SUMMARY The SDGs position health as a key feature of human development in a more integrated manner than was the case for the MDGs, emphasizing the fact that social, economic and environmental factors influence health and health inequalities and in turn, benefit from a healthy population Major population trends impact health fertility rates have fallen substantially almost everywhere, but still remain high in the African Region Close to 40% of the population growth in 2015-2030 will come from Africa, and more than one quarter of the world,s children will live there by 2030. The population aged 60 and over will increase by 50% in the SDG era. This presents many opportunities but will also challenge existing social norms, require a re-aligning of health systems and challenge countries to provide sustainable social security and long-term care By 2030, 60% of the world's population ill live in urban areas Poverty eradication is still a priority The world attained the MDg target-to cut the 1990 poverty rate in half by 2015-in 2010. Despite positive trends, one in seven people in developing regions still lives on less than USS 1.25 per day. In sub haran Africa, more than 40% of the population still live in extreme poverty in 2015 In 2013, total health spending reached USS 7.35 trillion, more than double the amount spent in 2000. Development assistance for health increased dramatically since 2000, but is now flattening and likely to become less prominent in the SDG era. The greatest need -as well as the focus of much traditional development finance- will become increasingly concentrated in the world, s most unstable and fragile countries Gender inequalities in education, employment and civil liberties not only deprive women of basic freedoms and violate their human rights, but also negatively affect health and development outcomes for societies as a whole. The SDGs expand the focus on gender equity across a range of goals, including health the right to health has been re-emphasized in terms of the achievement of UHC, but is also closely linked to the realization of other human rights, particularly for women and vulnerable groups such as migrants and people with disabilities Education is strongly linked to better health and the mdg goal of universal primary education has been broadened with 10 SDG targets addressing all sectors of education. Just over half of countries achieved the MDG goal, and 70% have achieved gender parity for primary education, but fewer than half have achieved parity for the secondary level Environmental sustainability is a central concern of the Sdgs and is addressed in goals for water and sanitation, energy cities and climate change. Climate change will have increasing consequences for health, ranging from the immediate impact of extreme weather events, to the longer term impacts of droughts and desertification on food production and malnutrition, and the increased spread of infectious disease vectors for malaria and dengue. The poorest and most vulnerable populations are likely to be affected most ECONOMIC SOCIAL AND ENVIFONMENTAL CONTEXT OF HEALTH
SUMMARY The SDGs position health as a key feature of human development in a more integrated manner than was the case for the MDGs, emphasizing the fact that social, economic and environmental factors influence health and health inequalities and, in turn, benefit from a healthy population. Major population trends impact health. Fertility rates have fallen substantially almost everywhere, but still remain high in the African Region. Close to 40% of the population growth in 2015–2030 will come from Africa, and more than one quarter of the world’s children will live there by 2030. The population aged 60 and over will increase by 50% in the SDG era. This presents many opportunities but will also challenge existing social norms, require a re-aligning of health systems and challenge countries to provide sustainable social security and long-term care. By 2030, 60% of the world’s population will live in urban areas. Poverty eradication is still a priority. The world attained the MDG target – to cut the 1990 poverty rate in half by 2015 – in 2010. Despite positive trends, one in seven people in developing regions still lives on less than US$ 1.25 per day. In subSaharan Africa, more than 40% of the population still live in extreme poverty in 2015. In 2013, total health spending reached US$ 7.35 trillion, more than double the amount spent in 2000. Development assistance for health increased dramatically since 2000, but is now flattening and likely to become less prominent in the SDG era. The greatest need – as well as the focus of much traditional development finance – will become increasingly concentrated in the world’s most unstable and fragile countries. Gender inequalities in education, employment and civil liberties not only deprive women of basic freedoms and violate their human rights, but also negatively affect health and development outcomes