Ukraine's report

Introduction

We are on the eve of the 10th anniversary of the International Conference on Population and Development organized by the United Nations Population Fund and the United Nations demography department on economical and social information analysis and politics which was held in Cairo on September 5-13, 1994. The conference was representative in the world-wide fame: 180 countries and more than 1500 non-governmental organizations took part in it. The Conference adopted the Program of Action in the field of demo-economic relations, elaborated the principles of demographic policy and its main directions. The principles and recommendations of the Program of Action based on the fundamental human rights became the basis for the activities in improving the national demographic policies aiming to increase their efficiency. In the Program of Action till 2015 adopted at the Conference, among its main components there is a statement “the state governments must create the necessary home institutional mechanisms and favorable social environment on all society levels to guarantee that population factors are taken into consideration in a proper way for decision making and administrative processes of all relevant state institutions responsible for economical, ecological and social policies and programs”. Principles and recommendations elaborated and adopted by the International Conference on Population and Development had to become a way guide in forming the national demographic policy of the young Ukrainian State.

Nine years have passed since the Conference. What changes in the demographic situation of Ukraine took place during this time? What peculiarities were the demo-economic relations characterized with? Did the principles and recommendations elaborated and adopted by the International Conference on Population and Development become the foundation for forming the national demographic policy of the young country? What must the scientific principles of forming the national demographic policy of Ukraine consist of? This survey is an attempt to explore these and other urgent demo-economic issues.

1. Features of the Current Demographic Situation in Ukraine

General characteristics of the demographic situation. The demographic peculiarities of a country are the reflection and general expression of its social and economic history, and current changes in the society. The demographic situation in Ukraine in the 90s acquired a nature of severe crisis. The crisis is progressing extremely sharply and painfully. Its manifestation is deterioration of nearly all demographic indicators caused by a very painful coincidence of circumstances of the socioeconomic life in Ukraine and deep deformations in the society. The content of the 90s is the historical period of transition from a closed totalitarian society with the state-governed and very militarized economics to an open civilian society with a market, socially oriented economy. This transition is accompanied by the deep socioeconomic crisis, and its demographic price appeared to be extremely high. Some components of the critical situation of the demo-reality had been forming during many decades, long before the current political and socioeconomic changes began, but at the time of the socioeconomic crisis these negative tendencies increased.

What is a demographic crisis? It is a situation of demo-reality when the ability of the society to reproduce population in quality and quantity is lost. Population reproduction is a system of processes and mechanisms of social being, of maintaining the unity of quality and quantity of the population characterized not only by its sex-age structure but by the system of other various social characteristics. In other words, population reproduction neither in content nor in appearance is limited by the natural movement of the population. That’s why the demographic crisis cannot be equaled to depopulation, a decrease in population resulting from prevailing of the number of deaths over the number of births. Depopulation is only a component of a demographic crisis, but it is not the sufficient evidence of the demographic crisis. Population reproduction as a social and historical process can take place in the condition of a moderate depopulation. This phenomenon takes place in those cases where depopulation is accompanied by the population quality improvement, that is, when the population quantity decrease is sufficiently compensated by the quality increase of its socioeconomic and demographic potentials. That’s why, in the developed countries where depopulation has begun, the demographic crisis is not spoken about. Ukraine considerably differs from these countries with its great change for the worse of the population quality. It is just the population quality degradation that attaches the crisis feature to the demographic situation. At the same time, one cannot affirm absence of a demographic crisis if the population is characterized by the natural increase and quality reduction. For instance, in some regions of Ukraine depopulation may not be observed but the population reproduction has not taken place, as far as the health status of people and their labor potential have changed for the worse.

Basic features of population reproduction are the ultimate, generalized, most profound indicators of the economic development of the state. Changes of the demographic indicators in the 90s show that the time for developing self-sufficient economics as basis for people's well-being was spent inefficiently. The great significance of the demographic crisis was not deeply comprehended by the government and political authorities. As a consequence of it, the demographic losses due to unsuccessful attempts of transition to the market economy were not avoided.

