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Dynamics of life expectancy change during the transition to democracy in the ex-Yugoslav countries

Dynamique de l’évolution de l’espérance de vie durant la transition vers la démocratie dans les pays de l’ex-Yougoslavie
Dijana Spasenoska

Résumés

Les bouleversements politiques inhérents à l’éclatement de la Yougoslavie au début des années 1990 ne se sont pas traduits seulement par des changements socio-économiques. Ils ont ouvert une décennie marquée par de nombreuses guerres et des troubles civils. La santé, en tant que phénomène social, est directement et indirectement affectée par ces changements. Elle en est un des marqueurs. L’objectif de cet article est d’étudier l’évolution de l’espérance de vie - considérée ici comme mesure de la santé de la population - en période de crise et de grands changements sociétaux. La dynamique du changement de l’espérance de vie dans les différents pays issus de l’ex-Yougoslavie est analysée en calculant les contributions des variations de la mortalité par âge et par cause.
Ce travail s’appuie sur des données de mortalité issus des registres civils nationaux des six républiques de l’ex-Yougoslavie. Ces derniers constituent des sources reconnues pour leur exactitude et leur exhaustivité. La méthode d’Arriaga est utilisée pour décomposer les contributions des groupes d’âges et des causes de décès à l’évolution de l’espérance de vie. Trois périodes ont été déterminées : les années précédant l’éclatement de la Yougoslavie (1975-1985), les années de crise dominées par les guerres et les troubles civils (1988-2000) et les années récentes au cours desquelles chaque nouvel état a pu affirmer son indépendance dans un climat géopolitique pacifié (2007-2017). D’une manière générale, sur le temps long, de grandes améliorations de l’espérance de vie à la naissance sont notées dans tous les pays. Mais les dynamiques ont été affectées de manières diverses par l’éclatement de la Yougoslavie. Jusque dans les années 1980, pendant la période de la Fédération socialiste, l’espérance de vie a augmenté de façon constante dans tous les pays, principalement en raison de la réduction de la mortalité infantile et juvénile, ainsi que de la réduction de la mortalité due aux maladies infectieuses. Pendant les années 1990, les tendances ont divergé : malgré le contexte régional de crise, certains pays ont continué d’enregistrer une augmentation continue de l’espérance de vie, tandis qu’en Serbie-et-Monténégro elle diminuait. Au cours des dix dernières années, dans tous les pays, l’espérance de vie a poursuivi ou repris sa progression, en raison d’une réduction de la mortalité due aux maladies non transmissibles parmi la population âgée.
Les données mobilisées ont permis de produire des estimations précises de l’espérance de vie et de la dynamique de l’évolution de la mortalité, permettant une analyse plus approfondie des déterminants sociaux de la santé dans les pays issus de l’ex-Yougoslavie depuis le milieu des années 1970. De ce fait, compte tenu de l’évolution du contexte géopolitique au cours des quarante dernières années, cette étude permet de saisir les effets immédiats, différés et diversifiés d’une crise majeure sur l’évolution de la santé de populations appartenant initialement à un même pays.

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Texte intégral

I would like to thank Dr. Arjan Gjonça and Dr. Berkay Ozcan for their helpful guidance.

1. Introduction

1The collapse of the Socialist Federal Republic of Yugoslavia (SFRY) in the early 1990s led to a period of crisis and large societal changes in the constituent republics; from changes in the governance structure resulting in a multi-party system, to changes in the material circumstances in which people live. This had a formative influence on the social arrangements and consequently, the socioeconomic position of the individuals, shaping the distribution of opportunities individuals have to achieve good health. There are many known mechanisms through which health can be affected by changes in the societal context, changes in the structural and/or intermediary determinants of health (World Health Organization, 2010).

2For instance, changes in the political context, or specifically the governance structure affect health in various ways. A democracy, measured by its hallmarks election of a representative government, guaranteed civil and political rights and free media, results in an improved individual freedom, leading to an increase in the agency of the individual’s ability to make choices, which could potentially decrease premature mortality or prevent morbidity [Ruger et al., 2005]. Moreover, a multi-party system that ensures better representation and greater electoral proportionality is positively associated with overall population health and improvements of the health of the poorest [Wigley and Akkoyunlu- Wigley 2011]. However, the process of democratization could have mixed effects depending on whether it is coupled with other large societal changes [Mackenbach et al., 2013].

3The structural determinants of health refer to the relationship between the socioeconomic and political context and the resulting social stratification defining the socioeconomic position of the individual in the society. They operate through intermediary determinants linking them to individual level influences, such as physiological and psychosocial factors, and health-related behaviours. Times of crisis and societal changes can lead to changes in either or all these influences.

4For example, material deprivations can lead to changes in the living conditions and negative change in the socio-economic status. Psychosocial variables such as anxiety, insecurity, and depression can lead to negative health outcomes [Kunitz, 2004]. The anxiety can be exacerbated by loss of control over lifestyle, feelings of disadvantage, and little reward for effort at work, all of which are characteristic of a period of political and socio-economic changes, leading to an increase in prevalence of smoking and alcohol consumption, both of which are common risk factors for many diseases [Bobak & Marmot, 1996].

5These examples highlight only few of the mechanisms through which periods of crisis, such as the dissolution of Yugoslavia and the transition period, could have affected population health.