for societies as a whole. The SDGs expand the focus on gender equity across a range of goals, including health. The right to health has been re-emphasized in terms of the achievement of UHC, but is also closely linked to the realization of other human rights, particularly for women and vulnerable groups such as migrants and people with disabilities. Education is strongly linked to better health and the MDG goal of universal primary education has been broadened with 10 SDG targets addressing all sectors of education. Just over half of countries achieved the MDG goal, and 70% have achieved gender parity for primary education, but fewer than half have achieved parity for the secondary level. Environmental sustainability is a central concern of the SDGs and is addressed in goals for water and sanitation, energy, cities and climate change. Climate change will have increasing consequences for health, ranging from the immediate impact of extreme weather events, to the longer term impacts of droughts and desertification on food production and malnutrition, and the increased spread of infectious disease vectors for malaria and dengue. The poorest and most vulnerable populations are likely to be affected most. ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH 17
Health is central to human development, both as an International Conference on Population and Development inalienable right in and of itself and as a key contributor and the beijing Platform for Action and Target 5.6 refers to the growth and development of communities and directly to this programme of action, calling for efforts societies. Health was central to the MDGs, and in the SDGs to: "Ensure universal access to sexual and reproductive is positioned as a key feature of human development in a health and reproductive rights ." There is one goal on cities more integrated manner. One SDG is specifically focused(Goal 11: Make cities and human settlements inclusive, safe on health and several others incorporate actions to improve resilient and sustainable) that addresses the challenges health and to address its broader social, environmental of rapid urbanization, and two targets specifically refer to and economic determinants. These determinants have migrants(SDG Targets 8.8 and 10.7) an impact on health and, in turn, benefit from a healthy population Fertility and population growth While health is still considered an important factor for Fertility rates are falling globally and, as a consequence, development, it now finds its place alongside many more population growth is slowing almost everywhere except development priorities than was the case during the mdg Africa. In mid-2015, the world population reached 7.3 era. This reflects a number of new and growing challenges, billion people-almost a tripling of the population in 1950 including: (i rising inequalities within and between states: -of which 60%lives in Asia. Even as population growth (ii) profound demographic and epidemiological changes; rates continue to slow, the world population is projected (ill)spiralling conflict, violence and extremism; (iv)increased to reach 8. 5 billion by 2030. Close to 40% of the growth migratory flows;(v)depletion of natural resources; in 2015-2030 will come from the African Region(Figure (vi) adverse impacts of environmental degradation; and 2.1). The parts of the world where populations are growing (vii) the prospect of irreversible climate change. Needless fastest are, in many cases, also those most vulnerable to to say, all of these challenges have profound implications for climate change. Rising populations may exacerbate some health, and the Sdgs that seek to address them have health of the consequences of global warming, such as water concerns woven into their fabric(Table 1.3). This chapter shortages, mass migration and declining food yields examines the principal trends, determinants and risks that impact health, including population trends, including fertility decline and World population by region, 1950-205023 population growth, changing population structure and AFR AMR SEAR BEUR WEMR WPR High-income OECD ageing, migration and urbanization economic and development trends, including poverty eradication and equity globalization and trade and financing for development; social determinants such as gender, education and human rights and equity environmental determinants and other risks, including climate change 876543210 In each section, a brief overview is provided on ho 1950 1970 990201520302050 determinants are reflected in the sDgs. and the plications for health actions in the coming 15 outlined Between 1990 and 2015, the average expected number of children per woman(total fertility rate) fell close to or below replacement level (2.1 children) in all regions POPULATION TRENDS except the African Region and the Eastern Mediterranean Region(Figure 2.2). The fertility rate is now at or below replacement level in 44% of countries, including Brazil, Demographic trends fundamentally influence countries' China, the Russian Federation and the United States of economic, social and health conditions. Population growth, America. The total fertility rate for the african Region is changes in fertility rates, and population structure, all have projected to remain high until after 2030. 