Population Health and Average Life. The foremost quality of population is its health. In Ukraine, it catastrophically worsened in the transition period. The health crisis became the most important component and feature of the current demographic crisis. General mortality increased in all age groups with the exception of children from 1 to 14 years old. In the early 90s the constant mortality increase was observed. For the last decade, the common mortality factor reached the highest rate in 1995, after that it began a slow decrease in 1996-1998 and in 2001. In 2002, mortality increased again (Table 1).
Table 1. General mortality and infant mortality in Ukraine in 1989-2002 (%)
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_{Source: Data of the State Statistic Committee of Ukraine}

Infant mortality in 1994-2000 decreased a little and in 2002 it was 10.3 children under 1 year per 1000 livebirths. Studies show that if there is a transition to international standards of calculating, infant mortality can rise almost twofold. But it will still be lower than the rate set as a goal in the ICPD Program of Action – 35‰ towards 2015. But it is not a reason for self-calming. We must take our bearings to the countries with the lowest infant mortality. In particular, in Japan 4 children under 1 year die per 1000 livebirths, in the countries of Western Europe this rate is about 6, which is too less than in Ukraine. Decreasing this considerable difference is one of the most important tasks of the Ukrainian National Program “Reproductive Health 2001-2005”.

From 1989 to 1995, the average life of men has shortened by 4.9 years, of women by 2.7 years. After 1995, it became a little longer. But this slight increase was not a result of some positive changes in the living conditions of the population. There is a reason to consider that it was connected with the fact that in the difficult conditions the those having the worst health die first, which is a peculiar selection, after which the mortality can decrease for some time (such a situation happens particularly after a flu epidemic), – and that was what happened in Ukraine.

It is doubtful that the mortality decrease was a turning-point for the tendency of average life to shorten. It’s confirmed by the fact that in 1999 general mortality resumed increasing again and average life shortened, the decreasing tendency renewed. In 2001 average life rather increased, in 2002 decreased again. On the whole, during 1989-2002 the average life of men shortened by 4.5 years, of women by 2.0 years (Table 2), and in 1995-2002 it became somewhat longer: of men by 4.0 years, of women by 0.7 years (Table 2, Fig. 1).
Table 2. Average life expectancy at birth (e00) in Ukraine in 1989-2002*
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_{* In accordance with the short mortality tables, made on the base State Statistic Committee of Ukraine in the demography and reproduction of labor resources department of the Economical Institute of National Academy of Sciences of Ukraine.
** Calculations for 2001 and 2002 made on the base of the former data.}

In 2002 the average life in Ukraine was 67.5 years (61.7 years in men and 73.3 years in women). The considerably higher mortality of men than of women in their laborable age stipulated an extremely big difference of the average life of men and women (11.6 years in 1995 and 11.6 years in 2002). There is a paradox: higher average life of women compared with men’s, is not an indicator of their better health. According to annual reports data about the Ukrainian population's health and activities of medical and preventive institutions of the national healthcare system, women’s morbidity of large number of disease classes is significantly higher than men’s one.

The average Ukrainian men's lifetime is 16 years shorter, and the average Ukrainian women's lifetime is 12 years shorter than in the country of the longest average life, Japan. According to this indicator, Ukraine ranges among such countries like Tajikistan, Jordan, Algeria, Peru, and Honduras. The downfall of the average lifespan to the level of the less developed countries is accompanied by two epidemics: of tuberculosis and HIV/AIDS. If we consider that there is no other ultimate goal but preservation of human lives, then we can clearly realize the real outputs of the socioeconomic reforms of the 90s.

Figure 1. Average lifespan of men and women in Ukraine in 1989-2002

Among the causes of deaths of men, cardiovascular diseases are ranked first, the second are the "external causes" (accidents, murders, suicides and other external causes), and the third are malignant neoplastic diseases. As for women, this order is traditional: cardiovascular diseases, neoplasms, external causes. This way, the external causes of men's deaths took the next rank after cardiovascular diseases, and for men of laborable age they rank the first among all causes of death. It testifies the immense social stress having an extremely negative influence on the mental health of the population. The considerably higher mortality of men due to external causes, in comparison to women, definitely contributes to the excess of the mortality of laborable men over the mortality of women. A considerable part (over one fifth) of external causes of death is suicide. In 2002, 12.2 thousand people committed suicides.