6The health of populations during transition periods has been previously studied in other Central and Eastern European countries [Dolea, Nolte & McKee, 2001; Shkolnikov, McKee & Leon, 2001; Nolte, Shkolnikov, McKee, 2000]. However, earlier studies have shown that Yugoslavia did not follow the trends in population health of those countries [Gjonça, 2004]. Moreover, there are numerous differences between the countries of the former Soviet Union and the countries of former Yugoslavia in terms of economic development, health systems, policies prior to and after the collapse of communism, the violent transition period in the Balkan countries and the cultural differences between the populations. Thus, the changes in population health in the Balkan countries during the period of crisis must be studied separately to understand the dynamics of change of population health during the dissolution of Yugoslavia.

7The objective of this study is to give an overview of the changes in population health, using life expectancy as a measure, during times of crisis and large societal changes. Furthermore, it will analyse the contributions of age groups and causes of death to the observed changes of life expectancy to compare the dynamics of change between the different Balkan countries experiencing crisis.

2. Regional context

  • 1 Due to data availability limitations Kosovo was not included in the study.
  • 2 Hereafter, referred to as Macedonia for clarity, as the name of the country was changed to North Ma (...)

8This study focuses on the countries of the former Yugoslavia1: Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia2, Serbia and Slovenia. The countries are spread over a relatively small geographic area and together have a population of approximately 19 million people. They share a common history marked by periods of political crisis and similar political aspirations of joining the European Union (EU). Some of the countries also share current challenges, such as population decline, emigration, high unemployment, high public debt, underperforming state institutions, and outdated education systems (EUISS, 2018).

9In this study the period from 1975 until 2017 is analysed, capturing the zenith of the Socialist Federation and its collapse, and the transition to democracy; a period marked by political turmoil, socio-economic crisis, and war. For the purposes of the analysis in this study three periods are identified.

10Socialist Federation 1975-1985: During this period all 6 countries were under communist rule and existed as The Socialist Federal Republic of Yugoslavia (SFRY). During the 1970s the highest economic growth and development was achieved by shifting the economy from predominately agricultural to industrial, leading to improvements in infrastructure and quality of life [Hudson, 2003; Uvalic, 2012]. During the 1980s a period of crisis began escalating further towards the end of the decade; the Yugoslav economy collapsed, leading to hyperinflation and unemployment [Hudson, 2003].

11Transition 1990-2000: This period was characterised by political turmoil, instability, wars and civil unrest, manifested differently from country to country. The dissolution of Yugoslavia led to wars in Slovenia, Serbia and Montenegro, Bosnia and Herzegovina and Croatia. There was another escalation of violence in 1998 in Kosovo; as a response sanctions were placed on Serbia and Montenegro by the international community and NATO launched airstrikes. These wars resulted in a large number of casualties, refugees and internally displaced people, and deepened the political crisis.

12Independence 2001-2017: The post war period was characterised by the strengthening of democratic systems, economic growth, and health reforms, although in several countries political crises persisted. During this period Montenegro gained independence, Slovenia and Croatia joined the EU, while the remaining countries have aspirations to join the EU, but need to further strengthen the rule of law, enhance the socio-economic development and support reconciliation and good neighbourly relations [Perry, 2018].

3. Data and methods

13Data on the underlying causes of death, disaggregated by age group and sex was collected from the office for national statistical (ONS) of each country for the period of 1975 until 2017. The data for the period before 1990 for the ex-Yugoslav republics was published by the Yugoslav Statistical Office, in Demografska Statistika (Yugoslavia) 1959-1990 [Demographic Statistic (Yugoslavia)]. Data for Serbia includes Vojvodina, but excludes Kosovo and Metohija for the whole period. In instances when disaggregated data was not available directly from the ONS (either electronically or in print), the WHO Mortality Database, which is a compilation of raw mortality data as reported by the member states based on their civil registration and vital statistics, was used. Data from the ONS and the WHO Mortality Database were used simultaneously because no data source contained the entire dataset needed for analysis of the three time periods, for all countries.

14The data quality and completeness were assessed. The data before 1990 was collected by the Yugoslav Statistical Office, which was highly regarded, as the data was triangulated between agencies, published consistently, and published in several UN language to allow for international use. Moreover, censuses were conducted regularly every ten years. To calculate the consistency of death registration with census counts taken in 1971 and 1981, the ratio of observed to expected population in the second census was calculated (Rc), where deviations of Rc values from 1 could be caused by coverage errors and/or age misreporting in any of the data sources [Preston, Heuveline & Guillot, 2001]. The results showed great consistency for all age groups and across all countries. In recent years, censuses have not been conducted regularly, so such consistency test could not be performed. Yet, international organizations have assessed the completeness of the vital registration system as relatively high, with birth coverage of above 90% and mortality coverage above 90% for all countries [UNstats, 2016]. Moreover, the accuracy of the death registers classification was above 93% for all countries [GHO, 2022].

15All deaths are coded according to the International Classification of Disease (ICD). Given the long study period there has been a change between the ICD versions used; earlier data was coded using ICD-8, ICD-9 and current data is coded using ICD-10. To ensure that the differences between the coding versions do not affect the analysis (in terms of precision and specificity), as well as to account for reporting practices and the possibility that medical advancements have allowed for more precise coding, 7 broad disease categories were selected for analysis: infectious, neoplasms, circulatory, respiratory, digestive, external and other (Annex 1 shows the ICD codes included in each category). The category other includes less common diseases, pregnancy, childbirth, congenital malformations, ill-defined or unspecified causes of mortality and symptoms not elsewhere classified.