2 a profound influence, as do migration, which is increasingly a cross-border issue, and growing urbanization, which Projections indicate that approximately 2.1 billion babies may spur economic growth, but also puts strains on food will be born worldwide during 2015-2030, an increase of and water resources. The SDGs are more explicit about almost 3% of the total number of births in the previous 15 population issues than the MDGs. The SDGs outcome year period. Half of these babies will be born in Asia and document references the Programme of Action of the one third in Africa. Over the same period, the total number HEALTH IN 2015: FROM MDGs TO SDGs
Health is central to human development, both as an inalienable right in and of itself and as a key contributor to the growth and development of communities and societies. Health was central to the MDGs, and in the SDGs is positioned as a key feature of human development in a more integrated manner. One SDG is specifically focused on health and several others incorporate actions to improve health and to address its broader social, environmental and economic determinants. These determinants have an impact on health and, in turn, benefit from a healthy population. While health is still considered an important factor for development, it now finds its place alongside many more development priorities than was the case during the MDG era. This reflects a number of new and growing challenges, including: (i) rising inequalities within and between states; (ii) profound demographic and epidemiological changes; (iii) spiralling conflict, violence and extremism; (iv)increased migratory flows; (v) depletion of natural resources; (vi) adverse impacts of environmental degradation; and (vii) the prospect of irreversible climate change. Needless to say, all of these challenges have profound implications for health, and the SDGs that seek to address them have health concerns woven into their fabric (Table 1.3). This chapter examines the principal trends, determinants and risks that impact health, including: • population trends, including fertility decline and population growth, changing population structure and ageing, migration and urbanization; • economic and development trends, including poverty eradication and equity, globalization and trade, and financing for development; • social determinants such as gender, education and income; • human rights and equity; • environmental determinants and other risks, including climate change. In each section, a brief overview is provided on how these determinants are reflected in the SDGs, and the possible implications for health actions in the coming 15 years are outlined. POPULATION TRENDS Demographic trends fundamentally influence countries’ economic, social and health conditions. Population growth, changes in fertility rates, and population structure, all have a profound influence, as do migration, which is increasingly a cross-border issue, and growing urbanization, which may spur economic growth, but also puts strains on food and water resources. The SDGs are more explicit about population issues than the MDGs. The SDGs outcome document references the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action,1 and Target 5.6 refers directly to this programme of action, calling for efforts to: “Ensure universal access to sexual and reproductive health and reproductive rights...”. There is one goal on cities (Goal 11: Make cities and human settlements inclusive, safe, resilient and sustainable) that addresses the challenges of rapid urbanization, and two targets specifically refer to migrants (SDG Targets 8.8 and 10.7). Fertility and population growth Fertility rates are falling globally and, as a consequence, population growth is slowing almost everywhere except Africa. In mid-2015, the world population reached 7.3 billion people – almost a tripling of the population in 1950 – of which 60% lives in Asia. Even as population growth rates continue to slow, the world population is projected to reach 8.5 billion by 2030.2 Close to 40% of the growth in 2015–2030 will come from the African Region (Figure 2.1). The parts of the world where populations are growing fastest are, in many cases, also those most vulnerable to climate change. Rising populations may exacerbate some of the consequences of global warming, such as water shortages, mass migration and declining food yields. Figure 2.1 World population by region, 1950–20502,3 AFR AMR SEAR EUR EMR WPR High-income OECD 1950 Population (billions) 9 6 3 2 1 10 1970 1990 2015 2030 2050 7 8 5 4 0 Between 1990 and 2015, the average expected number of children per woman (total