The Program of Action intended for a period of 20 years and adopted by the ICPD has set the task before the world’s commonwealth to achieve the average life of nearly 70 years before 2005, and of nearly 75 years before 2015. Thus, in the field of improvement of the population health Ukraine has the most important and difficult task, especially if we take into consideration the expected demographic consequences of the HIV/AIDS epidemic that became the most acute distinctive mark of the demographic situation in Ukraine in the years after the ICPD. There is a very swift spread of the HIV infection. According to the official reports, on April 1, 2003 there were about 97 thousand of HIV infected persons, 54.7 thousand Ukrainian citizens (4.8 thousand of them are children) were officially registered as people living with HIV. The real number of HIV infected people according to international experts' estimate is over 500 thousand people. As statistics testifies, there is no single region without a case of HIV infection. At present, 4709 people are registered as having AIDS, 151 of them are children; 21151 people died of AIDS (83 children). We can see an increase of a number of babies born of HIV infected mothers: in 1996 – 92 babies, in 1997 – 197, in 1998 – 379, in 1999 –545, in 2000 – 730, and in 2001 – 957.

On the background of the HIV infection epidemic, there is tuberculosis epidemic observed since 1995. Today tuberculosis is the most widespread infectious disease in Ukraine. The number of people ill of the disease is 1.4% of the population of the country. During the 90s, the tuberculosis morbidity almost doubled. In 2000, 29.8 thousand of new tuberculosis cases were diagnosed; 781 thousand patients were under treatment at tuberculosis clinics. In 2002, 9.9 thousand people died of tuberculosis related complications. Specialists arrived at a conclusion that pulmonary tuberculosis is one of the reasons of infertility, pregnancy miscarriages, premature childbirths, low birth weight and other complications of pregnancy and childbirth. The Presidential Decree #643/2001 of 20 August 2001 adopts the national program of fighting tuberculosis for 2002-2005.

Deterioration of the Ukrainian population's health is connected with the severe and lingering socioeconomic crisis that lead to a situation observed today: people's lives are reduced to simple survival, population reproduction is not economically supported, and targeted governmental interventions in the demography sector are extremely insufficient. The population, the majority of which being thrown out of the limits of social welfare, drags out a miserable existence having extremely unsatisfactory health and lost professional opportunities – thus it cannot be an active subject of developing effective forms of national economics functioning. Therefore the situation is that the critical state of economics aggravates the demographic crisis and the demographic crisis prevents revival of the society from the total depression.

Nutrition of the prevalent part of the population has worsened. There have been even several cases of starvation registered by the state statistical bodies. Inferior nutrition of population, and especially children, seriously threatens reproduction in quality of the demographic, intellectual and working potentials of the nation achieved in the whole previous history of socioeconomic development of Ukraine. People who have living standards not allowing them to satisfy their intellectual requirements cannot be creative force of building effective economics and society capable of reproduction. Poverty and malnutrition have extraordinary negative influence not only on intellectual but on physical development, especially of children, and hamper the biological basis of the nation's intellectual potential and population's health.

Shortening of the average lifetime is evoked both by socioeconomic reasons and the fact that vitality of the population, especially of the elderly, has decreased and became an essential reason for fading of the people's “will for health” (after S.A.Tomilin), which in turn influenced negatively the lifesaving behavior. One more important reason of the average life shortening is the crisis of the national healthcare system due to which the majority of population has very limited access to quality medical services. But the main reason is that the basic function of any civilized state, namely saving and development of conditions for normal demo-reproduction has been destroyed and then neglected in Ukraine. An elementary but important function of, so to say, “night watchman” of the people’s property to ensure preconditions for national economics development, has not been realized. There are no grounds for effective economic activities of the national economic agents and of the working population, and, as a result, the possibility of the average life to become longer was lost. International comparative analysis also testifies this. Let’s consider Poland. Poland and Ukraine had the same average life level in the pre-transition period. During the 90s, it increased in Poland by 3 years, and in Ukraine it shortened by 3 years. Now the difference is 6 years. The loss of these 6 years can serve as a generalized evaluation of failure in economic reforms, the mark of unused opportunities. Statistical evidences show that now in Poland the average life of men is 8 years longer than in Ukraine, and of women is 4 years longer. This example confirms again the idea that the best demographic policy is an effective socioeconomic policy.