16All life expectancy estimates are based on life expectancy at birth, calculated by the author using abridged life tables (5 years age groups, except for age 0, 1-4, and 85+) based on the compiled dataset. The average person-years lived in the interval by those dying in the interval (nax) was calculated using the formula proposed by Keyfitz [1966], except for 1a0 , 1a4 for which the formula proposed by Coale and Demeny [1983] was used [Preston, Heuveline & Guillot, 2001].

17Arriaga’s method [1984] was used to calculate the contributions of different age groups and disease-specific causes of death to the changes in life expectancy at birth. The effect of change in mortality of a specific age group on life expectancy at birth may be a result of the direct effect, where changes in the age range (x, x+n) will result in changes in the number of years of life lived between ages x and x+n, and the sum of the indirect and interaction effect which is the contribution resulting from the person-years to be added because additional survivors at age x+n are exposed to new mortality conditions. The age- and disease- contributions were calculated for 10 years age groups (except for 0, 1-4 and 85+) because the number of deaths for several countries and causes of death was very small (< 10 deaths) for smaller age groups. After analysis, age groups were aggregated where appropriate for presentation purposes.

18The decomposition analysis shows the difference in life expectancy between the start and end year of each indicated period, Socialist Federation (1975-1985), Transition (1988-2000) and Independence (2007-2017). Meaning deaths in the indicated interval end years of each period were taken for the decomposition analysis. The longer length of the analysis period was selected to capture a broader set of societal changes, as well as to account for the fact that, to see effects on mortality of non-communicable diseases, a significant time has to pass after exposure to risk factors or preventive measures. The difference between the end years for the Transition is 13 years, compared to the 11 years for the other two periods, due to data constrains both in terms of quality and availability.

19For Bosnia and Herzegovina, the earliest data available on causes of death and population estimates post-independence was for the year 2011, and hence the Transition period is calculated as the difference between 1988-2011, while Independence is calculated as the difference between 2011-2017. While this is a limitation, and thus the analysis should be cautiously interpreted when comparing it to the other countries or between periods in terms of absolute numbers, nevertheless, the calculation is still indicative of the period for which it is calculated.

4. Results

20Life expectancy at birth has significantly improved in all countries in the past 40 years, despite occasional reversal or stagnation. Trends in life expectancy for all 6 countries are shown for males in Figure 1 and for females in Figure 2.

Figure 1: Trends in life expectancy at birth for males in the 6 Balkan countries 1962-2017.

Figure 1: Trends in life expectancy at birth for males in the 6 Balkan countries 1962-2017.

Source: Author’s calculations

Figure 2: Trends in life expectancy at birth for females in the 6 Balkan countries 1962-2017.

Figure 2: Trends in life expectancy at birth for females in the 6 Balkan countries 1962-2017.

Source: Author’s calculations

21While the focus of this analysis is in the period right before the collapse of SFRY, the transition and the aftermath, in order to contextualise the trends in life expectancy change, it is important to consider the improvement processes that started after World War II. In 1962, there were large disparities in life expectancy between the countries. For males, while three countries are clustered around 65 years, the gap between Macedonia and Montenegro is almost 10 years. For females, the gap between countries is even wider reaching 13 years. However, during the following decade, in the context of economic and health care development in Yugoslavia, steep improvements in life expectancy can be observed for all countries, narrowing the gap between the countries.

22In the period of 1962 to 1975, the rate of improvement varied between countries and countries with lower life expectancy experienced the highest gains. For example, females in Macedonia gained 10.8 years, while males gained 8.8 years in life expectancy in birth. Moreover, in several countries the change was larger for female life expectancy compared to male. In Slovenia female life expectancy increased by 5.5 years, while male increased by only 0.9 years, while in Croatia the increase was 4.7 and 2.8 for females and males respectively. The increase in life expectancy continued throughout the 1980s as well, although the rate of change was slower.

23The difference between the countries was the lowest at the beginning of the 1990s, the start of the Transition period, before the trends started to diverge. The gap between the countries in life expectancy was reduced to 6.3 years for both males and females. However, during this period Serbia and Montenegro experienced declines in life expectancy. In Serbia the decrease was -0.5 years for both males and females, while in Montenegro the decrease was greater for females, at -4.3 years, compared to -3.0 for males. In Bosnia and Herzegovina from 1990 to 2001 life expectancy increased by 0.2 and 0.9 years for males and females respectively. This finding is particularly interesting, as it suggests that the impact of the war on life expectancy was acute and by the early 2000s life expectancy continued to improve. Slovenia experienced the largest gains in life expectancy of 2.5 and 2.3 for males and females respectively.

24During the Independence period, between the years 2000 and 2017, the divergence of life expectancy continued. While Slovenia experienced the highest life expectancy of all 6 countries, 78.3 years and 84.1 years for males and females respectively, the largest increase was in Croatia, 5.6 and 4.0 years for males and females respectively. A large increase was also noted in Montenegro of about 5 years, and Serbia of 4 years. Particularly interesting is the plateauing of female life expectancy in Macedonia where the increase was only 2.42 years, which is unusual given that the country is experiencing the lowest female life expectancy in the region at only 78.0 years. This results in a difference in female life expectancy between Slovenia and Macedonia of 6.1 years.

25Decomposition analysis of the observed changes in life expectancy by age- and cause of death contributions show clear patterns (see Figures 3 and 4). The change in life expectancy between the end years of each period is the sum of values, negative and positive. Bars above the horizontal axis indicate positive contributions to the observed change, while bars below the horizontal axis indicate negative contributions to the observed changes of life expectancy. Positive contributions led to an increase in life expectancy, while negative contributions led to a decrease. The y-axis shows the number of years that changing death rates in each age group contributed to the change in life expectancy.