fertility rate) fell close to or below replacement level (2.1 children) in all regions except the African Region and the Eastern Mediterranean Region (Figure 2.2). The fertility rate is now at or below replacement level in 44% of countries, including Brazil, China, the Russian Federation and the United States of America. The total fertility rate for the African Region is projected to remain high until after 2030.2 Projections indicate that approximately 2.1 billion babies will be born worldwide during 2015–2030, an increase of almost 3% of the total number of births in the previous 15 year period. Half of these babies will be born in Asia and one third in Africa. Over the same period, the total number 18 HEALTH IN 2015: FROM MDGs TO SDGs
Trends in fertility by region, 1990-203023 populations as opposed to maternal and child health and ■19902015■2030= Replacement level to infectious diseases. The demographic transition is accompanied by an epidemiological transition where ncds mental health disorders and injuries become much more prominent as a cause of death and disability than infectious E看 diseases. Figure 2.3 shows where countries are in the epidemiological transition, using years of life lost(YLL)due to reproductive, maternal, child health and undernutrition and infectious diseases -the mdg conditions -on the one hand (y-axis), and NCDs and injuries on the other hand (x-axis). At the top there are 22 African countries where the poverty-related conditions are still responsible for more than 70% of all YLL. At the other end of this epidemiological OECD shift, there are 48 countries where NCDs and injury-related conditions cause at least 90% of all YLL of women of reproductive age is projected to increase by 9% and reach 2.0 billion in 2030. Even though the average The youth bulge births per woman is projected to decline in Africa, the number of reproductive age women is projected to increase Globally, the total number of young people is at an all by 47% by 2030, which yields a projected increase in high, with 1.8 billion people between the ages of 10 numbers of births of 24%.2 24 in 2015 and nearly 2.0 billion projected by 2030. The number of adolescents and youth between ages 10 and 24 High fertility has multiple consequences for health and in the African Region will increase from 315 million in 2015 health-related issues Continued rapid population growth in to 453 million in 2030 low-and lower-middle-income countries, along with higher fertility rates in the poorest segments of the population, The youth bulge, where a large proportion of the total is likely to make it harder for those countries to eradicate population is youths or adolescents between ages 10 and 24 poverty and inequality combat hunger and malnutrition, or 15 and 24 ( showing a"bulge" in the population pyramid), invest in education and health, improve access to basic rvices, plan and develop cities, protect local ecosystems and promote peaceful and inclusive societies Global reproductive, maternal, newborn and child health programmes will remain focused on Africa and Asia, which together account for more than four fifths of global fertility. Especially in Africa, high fertility rates and rising numbers of women of reproductive age have considerable implications for the efforts to achieve the SDG targets for ending preventable child and maternal deaths. Investments in reproductive health, especially in family planning, are needed to ensure that all women and men can achieve thei desired family size. In addition, reducing child mortality and poverty are critical to reducing fertility and accelerating the demographic and epidemiological transitions Interventions before school age have very substantial benefits for children throughout schooling and life. The continued high fertility of Africa makes it more difficult to implement low-cost but effective early childhood development interventions for countries with limited financial and human resources For countries in demographic transition, where age structures change rapidly, a reorientation of the health sector is critical. For example, in countries where fertility and mortality levels have fallen, progressively greater resources need to be committed to adult health and ageing ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH
