cent compared to 54.16 per cent for all-India.

(III) Occupation: The very state of being employed in productive work promotes health, because the unemployed usually show a higher incidence of illhealth and death. For many, loss of work may mean loss of income, and status. It can cause psychological and social damage.

(IV) Political system: Health is also related to the country’s political system. Often the main obstacles to the implementation of health technologies are not technical, but rather political. Decisions concerning resource allocation, manpower policy, choice of technology and the degree to which health services are made available and accessible to different segments of the society are example’s of the manner in which the political system can shape community, health services. The percentage of GNP spent on health is a quantitative indicator of political commitment. Available information shows that India spends about 3 per cent of its GNP on health and family welfare. To achieve the goal of health for alt, WHO has set the target of at least 5 per cent expenditure of each country’s GNP on health care. What is needed is political commitment and leadership which is oriented towards social development, and not merely economic development. If poor health patterns are to be changed, then changes must be made in the entire sociopolitical system in any given community. Social, economic and political actions are required to eliminate health hazards in people’s working and living environments.

5. Health services

The term health and family welfare services cover a wide spectrum of personal and community services for treatment of disease, prevention of illness and promotion of health. The purpose of health services’ is to improve the health status of population. For example, immunization of children can influence the incidence/prevalence of particular diseases. Provision of safe water can prevent mortality and morbidity from water-borne diseases. The care of pregnant women and children would contribute to the reduction of maternal and child morbidity and mortality. To be effective, the health services must reach the -social periphery, equitably distributed, accessible at a cost the country and community can afford and socially acceptable. All these are ingredients of what is now termed “primary health care”, which is seen as the way to better health.

Health services can also be seen as essential for social and economic development. It is well to remind ourselves that “health care does not produce good health”. Whereas, there is a strong correlation between GNP and expectation of life at birth, there is no significant correlation between medical density and expectation of life at birth. The most we can expect from an effective health service is good care. The epidemiological perspective emphasizes that health services, no matter how technically elegant or cost-effective, are ultimately pertinent only if they improve health.

6. Aging of the Population

By the year 2020, the world will have more than one billion people aged 60 and over and more than two • thirds of them living in developing countries. Although the elderly in many countries enjoy better health than hitherto, a major concern of rapid population aging is the increased prevalence of chronic diseases and disabilities both being conditions that tend to accompany the aging process and deserve special attention.

7. Gender

The 1990s have witnessed an increased concentration on women’s issues. In 1993, the Global Commission on Women’s Health was established. The commission drew up an agenda for action on women’s health covering nutrition, reproductive health, the health consequences of violence, aging, lifestyle related-conditions and the occupational environment. It has brought about an increased awareness among policy – makers of women’s health issues and encourages their inclusion in all development plans as a priority.

8. Other factors

We are witnessing the transition from post industrial age to an information age and experiencing the early days of two interconnected revolutions, in information and in communication. The development of these technologies offers tremendous opportunities in providing an easy and instant access to medical information once difficult to retrieve. It contributes to dissemination of information worldwide, serving the needs of many physicians, health professionals, biomedical scientists and researchers, the mass media and the public.

Other contributions to the health of population derive from systems outside the formal health care system, i.e., health related systems (e.g., food and agriculture, education, industry, social welfare, rural development) as well as adoption of these in the economic and social fields that would assist in raising the standards of living. This would include employment opportunities, increased wages, prepaid medical programmes and family support systems.

In short, medicine is not the sole contributor to the health and wellbeing of population. The potential of intersectoral contributions to the health of communities is increasingly recognized.

Methodology of morbidity study (general, with the temporal disability)

Morbidity of population is a collapsible concept that includes values, which are characterizing the level of different diseases and their structure among all population or its separate groups on the given territory.

In the complex of medical values of the health the morbidity takes a special place, its medical and social value is determinate by the fact that disease is the principal reason of death, temporal and permanent disability that by the turn results big economical losses of society, the negative influence on the health of future generations and diminishment of population quantity.