Figure 3: Contributions of different age- and cause-specific deaths to changes in life expectancy for males in the three time periods: Socialist Federation (1975-1985), Transition (1988-2000, except for Bosnia and Herzegovina 1988-2011) and Independence (2007-2017, except for Bosnia and Herzegovina 2011-2017)

Figure 3: Contributions of different age- and cause-specific deaths to changes in life expectancy for males in the three time periods: Socialist Federation (1975-1985), Transition (1988-2000, except for Bosnia and Herzegovina 1988-2011) and Independence (2007-2017, except for Bosnia and Herzegovina 2011-2017)

Figure 4: Contributions of different age- and cause-specific deaths to changes in life expectancy for females in the three time periods: Socialist Federation (1975-1985), Transition (1988-2000, except for Bosnia and Herzegovina 1988-2011) and Independence (2007-2017, except for Bosnia and Herzegovina 2011-2017)

Figure 4: Contributions of different age- and cause-specific deaths to changes in life expectancy for females in the three time periods: Socialist Federation (1975-1985), Transition (1988-2000, except for Bosnia and Herzegovina 1988-2011) and Independence (2007-2017, except for Bosnia and Herzegovina 2011-2017)

26It is evident that the large increase in life expectancy during the Socialist Federation (1975-1985) period is attributable to declining infant and child mortality. This can be observed on Figures 3 and 4, as the positive contribution of the disease category other (dark green colour) which indicates reduction in deaths related to perinatal period, and in Macedonia it is a result of the reduction in deaths due to respiratory diseases among infants and children (blue colour). It is noteworthy that for the very old ages (75+) the positive contribution of other, and the equal negative contribution of circulatory diseases (red colour) might indicate improvements in diagnosis of causes of death and specificity of coding practices, as over time there has been a reduction in the deaths coded as ill-defined causes of mortality (captured under the category other).

27As with the changes in life expectancy, divergence of patterns between countries are observed during the Transition (1990-2000) period. In Macedonia, the positive increase in life expectancy is a result of the further declines in infant and child mortality (age group 0-4). In Slovenia, circulatory diseases (red colour), especially among the older age groups, positively contributed to the observed changes in life expectancy, in conjunction with the reduction in the prevalence of external causes of death among young adults. The largest negative contribution to the change in life expectancy in Serbia was deaths due to circulatory diseases in the age groups 45-75. Meanwhile, infant and child mortality continued to decline, but its positive contribution to the observed change in life expectancy was smaller than the negative contribution of circulatory diseases, resulting in an overall decline in life expectancy. In Montenegro the death rates among the age groups over 45 negatively contributed to the observed decline in life expectancy.

28During the Independence (2007-2017) period, in all countries, the observed increase in life expectancy is mainly attributable to reduction in circulatory diseases mortality among the older age groups. In addition, for males, further reductions in mortality due to external causes, especially in those aged 15-44 years contributed positively the changes in life expectancy.

5. Discussion

29In this study an original set of life-tables is used to provide an accurate calculation of life expectancy during a period of crisis in 6 Balkan countries. Overall, life expectancy significantly increased for all countries. The largest gains in life expectancy occurred during the period of the Socialist Federation. The Transition disrupted the homogeneous improvements in population health, causing a variation in the trajectories of change. This is excepted during a period of political and economic crisis, wars, and instability. The Independence period, or the consolidation phase, led to further improvements in life expectancy in all countries. However, the slower rate of change or plateauing in some countries raises the questions whether the gap between the countries will be closed in the short term or whether the countries move on divergent trajectories as a legacy of the Transition period. The decomposition analysis accentuated the contributions of age groups and cause specific mortality to those changes.

30However, before discussing the plausible explanations of the observed changes, it is necessary to explore the limitations of this study, which relate to data gaps and coding practices. Data gaps exist in terms of deaths disaggregated by causes of death especially during the Transition. This resulted in the end years to capture a period of 13 years for all countries except for Bosnia and Herzegovina, for which it was 19 years. However, given that majority of observed change is attributable to non-communicable diseases, which develop over time and given that there were no large fluctuations in life expectancy at birth or age 15 and 65, it is unlikely that the larger period impacted the age- and cause of death composition of the change in life expectancy.

31The second limitation relates to coding of deaths, and this is most applicable to the 1970s and 1980s. Over time there was an increase in the number of people that died in health facilities, and thus increase in the number of deaths diagnosed by a doctor. The development of diagnostic tools, knowledge of the pathology of non-communicable diseases and recognition of risk factors [Jamison et al., 2006], and changes in the diagnosis criteria [Nowak and Paczek, 2011] contributed to more specific diagnoses. The broad category grouping reduces the impact of changes in specificity of disease coding on the analysis (e.g. in 1975 neoplasms were coded as either malignant or benign neoplasms, while in 1985 they were assigned the exact affected organ, but all of these would be captured under the category neoplasms for both years), the increase in specificity needs to be considered when interpreting the results as it might signal a better understanding and management of non-communicable diseases, which eventually leads to better health outcomes.