Women’s Reproductive Health. An important cause of influence on demographic processes is the state of Ukrainian women in the society conditioned both by objective reasons and expressions of patriarchal thinking stereotypes. Although for last years certain changes were taking place in the relations of men and women, they are not always in women’s favor; social inequality of genders and women’s discrimination remain. First of all, existing difference in wages and salaries of men and women testifies to this. Women’s salaries are considerably lower than men’s, despite that there are no gender differences in their education levels. It happens because women more often than men carry out jobs than need less qualification. In some branches of economic life women not only carry too hard (“non-woman’s) work but work under the conditions not meeting both sanitary/hygienic standards and civilized standards of attitude to women as mothers and up-bringers of children (a woman who worked long under such unfavorable conditions usually has reproductive health disorders and thus becomes unable to give birth to a healthy baby). Women work in the branches of economy of the least prestige, the number of women in the leadership of all the fields of industry, science and culture is the last; they have the least access to economic resources. Women are the biggest part among the unemployed and among working people who have to be on short time, that is, they have a higher risk to become impoverished because of losing their job. Moreover, chances of women to get a job become less because of increasing competition in the work market. Explorers arrived at a conclusion that formation of the women's work market is characterized with low qualification and wages, limited choice of professions, with unfavorable conditions of work and horizontal career mobility with a tendency to the social status descent. As a result of it, professional educational training of women is not used adequately, and this not only has negative influence on women’s development but turns into great losses for the society on the whole. A great deal of working women more than before carry a twofold burden of the professional and housekeeping duties because of the poverty and decay of the pre-school educational system and community services.

All that results in a higher risk of marginalizing women in comparison with men. Women’s marginalizing is caused not only by decrease of the general living standards of the large part of the population of the country but also by other derivative factors, in particular, increasing amount of childless families and alcoholism that was unlike in the past times and now quite widely seized women. Working women largely more than before carry a twofold burden of their professional and housekeeping duties because of poverty and decay of community services. The societal status of women surely contributes to their reproductive health.

The state of women’s reproductive health remains unsatisfactory. It is characterized by high morbidity of pelvic inflammatory diseases greatly connected with abortions, wide spread of sexually transmitted infections (STI) including HIV infection, neglected oncological pathology, increasing somatic (extragenital) pathologies of pregnant women (cardiovascular diseases, genitourinary diseases, anemia), widespread of abortions and, as a result, proliferation of stillbirths and infertility. According to the calculations based on the survey data of the “Ukrainian Women’s Reproductive Health – 1999” made by the American Center of Disease Control (CDC) and Kiev International Institute of Sociology, the number of women who suffer infertility in Ukraine is 868 thousand (1990) or 68 women per each 1000 women of fertile age. Amount of complicated childbirths grows (58.3% in 1990, 66.1% in 1995 and 67.1 % in 2001).

In the 90s, the considerable growth of STI incidences has been observed in Ukraine. In particular, syphilis in women acquired a character of a real epidemic: in 1990 6.2 women per 100 thousand had it, and in 1997 144 women had it (the number multiplied 23 times!). In 1995-2001 there were 17.2 thousand pregnant women having syphilis registered, and 440 cases of congenital syphilis. In 2001 the syphilis spread rate reduced to 74.7 per 100 thousand women (Fig. 2). But it is difficult to make a conclusion how much the real situation improved because of the unreliable statistics connected with the development of private medicine. Doubt of the reliability of the syphilis spread statistics is inspired by the dynamics of gonorrhea, the spread of which did not almost change for the analyzed period. Syphilis and gonorrhea always had a definite correlation, which in the 90s was "broken". Syphilis spread was commonly considered as an indicator of STI spread. Does it follow that it is not such an indicator any more? Besides syphilis, there is growth of trichomoniasis, chlamydiosis, mycoplasmosis and other STI.

Figure 2. Spread of syphilis and gonorrhea among women in Ukraine in 1995–2001, per 100 thousand women.
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The most important indicator of depression of women’s reproductive health is maternal mortality that remains high, though from 32.3 per 100 thousand livebirths in 1995 it reduced to 24.1 in 2001 and 22.5 in 2002. Although there is a tendency to reducing maternal mortality, it is quite higher than in Switzerland, Norway, Canada and other developed countries. The reason of such a rate of maternal mortality is low level of not only reproductive but also somatic health of women of fertile age. This, in turn, leads to the increasing number of some extragenital diseases of pregnant women. In 1995 every third pregnant women had an internal disease and frequency of anemia combined with pregnancy from 1989 to 1999 multiplied 4.4 times, genitourinary diseases – 3.6 times, and the circulatory diseases – 1.7 times.

Another reproductive health indicator, infant mortality, in that period had a favorable trend, but its level as compared with developed countries (Japan, Germany, Finland, Canada and others), as it was mentioned, remains high even on the condition of not using the international measurement standards.