Materials about the level and structure of the morbidity in different regions, and also in separate sexual-age groups, especially in a dynamics for the definite period of time, are necessary for aimed programs development as for strengthening of health, in particular in planning of network developing of curing and prophylactic establishments and medical personnel training.

Also it is important that the values of the morbidity are one of the most informing criteria’s of activity of organs and establishments of the health protection and efficiency of conducting of medical, prophylactic, social and other measures care.

Finally, their studying determinate the ways of prophylactic of different diseases.

The statistics of morbidity in a great deal complements the statistics of death rate at estimation of population health and takes important advantage comparative with it, mainly effectiveness. At the same time, unlike the demographic phenomens (birth, death), which are easily determinate, the studying of morbidity is connected with considerable difficulties. The disease can have the indefinite beginning  as well as the end indefinite in time. It’s possible to observe “erased” forms of disease, bacillus carrying that can be difficult to distinguish the disease and the morphological, skeletal changes etc.

Besides the population does not always appeal for medical help. The disease mostly becomes accessible for registration only when the patient applies for it. As a result plenitude of information about morbidity foremost depends from the volume and character of medicare, its availability and quality.

The main methods for studying the morbidity are those one, which foresee the use of such given:

– appeals for medical help in medical establishments;

– medical examinations of separate groups of population;

– about the reasons of death;

– questioning of population;

– special selective researches.

Each method has advantages and disadvantages which are taken into account in practical activity. Anyone of them gives the exhaustive picture of population morbidity. Only their united using can give the complete information (table 1).

Table 1

Comparative description of basic methods of studying the population morbidity

• at insufficient availability of medicare (for example, in rural locality);

• bad level of medical culture of population;

• insufficient authority among the population of medical establishment on the whole or separate doctors etc.

The study of morbidity from materials of appeals aloud us most to take into account the so-called “acute” diseases more completely. This method does not need additional facilities.

At the studying of morbidity from data of medical examinations, plenitude of information about morbidity depends on:

• their systematic providing;

• participation of doctors of necessary specialties;

• sufficient diagnostic providing;

• the control of timeliness and plenitude of examinations.

 Using this method the most complete account before the unknown chronically diseases is provided, or those, which the population actively does not apply to the medical establishments. The advantage of this method is also exposure of initial forms and stages of diseases, clarification of diagnosis of some chronically diseases etc.

The studying of morbidity from data of death reasons is the additional method for two mentioned above. It is especially actual in relation to the account of those diseases, which are possible to be registered only at the appeal for the getting the medical certificate about the death (the question is about the patients, that had never appeal to the medical establishments and died at home), and also suddenly diseases which are given high lethality and were not exposed by the both first methods (heart attacks, strokes, traumas etc.)

If during previous years the methods of morbidity studying from data of appeals and medical examinations were leading, in modern terms, in case of the considerable number of private medical establishments and especially at introduction of elements of insurance medicine, the most complete information about the morbidity can be obtained from data’s of the special selective researches and questioning of population.

The advantage of the questioning method is the possibility of account of diseases, with which the population does not apply on those or other reasons for medical help, and also finding out of opinion of man in relation to the disease.

At the same time the subjectivity connected with the self-diagnostics and also with the considerable quantity of wrong answers for the questions of questionnaire is appropriated to it.

Studying of the morbidity with the use of separately each of the indicated data’s does not give the picture of actual exhaustive prevalence of pathology. Special selective, deep researches answer these tasks more completely. During their conducting the regional, sexual-age features of the morbidity are determined at different levels of the medical providing.

The selective special researches, including the morbidity of population, make it possible to obtain more detailed and high-quality information in more short terms and for less facility. Wide distribution of them is proposed by Program of reformation of state statistics on a period till 2000, by Decision of Cabinet of Ministers of Ukraine №971 from June, 22, 1999.