32In the period of the Socialist Federation the increases in life expectancy in all countries were predominantly driven by reduction in infant and child mortality, as well as reduction in mortality due to infectious diseases. The epidemiological transition provides the theoretical background for understanding these reductions [Omran, 2005; Olshansky and Aulit, 1986]. Improvements in the socio-economic situation in the countries, resulted in improvements in sanitation, nutrition and provision of health care leading to a transition from infectious diseases to non-communicable diseases.

33More specifically, in SFRY, mortality due to infectious diseases was reduced through improvement in the quality of living conditions and very strong public health measures. The reduction of tuberculosis was attributable to increased testing, case notification strengthened through legal measures, mass X-ray surveys, mandatory BCG vaccination, health education using mass media, and treatment [WHO, 1953]. Effective vaccination campaigns resulted in the elimination of smallpox [WHO, 1973], and reduction in the prevalence of diphtheria and pertussis, both of which were leading causes of death among children [Galazka and Robertson, 1995; Baće and Duancić, 1990].

34In addition, infant and child mortality were reduced through improved pregnancy and birth management. Family planning services were introduced, leading to an increase in the number of gynaecological visits, the number of children having a doctor visit, and the number of patronage nurses (based on administrative data published by the Federal Statistical Office of Yugoslavia in Demografska Statistika (Yugoslavia) 1959-1990 [Demographic Statistic (Yugoslavia)]). Patronage nurses play an important role in the reduction of infant mortality, as they provide appropriate advice about living conditions and educate mothers how to breastfeed and care for the infant [Nurmukhambetova, 2017; Thompson and Keeling, 2012].

35The increase in the number of health workers resulted not only in improved access to health services, but also improved health education among the population leading to an improvement in health seeking behaviours. The emphasis on reduction of infant and child mortality continued, although at a slower rate, even during the economic crisis in the 1980s. Strong redistributive social policies protected the poorest regions from deterioration during the crisis [Kunitz, Simić and Odoroff, 1987]. The decrease in infant and child mortality during crisis contrasts the situation that was observed in other communist countries, such as those of the Soviet Union, where infant mortality initially decreased but suddenly increased during the 1970s [Ryan, 1988].

36During the Transition period the Balkan countries did not experience the same trends in life expectancy as those noted by other Eastern European countries. In post-Soviet states, excess premature adult male mortality due to high levels of alcohol consumption, smoking and poor nutrition led to significant decreases in male life expectancy, and a large increase in the gap between male and female life expectancy [McKee and Shkolnikov, 2001]. In contrast, in the majority of Balkan countries there were reductions in mortality for both men and women, resulting in an increase of life expectancy. In Macedonia the increase in life expectancy was a result of further reductions in infant and child mortality, while in Slovenia and Croatia adult mortality decreased, in particular, mortality due to external causes of death and cardiovascular diseases.

37In Serbia and Montenegro during this period a reduction in life expectancy was noted and circulatory diseases among the older age groups had the highest negative contributions to the observed reduction. There are two plausible explanations. First, it is plausible that the reduction in mortality of infectious and respiratory diseases led to a shift in the disease profile in the countries; meaning, non-communicable diseases, including circulatory diseases emerged due to a prolonged exposure to risk factors. For example, Kozarević et al., found that men in Yugoslavia with higher serum cholesterol had lower death rate due to respiratory diseases [1981]. Yet, it is known that high serum cholesterol leads to increased risk of mortality due to cardiovascular diseases [Jung et al., 2022]. Hence, exposure to certain risk factors might have been advantageous only for the reduction in mortality of infectious diseases, but led to onset of chronic diseases.

38Second, the decrease in life expectancy in Serbia and Montenegro can be understood in the context of the prolonged crisis that they experienced, including the UN sanctions and conflicts in the 90s. During the period of sanctions humanitarian assistance was provided, yet there were delays in shipments, shortages of drugs for mental illnesses, cardiac diseases, diabetes and asthma, as well as drugs for kidney transplants [The Phramaletter, 1992]. Even medical supplies such as X-ray films and antibiotics and anaesthetics were missing. This gave rise to a black market, potentially leading to mismanagement of chronic diseases due to the inappropriateness of the drugs available [Stojanovic, 1993]. Hence, the crisis plausibly led to an increase in mortality due to circulatory diseases.

39During the Transition, the direct impact of the war was acute in terms of deaths of external causes negatively contributing to the changes in life expectancy. The deadliest war was the Bosnian war with more than 100,000 casualties [Tabeau & Zwierzchowski, 2010]. Yet, the interpersonal violence was acute around the times of the war, and it did not persist after the war [UNODC, 2008], hence the negative impact is not observed in the decomposition analysis of the difference at the end years. In addition, the severity of the impact of the wars on mental health in the countries studied is not clear. In a survey in Bosnia, 13% of the respondents reported 7 or more war-related distress symptoms [Ringdal et al., 2008]. Data from Croatia showed only a small number of patients under medical surveillance for post-traumatic stress disorder (PTSD) (Flögel and Lauc, n.d.). During the years of war, the number of people intentionally self-harming in Bosnia was either stagnant or decreasing [Ilic and Ilic, 2016; Miltenovic and Vujetic, 2020]. Grubisic-Ilic et al., has shown that there was no significant difference in the incidence of self-harm between those affected by the war and those not been affected [2002]. In addition, in Serbia and Montenegro it was noted that rates of intentional self-harm among former military personnel are at lower rate than among the civilian population [Dedic and Panic, 2007]. There is a possibility that there has been underreporting of mental health related problems, however, these numbers are consistent with the data on suicide rates, and with the decomposition analysis.