During the recent years some positive changes in contraception prevalence has been marked, as a result of the implementation of the National Program "Family Planning". Statistics of 1999 show that condoms are used by 13.4% of married couples; IUDs by 14.4% (this prevalence is too low however, especially considering the high spread of STI and HIV infection), oral contraception by 6.7% and vaginal pills (spermicides) by 0.8%.

The abortion rates in Ukraine are still too high, though the number of abortions considerably reduced. In 1994 in Ukraine there were on average 146 registered abortions per 100 births, in 2001 – 93 (that is nearly one abortion per one childbirth). In the Eastern and Central Europe only the Russian Federation, Romania and Belarus had higher abortion rates. Abortions compensate for unsatisfactory conditions of inculcation of modern highly effective contraception. Pregnancy losses through abortions in Ukraine as compared with economically developed countries are extremely high; moreover the rates are highest in the regions where the birth rate is extraordinary low as for the peace time. Experts consider that “medical professionals play an important part in maintenance of the thing known as the “culture of abortion”. Part of this reality can be explained by the insufficient access to modern contraception, doctors’ isolation from the contraception development in the West and deficit of relevant medical technologies. This interpretation is well supplemented by the documental information about the state of medical services' expenditures in the Central and Eastern Europe. It fully concerns Ukraine too. In addition, we should say about high (as compared with abortion) price of modern highly efficient contraception, which is considerably connected with the absence of local contraception production. This situation makes it inaccessible for the majority of population. All this leads to "transition from abortion to contraception" to be incomplete in Ukraine. And the cost of this incomplete transition is aggravation of reproductive health, the state of which especially under the conditions of low childbirth activity is an important cause of forming the birthrate.

Data of the reproductive health survey of Ukrainian women of 1999 about abortion rates by women’s age in five age groups gives an opportunity to compare age intensity of childbirths and abortions. As for this comparison, the abortion intensity in the age 15-24 is lower than the childbirth intensity and beginning from the age 25-29 the abortion rate is considerably higher than the childbirth rate (Fig. 3), moreover the older childbirth age of women, the more abortion intensity exceeds the birthrate. If in the age 25-29 the number of abortion is 1.6 times higher than of childbirth, then in the age 30-34 it is 2.7 times higher, in the age 35-39 – 3.8 times, and in the age of 40-44 – 9.5 times higher.

Source of calculations: data of the State Statistic Committee of Ukraine, and investigations of reproductive health of Ukrainian women, 1999

Fig. 3. Age/birth rate and age/abortion rate in Ukraine in 1998–1999, %
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Calculated based on of the consolidated age-split data of the Ministry of Health of Ukraine, summarized abortion rates (similarly to summarized birth rate) of women of the age 15-44 were 1.33 abortions in 1998, and 1.41 in 1999. According to the results of the mentioned medical survey that reflect the data for the two-year period preceding the survey, this indicator in 1999 was 1.57 abortions (which is more reliable). That means the realized fertility was almost 30% lower than the unrealized one due to abortions.

The Program of Action adopted by the Cairo Conference regards prevention of unwanted pregnancy through development and improving of family planning services as the highest priority and one of the main problems in reproductive health care for women (Recommendation 8.25). The high level of abortions in the context of the ICPD Program of Action means access to all the spectrum of safe and reliable methods of contraception and other reproductive health protection service is still insufficient, in other words, the right of women to have the highest standard of reproductive health care, and the right to decide free and responsibly how many children to have and with which intervals, are not fully guaranteed.

Fertility. One of the most important displays of the current demo-reality crisis is the crisis of reproductive activity of the population. Dramatic events of last decade had a negative influence on all components of population reproduction, broke off relatively smooth dynamics of demographic processes, but especially destructively affected the reproductive activity of the population. The negative tendencies in the birth rate dynamics quickly intensified causing depopulation intensification. At last, the features of population reproduction of a certain society are determined by a real status of a human being in this society, as far as the life activity of people as society subjects stipulates directly and immediately for main characteristics of their reproduction, and fertility in particular. Under the conditions of mass unemployment created by the destruction of many industrial enterprises, the financial base for practical realization of people's wishes to have children catastrophically diminished. With the financial base existing in Ukraine, we can see not only diminishing opportunities to match the important living needs of people, but decreasing of the living standards of the majority of population. As follows from investigations, the main reason of negative demographic tendencies strengthening is that population reproduction is not substantiated economically because of the permanent socioeconomic crisis.