of women of reproductive age is projected to increase by 9% and reach 2.0 billion in 2030. Even though the average births per woman is projected to decline in Africa, the number of reproductive age women is projected to increase by 47% by 2030, which yields a projected increase in numbers of births of 24%.2 High fertility has multiple consequences for health and health-related issues. Continued rapid population growth in low- and lower-middle-income countries, along with higher fertility rates in the poorest segments of the population, is likely to make it harder for those countries to eradicate poverty and inequality, combat hunger and malnutrition, invest in education and health, improve access to basic services, plan and develop cities, protect local ecosystems and promote peaceful and inclusive societies. Global reproductive, maternal, newborn and child health programmes will remain focused on Africa and Asia, which together account for more than four fifths of global fertility. Especially in Africa, high fertility rates and rising numbers of women of reproductive age have considerable implications for the efforts to achieve the SDG targets for ending preventable child and maternal deaths. Investments in reproductive health, especially in family planning, are needed to ensure that all women and men can achieve their desired family size. In addition, reducing child mortality and poverty are critical to reducing fertility and accelerating the demographic and epidemiological transitions. Interventions before school age have very substantial benefits for children throughout schooling and life.4 The continued high fertility of Africa makes it more difficult to implement low-cost but effective early childhood development interventions for countries with limited financial and human resources. For countries in demographic transition, where age structures change rapidly, a reorientation of the health sector is critical. For example, in countries where fertility and mortality levels have fallen, progressively greater resources need to be committed to adult health and ageing 1990 2015 2030 Replacement level Figure 2.2 Trends in fertility by region, 1990–20302,3 Total fertility rate (births per woman) AFR Highincome OECD AMR SEAR EUR EMR WPR 7 2 1 4 3 6 5 0 populations as opposed to maternal and child health and to infectious diseases. The demographic transition is accompanied by an epidemiological transition where NCDs, mental health disorders and injuries become much more prominent as a cause of death and disability than infectious diseases. Figure 2.3 shows where countries are in the epidemiological transition, using years of life lost (YLL) due to reproductive, maternal, child health and undernutrition and infectious diseases – the MDG conditions – on the one hand (y-axis), and NCDs and injuries on the other hand (x-axis). At the top, there are 22 African countries where the poverty-related conditions are still responsible for more than 70% of all YLL. At the other end of this epidemiological shift, there are 48 countries where NCDs and injury-related conditions cause at least 90% of all YLL. The youth bulge Globally, the total number of young people is at an all-time high, with 1.8 billion people between the ages of 10 and 24 in 2015 and nearly 2.0 billion projected by 2030. The number of adolescents and youth between ages 10 and 24 in the African Region will increase from 315 million in 2015 to 453 million in 2030.2 The youth bulge, where a large proportion of the total population is youths or adolescents between ages 10 and 24 or 15 and 24 (showing a “bulge” in the population pyramid), ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH 19
Countries at different stages of the epidemiological transition from MDG conditions to NCDs and injuries as the main causes of years of life lost ( YLL), 2012 Republic, Chad, Niger, Somalia, Malawi, Zambia, Democratic Republic of the Congo, Lesotho linea-Bissau, Angola, Mozambique, Nigeria, Sierra Leone, Mali, Congo, Swaziland, South Sudan, Togo, Mauritania Burundi, Ethiopia, Liberia, Cote d'lvoire, Cameroon, Burkina Faso, Uganda, Equatorial Guinea, Gabon, United Gambia, Senegal, Benin, Botswana, Djibouti, Comoros, Sudan, Ghana, Madagascar, Rwanda, South Africa, Eritrea, Timor-Leste, Namibia, Lao People's Democratic Repubhc men, Afghanistan, Papua New Guinea, Haiti, Pakistan 2s是2g Tajikistan, Cambodia, Bangladesh, Nepal, Guatemala, India, Myanmar, Solomon Islands Bolivia(Plurinational State of), Indonesia, Honduras, Bahamas, Bhutan, Iraq, Philippines, Cabo Verde, Dominican Republic tan, Belize, Guyana, Nicaragua, Ecuador, Suriname, Jamaica, Jordan, Paraguay, Viet Nam Panama, Oman, Azerbaijan, Kyrgyzstan, Thailand, Kuwait, Malaysia, Mongolia, Egypt km③几D点 10 Australia Belarus, Italy, Switzerl prus, Latvia, Liti former Yuposiay Republic of Macedonia, Bosnia and Herzegovina, Estonia, Slovenia, Serbia, Austria, Hungary, Croatia, Finland 50 2 of YLl due to NCDs and injuries has been a common phenomenon in many countries during The prominence of youth in the population and the the MDG period(Figure 2.4). High fertility and, to a lesser importance of improving health behaviours and services for extent, declines in child mortality are the main causes. adolescents needs much more attention in many countries A rapid fertility decline, such as occurred in the Western This includes extending the improvements in maternal and Pacific Region, may also give rise to a temporary increase child health to adolescents, a focus on health promotion and of the youth bulge. In the African Region, more than 30% preventive measures, and on