40During the Independence period most of the gains in life expectancy are attributable to reductions in mortality of chronic diseases among older populations, particularly reductions in circulatory diseases mortality. The decline in mortality can be attributed to availability of treatment and medications for better management of circulatory diseases. For example, in Serbia 53% of the adult patients with hypertension had adequately managed blood pressure, and more than 75% of the patients receive key medications after acute myocardial infraction [WHO EURO, 2018]. However, problems with treatment coverage persist. In Slovenia 33.4% of those with hypertension do not receive antihypertensive medications [Bozic Jese, 2021]. In Macedonia important treatment medications for circulatory diseases are not included on the list of outpatient prescription medicine covered by the fund for health insurance [Dimkovski and Mosca, 2021].

41However, despite the decline in mortality, age-standardized mortality rates show that mortality due to circulatory diseases is still very high in comparison to other European countries. This is unsurprising given the very high prevalence of risk factors such as smoking, alcohol consumption, salt intake and obesity prevalence [GHO, 2022]. For example, smoking prevalence among males in 2016 was lowest in Slovenia at 27.5% of the adult population, while the highest is in Macedonia 46.7% [GHO, 2022]. Meanwhile, the percentage of adult population that is obese ranges from 17%-25% [GHO, 2022]. The high prevalence of risk factors threatens further declines in mortality among adults, and could potentially lead to stagnant life expectancy or even reversal.

42Finally, during the Independence, it is noteworthy, the reduction of mortality due to external causes of death among younger adults as it contributed positively to increase in life expectancy. The number of casualties in traffic accidents was reduced through investments in physical infrastructure leading to better traffic safety [Banfi, 2018; Zavod Vozim, 2017; Babic, 2014], and reduction of the number of people driving under influence of alcohol, driving outside the speed limits, and reductions in the use of cell phones while driving [OECD, 2020; Missoni, Bozic and Missoni, 2012].

6. Conclusion

43The collapse of SFRY and the transition to independence has altered the population health. This study analysed the changes in life expectancy, as a measure of population health, during the periods of Socialist Federation, Transition and Independence in the 6 Balkan countries. The improvement in quality of life and provision of health care reduced mortality among the younger age groups, leading to a rapid increase in life expectancy and reducing the gap between the countries. The disruptive Transition altered the trajectories of change of life expectancy, increasing heterogeneity between the countries. During the Independence the changes in population health have been more favourable albeit modest. The gap between the countries, and the plateauing of life expectancy highlight the potential for health gains, and the need to strengthen health policies.

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Bibliographie

Arriaga, E., 1984, Measuring and explaining the change in life expectancy. Demography, 21(1), pp. 83-96.

Babić, D., Fiolić, M., Prusa, P., 2014, The role of traffic signalization on reduction of accidents on the Croatian Roads. Scientific Proceedings XXII International Scientific-Technical Conference “trans & MOTAUTO ‘14”, 3, pp. 52-55.

Baće, A. and Duancić, V., 1990, Osvrt na današnje postavke prevencije, profilakse I terapije pertusisa I parapertusisa [Review of the present status of prevention, prophylaxis and therapy of pertussis and parapertussis]. Lijec Vjesn, 112(7-8), pp.262-8.

Banfi, B., 2018, Road safety in the Danube region with a focus on infrastructure. Ljubljana.

Bobak, M. and Marmot, M., 1996, East-West Mortality Divide And Its Potential Explanations: Proposed Research Agenda. BMJ: British Medical Journal, 312(7028), pp.421-425. DOI: 10.1136/bmj.312.7028.421

Božič Ješe, N., Knez, J., Dolenc, P., Beaney, T., Clarke, J., Poulter, N. and Brguljan Hitij, J., 2021, May Measurement Month 2019: an analysis of blood pressure screening results from Slovenia. European Heart Journal Supplements, 23 (Supplement_B), pp.B131-B133. DOI: 10.1093/eurheartj/suab030

Dedic, G. and Panic, M., 2007, Suicide Prevention Program in the Army of Serbia and Montenegro. Military Medicine, 172(5), pp.551-555. DOI: 10.7205/MILMED.172.5.551

Demografska statistika; Yugoslavia, 1959-1990. Savezni Zavod za Statistiku. [Demographic statistic; Yugoslavia, 1959-1990. Federal Bureau of Statistics.]

Dimkovski, V. and Mosca, I., 2021, Can people afford to pay for health care?. WHO EURO.

Dolea, C., Nolte, E. and McKee, M., 2002, Changing life expectancy in Romania after the transition. Journal of Epidemiology & Community Health, 56(6), pp.444-449. DOI: 10.1136/jech.56.6.444

EUISS- EU INSTITUTE FOR SECURITY STUDIES, Čeperković, M. and Gaub, F., 2018, Chapter 1: Megatrends in the Western Balkans. Balkan futures: Three Scenarios for 2025. DOI: 10.2815/460916

Flögel, M. and Lauc, G., 1998, War Stress – Effects of the War in the Area of Former Yugoslavia. NATO.

Galazka, A. and Robertson, S., 1995, Diphtheria: Changing Patterns in the Developing World and the Industrialized World. European Journal of Epidemiology, 11(1), pp.107-117. DOI: 10.1007/BF01719955.

GHO, 2022. Global Health Observatory.