The selective special researches are part of the programs of deep study of health, which are used during enumeration population.

The last researches of this kind were timed in Ukraine to the All-union censuses of population in 1970 and 1989. Because of the wide-Ukrainian census of population in 2001 duty full research of morbidity is planned within the limits of the general program of determination the Ukraine population health.

In most foreign countries the selective study of document about hospitalization of patients and questioning of selective groups in population with application of questionnaire method are used for description of morbidity.

The study of general morbidity from data of general practitioners, organs of social insurance etc. is held only in some countries.

In Great Britain, where the state system of health care exists, researches of general morbidity on the basis of records of general practitioners are conducted.

Most economic developed countries use other information – questioning (interview) of selective groups of population. So, in the USA permanent researches of health of population, since 1958, include the study of morbidity on the selective aggregate of families by a questionnaire which contains over 40 questions in relation to family members: their diseases, got medicare, used medicines etc. The method of conducting such researches in the USA at the years is perfected every year, a few specialized “Centers of the control of morbidity” are engaged in their co-ordination, which, apply an interview by phone, and also departures of the special brigades which conduct the instrumental methods of inspection, besides the questioning of population.

Japan conducts the study of morbidity by means of the method of questioning the population of selected districts. Answers about the suffered diseases which took place only 2 months before the questioning are registered.

Researches, which are conducted in Denmark, France, are also based on questioning of population after the special questionnaire.

The necessary condition at the study of health of population, in particular morbidity, is the standardization of approach of doctors of different countries to determination and formulation of diagnoses that enables to compare morbidity in time and in different regions.

As it’s known, there are about 5000 diagnostic terms, which are used by doctors in practice. Evidently, statistical development of information about morbidity is not possible without the rationally built groupment that is the classification and nomenclature of diseases.

The project of international nomenclature and classification of diseases was ratified in 1900 at International statistical conference in Paris, which collected representatives from 26 countries. In future international classifications from time to time were looked through and were changed accordingly with progress of medical science. It took place approximately every 10 years.

Since 1962, International classification of diseases, traumas and reasons of death (ICD) is used in our country. ICD is periodically looked through and adopted by the special committee of experts on medical statistics and subcommittee of diseases classification of World health care organization (WHCO).

International statistical classification of diseases of the last Tenth revision (ICD-10) was ratified by the forty-third Assembly of WHCO January, 1, 1993. In obedience to the decision of the Assembly the document has a new name “International statistical classification of diseases and close problems of health protection”, though the comfortable abbreviation ICD is preserved (table 2).

Table 2

INTERNATIONAL CLASSIFICATION OF DISEASES BY 10^TH REVIEW        (ICD-10)

The basic principles of construction of International classification of diseases, traumas and reasons of death are the community of etiology or pathogenesis of diseases or combination of locally-etiologic and local-pathogenetic principles. Every class of diseases is distributed on groups, and groups – on headings. For example, IV class of diseases of the endocrine system, disorders of feed and metabolic disturbances has 6 groups:

• diseases of thyroid;

• diabetes mellitus;

• violation of other endocrine glands;

• insufficiency of feed;

• obesity and other types of surplus feed;

• metabolic disturbance.

The group of thyroid diseases has 5 headings:

• syndrome of innate insufficiency iodine;

• diseases of thyroid, related to insufficiency iodine,

and the conditions;

• hypothyreosis;

• thyreotoxicosis (hyperthyreosis);

• thyreoiditis;

• other forms of thyroid diseases.

The basic innovation of ICD-10 is the using of alphabet-digital code (that replaces previous digital), when two numbers of the code are reflected the certain letter of the Roman alphabet, and at a necessity of the greater working out in detail of heading – its third number.

For example, class of diseases of the endocrine system, disorders of feed and metabolitical disturbances is marked by a three-digit code from Е00 to Е90. In the turn the diseases of thyroid have the codes from Е00 to Е07, diabetes mellitus — Е10-Е14 etc.