intersectoral approaches. For of the population is between ages 10 and 24, and this example, reducing road injuries, the top cause of mortality proportion will not change much in the coming 15 years. in 10-19-year-olds, will require action across a range of The youth bulge is projected to decline in the Eastern services, from education to transportation. Furthermore Mediterranean Region, although the proportion of the investing in health during adolescence can have critical population between ages 10 and 24 will still be over 30% benefits for health throughout the life course, influencing. in 2030 for several countries, including Afghanistan, Irag, for example, behaviours associated with an increased risk Somalia and Yemen of ncds In a country with a youth bulge, if most young adults Figure 24 entering the workforce can find productive employment, Trends in proportion of youth age 10-24, by region, 1990-203023 then the level of average income per capita should AFR B AMR -SEAR EUR WEMR BWPR B High-income OECD increase, producing a"demographic dividend". However, if many young people cannot find employment or earn a satisfactory income, then the youth bulge may become a potential source of social and political unrest, while young people themselves may become more susceptible =225 to mental disorders such as depression. Globally the youth unemployment rate is nearly three times higher than the& 15 adult rate and highest in the middle east. 2000 2020 2030 HEALTH IN 2015: FROM MDGs TO SDGs
Figure 2.3 Countries at different stages of the epidemiological transition from MDG conditions to NCDs and injuries as the main causes of years of life lost (YLL), 20125 % of YLL due to MDG conditions 0 10 20 30 40 50 60 70 80 90 100 Central African Republic, Chad, Niger, Somalia, Malawi, Zambia, Democratic Republic of the Congo, Lesotho, Zimbabwe, Guinea-Bissau, Angola, Mozambique, Nigeria, Sierra Leone, Mali, Congo, Swaziland, South Sudan, Kenya, Guinea, Togo, Mauritania % of YLL due to NCDs and injuries Israel, Chile, Portugal, Georgia, Albania, Armenia, Republic of Moldova, Republic of Korea, the USA, the United Kingdom, Romania, Cuba, Canada, Belgium, Norway, Slovakia, Denmark, Netherlands, France, New Zealand, Ireland, Spain, Greece, Luxembourg, Czech Republic, Malta, Sweden, Bulgaria, Germany, Australia, Belarus, Italy, Switzerland, Cyprus, Latvia, Lithuania, Poland, Iceland, Montenegro, the former Yugoslav Republic of Macedonia, Bosnia and Herzegovina, Estonia, Slovenia, Serbia, Austria, Hungary, Croatia, Finland Maldives, Fiji, Saudi Arabia, Iran (Islamic Republic of), El Salvador, Tunisia, Libya, Democratic People’s Republic of Korea, Brazil, United Arab Emirates, Venezuela (Bolivarian Republic of), Bahrain, Barbados, Argentina, Mexico, Singapore, Sri Lanka, Turkey, Trinidad and Tobago, Kazakhstan, Brunei Darussalam, Lebanon, Mauritius, Qatar, China, Costa Rica, Ukraine, Russian Federation, Uruguay, Japan Burundi, Ethiopia, Liberia, Côte d’Ivoire, Cameroon, Burkina Faso, Uganda, Equatorial Guinea, Gabon, United Republic of Tanzania, Gambia, Senegal, Benin, Botswana, Djibouti, Comoros, Sudan, Ghana, Madagascar, Rwanda, South Africa, Eritrea, Timor-Leste, Namibia, Lao People’s Democratic Republic Yemen, Afghanistan, Papua New Guinea, Haiti, Pakistan Tajikistan, Cambodia, Bangladesh, Nepal, Guatemala, India, Myanmar, Solomon Islands Bolivia (Plurinational State of), Indonesia, Honduras, Bahamas, Bhutan, Iraq, Philippines, Cabo Verde, Dominican Republic Morocco, Peru, Uzbekistan, Belize, Guyana, Nicaragua, Ecuador, Suriname, Jamaica, Jordan, Paraguay, Viet Nam, Algeria, Turkmenistan, Panama, Oman, Azerbaijan, Kyrgyzstan, Thailand, Kuwait, Malaysia, Mongolia, Egypt, Colombia 20 80 70 60 50 40 30 10 0 has been a common phenomenon in many countries during the MDG period (Figure 2.4). High fertility and, to a lesser extent, declines in child mortality are the main causes. A rapid fertility decline, such as occurred in the Western Pacific Region, may also give rise to a temporary increase of the youth bulge. In the African Region, more than 30% of the population is between ages 10 and 24, and this proportion will not change much in the coming 15 years. The youth bulge is projected to decline in the Eastern Mediterranean Region, although the proportion of the population between ages 10 and 24 will still be over 30% in 2030 for several countries, including Afghanistan, Iraq, Somalia and Yemen.2 In a country with a youth bulge, if most young adults entering the workforce can find productive employment, then the level of average income per capita should increase, producing a “demographic dividend”. However, if many young people cannot find employment or earn a satisfactory income, then the youth bulge may become a potential source of social and political unrest,6 while young people themselves may become more susceptible to mental disorders such as depression. Globally, the youth unemployment rate is nearly three times higher