Gjonça, A., 2004, Crossroads of Europe: regional adult mortality differentials in the Balkans. Espace, Populations, Societes. Specia (3), pp. 665-679. DOI

Grubišić-Ilić, M., Kozarić-Kovačić, D., Grubišić, F. and Kovačić, Z., 2002, Epidemiological study of suicide in the Republic of Croatia – comparison of war and post-war periods and areas directly and indirectly affected by war. European Psychiatry, 17(5), pp.259-264. DOI: 10.1016/S0924-9338(02)00679-X

Hudson, K., 2003, Breaking The South Slav Dream, The Rise And Fall Of Yugoslavia. Pluto Press, pp.39-88.

Ilic, M. and Ilic, I., 2016, Suicide in Serbia. Journal of Affective Disorders, 193, pp.187-193. DOI: 10.1016/j.jad.2015.12.063

Jung, E., Kong, S.Y., Ro, Y.S., Ryu, H.H, Shin, D.S., 2022, Serum Cholesterol Levels and Risk of Cardiovascular Death: A Systematic Review and a Dose-Response Meta-Analysis of Prospective Cohort Studies. Int J Environ Res Public Health, 19(14):8272. DOI: 10.3390/ijerph19148272

Keyfitz N., 1966, Sampling variance of age standardised mortality rates. Human Biology 38; 309-317.

Kozaervić, D., Pirc, B., Račic, Z., Dawber, T., Gordon, T. and Zukel, W. (1976). The Yugoslavia Cardiovascular Disease Study II. Factors in the Incidence of Coronary Heart Disease. American Journal of Epidemiology, 104(2), pp.133-140. DOI: 10.1093/oxfordjournals.aje.a112283

Kunitz, S., 2004, The Making and Breaking of Yugoslavia and Its Impact on Health. American Journal of Public Health, 94, pp.1894-1904. DOI: 10.2105/AJPH.94.11.1894

Kunitz, S., Simić, S. and Odoroff, C., 1987, Infant mortality and economic instability in Yugoslavia. Social Sciences & Medicine, 24(11), pp.953-960. DOI: 10.1016/0277-9536(87)90288-7

Mackenbach, J., Hu, Y., Looman, C., 2013. Social Science & Medicine. 93, pp.166-175. DOI: 10.1016/j.socscimed.2013.05.010

McKee, M. and Shkolnikov, V., 2001, Understanding the toll of premature death among men in eastern Europe. BMJ: British Medical Journal, 323(7320), pp.1051-1055. DOI: 10.1136/bmj.323.7320.1051

Miltenovic, S. and Vujetic, M., 2020, Suicides in Belgrade, Serbia in the period 2009-2018. European Journal of Public Health, 30(Supplement_5). DOI: 10.1093/eurpub/ckaa166.1181

Missoni, E., Bozić, B. and Missoni, I., 2012, Alcohol-related road traffic accidents before and after the passing of the Road Traffic Safety Act in Croatia. Collegium Antropologicum, 36(4), pp.1483-9.

Nolte, E., Shkolnikov, V. and McKee, M., 2000, Changing mortality patterns in East and West Germany and Poland. II: Short-term trends during transition and in the 1990s. Journal of Epidemiology and Community Health, 54 (12), pp.899-906. DOI: 10.1136/jech.54.12.899

Nowak, M. and Paczek, 2011, The paradox of the 21st century – is there really an epidemic of most common killers?. International Journal of General Medicine, 4, p.799-802. DOI: 10.2147/IJGM.S24777

Nurmukhambetova, Z., 2017, How visiting nurses help prevent child deaths in Kazakhstan. UNICEF. Available at: <https://www.unicef.org/stories/how-visiting-nurses-help-prevent-child-deaths-kazakhstan>

OECD, 2020, Slovenia. Road Safety Report. OECD.

Olshansky, S. and Ault, A., 1986, The Fourth Stage of the Epidemiologic Transition: The Age of Delayed Degenerative Diseases. The Milbank Quarterly, 64(3), pp.355-391. DOI: 10.2307/3350025

Omran, A., 2005, The Epidemiologic Transition: A Theory of the Epidemiology of Population Change. Milbank Quarterly, 83(4), pp.731-757. DOI: 10.1111/j.1468-0009.2005.00398.x

Perry, B., 2018, De-Balkanization: How Europe Plans to Incorporate its Final Frontier. Harvard International Review. 39(3), pp.6-7.

Preston, S., Heuveline, P. and Guillot, M., 2001, Demography. Oxford.

Ringdal, G., Ringdal, K., and Simkus, A., 2007, War-Related Distress Among Kosovar Albanians. Journal of Loss and Trauma, 13(1), pp.59-71. DOI: 10.1080/15325020701741781

Ruger, J., 2005, Democracy and health. QJM. 98(4), pp.299-304. DOI: 10.1093/qjmed/hci042

Ryan, M., 1988, USSR Letter: Infant mortality in the Soviet Union. BMJ: British Medical Jouranl, 296(6625), pp.850-851. DOI: 10.1136/bmj.296.6625.850

Shkolnikov, V., McKee, M. and Leon, D., 2001, Changes in life expectancy in Russia in the mid-1990s. The Lancet, 357(9260), pp.917-921. DOI: 10.1016/S0140-6736(00)04212-4

Stojanovic, D., 1993, Sanctions Devastate Serbia’s Health Care; Patients Dying With AM-Yugoslavia, Bjt. AP news. Available at: <https://apnews.com/article/c2de89e6e9b0c09320a67cbfdfabbf1e>

Tabeau, E., and Zwierzchowski, J., 2010. The 1992-95 war in Bosnia and Herzegovina: census-based multiple system estimation of casualties’ undercount. International Research Workshop on ‘The Global Costs of Conflict’ The Households in Conflict Network (HiCN) and The German Institute for Economic Research (DIW Berlin), 1-2 February 2010, Berlin. pp. 1-25.