Code example after separate subheadings:

Thyreotoxicosis (hyperthyreosis) – Е05, including:

Thyreotoxicosis with a diffuse goiter- Е05.0;

Thyreotoxicosis with a toxic one-node goiter- Е05.1;

Thyreotoxicosis with a toxic multi-node goiter – Е05.2.

In Ukraine the ICD-10 introduction in curing and prophylactic establishments was begun from 1999, according to the Decision of Cabinet of Ministers after №326 from 01.05.93 “About conception of construction of national statistics of Ukraine and Government program of transition on the international system of account and statistics”.

There are such kinds of morbidity at its study from the data of appeals for medical help:

1. general morbidity – the account of all diseases (sharp and chronic) which are registered at the population of certain territory for certain period of time;

2. infectious morbidity – the special account of acute diseases, connected with the necessity of the operative conducting of nonepidemical measures;

3. morbidity on the major nonepidemical diseases falls due the special account as a result of their epidemiology and social value (malignant new formations, tuberculosis, venereal, psychical diseases etc.);

4. hospital or “hospitalized” morbidity enables to learn composition of patients which were treated in permanent establishment;

5. morbidity with the temporal disability of workers and employees is selected as a result of its social and economic value.

Each of these types of morbidity is studied after certain registration documents and is estimated on different values (table 3).

Table 3

Basic sources of information and values, which characterize the separate types of morbidity

 

The general morbidity takes into account prevalence of all diseases among all population on whole and separate diseases in it’s certain groups on the given territory as a result of appeals.

Values of the general morbidity enable to estimate the levels of morbidity that were exposed and registered in ambulatory-policlinic establishments during a calendar year.

General morbidity is studied on the basis of current registration all primary appeals of patients.

The first appeal at the chronic diseases is considered the primary appeal in this year.

At the acute diseases, which can take place several times during a year, the first appeal concerning every case is taken into account.

The case of disease or trauma concerning which the patient appealed to medical establishment is taken for unit of supervision at study of general morbidity.

Two documents are the source about general morbidity: “Statistical coupon for registration of final (specified) diagnoses” (f.№ 025-2/о) and “Coupon of ambulatory patient” (f. № 025-6/о, f. 025-7/о).

The separate “Statistical coupon for registration of final (specified) diagnoses” with the mark “+” is filled on every case of acute disease. Code „1″ is marked alongside with the name of diagnosis in “Coupon of ambulatory patient” at the sharp diseases. Thus, a several cases of acute diseases can be registered at one man for a year.

The diagnoses of chronic diseases are registered only one time for a year. If a diagnosis is set for the first time in life of patient – note “+” in the “Statistical coupon for registration of final (specified) diagnoses” or code of “2” in “Coupon of ambulatory patient.” If the diagnosis of chronic disease is set earlier, at the first visit of doctor each next year in the “Statistical coupon for registration of final (specified) diagnoses” the mark of “-” or code 3 in “Coupon of ambulatory patient”.

Information of the mentioned registration documents above is basis for drafting of “Report about the number of the diseases, registered at patients, which live in the district of maintenance of medical establishment” (f. № 12).

 

There are such basic values of general morbidity:

— primary morbidity (Іпсіdепсе) – the level of t first registered diseases for a calendar year on this territory; all sharp and first set for a year chronic diseases are taken into account also:

— general morbidity, or prevalence of diseases (Рrеvаlепce) – the level of all registered diseases for a calendar year: sharp and chronic (registered at the first appeal in a current year, and exposed both in current and in previous years);

— structure primary and general morbidity of population.

There are terms recommended by MHCO.

The method of calculation of the values is represented on the picture 21.

Picture 21

The method of calculation of the values.

 

Using of “Coupon of ambulatory patient” extends possibilities of analysis of morbidity. It is possible to define the values of frequency of sharpening of chronic diseases also, separately level of the first registered sharp and chronic diseases etc by this document.