than the adult rate, and highest in the Middle East.7 The prominence of youth in the population and the importance of improving health behaviours and services for adolescents needs much more attention in many countries. This includes extending the improvements in maternal and child health to adolescents, a focus on health promotion and preventive measures, and on intersectoral approaches.8 For example, reducing road injuries, the top cause of mortality in 10–19-year-olds, will require action across a range of services, from education to transportation. Furthermore, investing in health during adolescence can have critical benefits for health throughout the life course, influencing, for example, behaviours associated with an increased risk of NCDs. 1990 2030 Youth age 10–24 (% of total population) 35 30 25 20 15 Figure 2.4 Trends in proportion of youth age 10–24, by region, 1990–20302,3 2000 2010 2020 10 AFR AMR SEAR EUR EMR WPR High-income OECD 20 HEALTH IN 2015: FROM MDGs TO SDGs
e the population age 65 and older as a percentage of the population age 54, by region, 1990-203023 Populations around the world are rapidly ageing. These AFR AMR SEAR BEUR .EMR .WPR High-income OECD older populations are a significant human and social resource, and this demographic transition therefore presents enormous opportunities to society. However, it will also be accompanied by a number of serious challenges. Global life expectancy increased, from 64 to 71 years between 1990 33 30 and 2015, an unprecedented rate of increase(see Chapter 1, Box 1.1). The number of people 60 and older reached 901 million in 2015 and will increase by 56% in the SDG era to a 20 regions except the African Region, where a modest increase an be expected(Figure 2.5). By 2030, 71% of older people will live in low- and middle-income countries. China wil have almost the same proportion of older people as the United States place. There is thus an urgent need to expand coverage, both in countries that have yet to put systems in place is in proportion of population age 60 and older, by region, 199 and in countries that already have such systems. Clearly, 70+60-69 this presents fiscal challenges. However, inadequate social protection constitutes a major obstacle to sustainable development, as it is associated with high and persistent levels of poverty and inequality Declining mortality rates at older ages in the last three decades suggest that with appropriate interventions it is possible to sustain longevity gains in all countries However, it is not at all clear if these gains in life expectancy at older ages have been coupled with increasing years 国点国总司虽总虽国目虽 of life gained in good health, mainly because of chronic AFR AMR SEAR EUR EMR WPR High- NCDs such as musculoskeletal conditions and dementia. 2 OECD A recent analysis shows that patterns of limitations in functioning vary across countries and within countri over time to a significant extent, with some suggestion in Population ageing will increase the proportion of the older high-income countries that subsequent generations may population relative to the younger population, and will live longer in better health than those preceding them 3 challenge the traditional framing of the life course around a However, recent studies from high-income countries have defined working age, followed by retirement. The projected raised questions regarding these health gains, given rises trends of the ratio of people over age 65 compared to those in obesity and related risk factors in the baby boomer aged 15-64 years show the large differences in population cohort. 4, 15,16 1 7 While health declines as we grow older, this age structure between regions. During the MDg period, the fall is even more significant in the oldest group, the most atio increased only slightly or not at all in st developing rapidly growing segment of the older population. The health regions( Figure 2.6). However, the situation is projected to status of this group is worse in poorer countries, among change drastically during the SDg period, with substantial women, those with lower education and those with lower increases in the ratio in all regions except in the African levels of income across all countries The health SDG of ensuring healthy lives and promoting Despite the fact that many middle-income countries well-being for all at all ages cannot be achieved without and even some low-income countries have expanded attention to the health of older adults, which is now pension coverage through a mix of contributory and non- an important agenda for all countries. This will require contributory schemes, nearly half of all older people do not major shifts in the way health systems are designed. The receive any form of pension and, for many of those who strategy should include a focus on primary prevention as do, the level of support is inadequate 0 Large numbers of well as on managing declines in functioning. Poor health older people are entering retirement age in countries where is not an inevitable outcome of ageing, and many of the significant social support systems have yet to be put in health problems that confront older people are associated ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH
Ageing Populations around the world are rapidly ageing.9 These older populations are a significant human and social resource, and this demographic transition therefore presents enormous opportunities to society. However, it will also be accompanied by a number of serious challenges. Global life expectancy increased, from 64 to 71 years between 1990 and 2015, an unprecedented rate of increase (see Chapter 1, Box 1.1). The number of people 60 and older reached 901 million in 2015 and will increase by 56% in the SDG era to around 1.4 billion people in 2030, of whom over 650 million will be 70 or older.2 The dramatic increases will occur in all regions except the African Region, where a modest increase can be expected (Figure 2.5). By 2030, 71% of older people will live in low- and middle-income countries. China will have almost the same proportion of older people as the United States. Population age 60 and older (% of total population) 30 20 15 10 25 5 70+ 60–69 Figure 2.5 Trends in proportion of population age 60 and older, by region, 1990–20302,3 Highincome OECD 1990 2015 2030 AFR 1990 2015 2030 AMR 1990 2015 2030 SEAR 1990 2015 2030 EUR 1990 2015 2030 EMR 1990 2015 2030 WPR 1990 2015 2030 0 Population ageing will increase the proportion of the older population relative to the younger population, and will challenge the traditional framing of the life course around a defined working age, followed by retirement. The projected trends of the ratio of people over age 65 compared to those aged 15–64 years show the large differences in population age structure between regions. During the MDG period, the ratio increased only slightly or not at all in most developing regions (Figure 2.6). However, the situation is projected to change drastically during the SDG period, with substantial increases in the ratio in all regions except in the African Region. Despite the fact that many middle-income countries and even some low-income countries have expanded pension coverage through a mix of contributory and noncontributory schemes, nearly half of all older people do not receive any form of pension and, for many of those who do, the level of support is inadequate.10 Large numbers of older people are entering retirement age in countries where significant social support systems have yet to be put in place. There is thus an urgent need to expand coverage, both in countries that have yet to put systems in place and in countries that already have such systems. Clearly, this presents fiscal challenges. However, inadequate social protection constitutes a major obstacle to sustainable development, as it is associated with high and persistent levels of poverty and inequality. Declining mortality rates at older ages in the last three decades suggest that with appropriate interventions it is possible to sustain longevity gains in all countries.11 However, it is not at all clear if these gains in life expectancy at older ages have been coupled with increasing years of life gained in good health, mainly because of chronic NCDs such as musculoskeletal conditions and dementia.12 A recent analysis shows that patterns of limitations in functioning vary across countries and within countries over time to a significant extent, with some suggestion in high-income countries that subsequent generations may live longer in better health than those preceding them.13 However, recent studies from high-income countries have raised questions regarding these health gains, given rises in obesity and related risk factors in the baby boomer cohort.14,15,16,17 While health declines as we grow older, this fall is even more significant in the oldest group, the most rapidly growing segment of the older population. The health status of this group is worse in poorer countries, among women, those with lower education and those with lower levels of income across all countries. The health SDG of ensuring healthy lives and promoting well-being for all at all ages cannot be achieved without attention to the health of older adults, which is now an important agenda for all countries. This will require major shifts in the way health systems are designed. The strategy should include a focus on primary prevention as well as on managing declines in functioning. Poor health is not an inevitable outcome of ageing, and many of the health problems that confront older people are associated 1990 2030 Population age 65 and older (% of population age 15–64) 25 20 15 10 5 Figure 2.6 Trends in the population age 65 and older as a percentage of the population age 15–64, by region, 1990–20302,3 2000 2010 2020 0 AFR AMR SEAR EUR EMR WPR High-income OECD 35 30 40 45 ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH 21