The Phramaletter. 1992, UN Sanctions hit Yugoslav drug supplies. Available at: <https://www.thepharmaletter.com/article/un-sanctions-hit-yugoslav-drug-supplies>

Thompson, M. and Keeling, A., 2012, Nurses’ Role in the Prevention of Infant Mortality in 1884–1925: Health Disparities Then and Now. Journal of Pediatric Nursing, 27(5), pp.471-478. DOI: 10.1016/j.pedn.2011.05.011

UNODC, 2008, Crime and its impact on the Balkans and affected countries. Available at: <https://www.unodc.org/documents/Balkan_study.pdf>

UNSTATS. 2016, UNSD — Demographic and Social Statistics. Available at: <https://unstats.un.org/unsd/demographic-social/crvs/>

Uvalic, M., 2012, Economies In Transition. Helsinki: Palgrave MacMillan, pp.364-399.

WHO EURO, 2018. Serbia country assessment. Better non-communicable disease outcomes: challenges and opportunities for health systems.

WHO Mortality Database, 2022. World Health Organization. Available at: <https://www.who.int/data/data-collection-tools/who-mortality-database>

WHO, 1953, Tuberculosis control in the People’s Republic of Yugoslavia. World Health Organisation.

WHO, 1973, Epidemiological aspects of smallpox in Yugoslavia in 1972. World Health Organisation.

Wigley, S. and Akkoyunlu-Wigley, A., 2010, Do electoral institutions have an impact on population health?. Public Choice. 148, 595-610. DOI: 10.1007/s11127-010-9686-6

World Health Organization, 2010, A Conceptual Framework For Action On The Social Determinants of Health. Geneva.

Zavod Vozim, 2017. Social media campaign »Don’t text and drive!«. MOBILITY AND TRANSPORT - European Commission. Available at: <https://road-safety-charter.ec.europa.eu/content/social-media-campaign-dont-text-and-drive_bg>

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Annexe

Annex 1

Category

ICD-10

ICD-8, ICD-9

Infectious diseases

A00-B99

000-139

Neoplasms

C00-D48

140-239

Circulatory

I00-I99

390-458

Respiratory

J00-J99

460-519

Digestive

K00-K93, E00-E90

240-279, 520-577, 280-289

External

S00-T98, V01-Y98

800-999

Other

D50-D89, F00-F99, G00-G99, H00-H59, H60-H95, L00-L99, M00-M99, N00-N99, O00-O99, P00-P96, Q00-Q99, R00-R99

290-319, 320-389, 680-709, 710-738, 580-629, 630-676, 760-779, 740-759, 780-796

* Detailed description of ICD codes: https://www.who.int/​standards/​classifications/​classification-of-diseases

* Note: The category digestive includes K00-K93 (Disease of the digestive system) and E00-E90 (Endocrine, nutritional and metabolic diseases) as there has been evidence for gastrointestinal manifestations of endocrine diseases.

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Notes

1 Due to data availability limitations Kosovo was not included in the study.

2 Hereafter, referred to as Macedonia for clarity, as the name of the country was changed to North Macedonia in 2018, which is after the period studied here. Prior to that the constitutional name of the country was the Republic of Macedonia, while the name used in international organizations was the Former Yugoslav Republic of Macedonia.

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Table des illustrations

Titre Figure 1: Trends in life expectancy at birth for males in the 6 Balkan countries 1962-2017.
Crédits Source: Author’s calculations
URL http://journals.openedition.org/eps/docannexe/image/12945/img-1.png
Fichier image/png, 73k
Titre Figure 2: Trends in life expectancy at birth for females in the 6 Balkan countries 1962-2017.
Crédits Source: Author’s calculations
URL http://journals.openedition.org/eps/docannexe/image/12945/img-2.png
Fichier image/png, 74k
Titre Figure 3: Contributions of different age- and cause-specific deaths to changes in life expectancy for males in the three time periods: Socialist Federation (1975-1985), Transition (1988-2000, except for Bosnia and Herzegovina 1988-2011) and Independence (2007-2017, except for Bosnia and Herzegovina 2011-2017)
URL http://journals.openedition.org/eps/docannexe/image/12945/img-3.png
Fichier image/png, 200k
Titre Figure 4: Contributions of different age- and cause-specific deaths to changes in life expectancy for females in the three time periods: Socialist Federation (1975-1985), Transition (1988-2000, except for Bosnia and Herzegovina 1988-2011) and Independence (2007-2017, except for Bosnia and Herzegovina 2011-2017)
URL http://journals.openedition.org/eps/docannexe/image/12945/img-4.png
Fichier image/png, 196k
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Référence électronique

Dijana Spasenoska, « Dynamics of life expectancy change during the transition to democracy in the ex-Yugoslav countries  »Espace populations sociétés [En ligne], 2022/2-3 | 2022, mis en ligne le 21 février 2023, consulté le 24 mai 2024. URL : http://journals.openedition.org/eps/12945 ; DOI : https://doi.org/10.4000/eps.12945

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Auteur

Dijana Spasenoska

Department of Social Policy, The London School of Economics and Political Science,
Houghton St, London, WC2A 2AE, United Kingdom
Email: d.spasenoska[at]lse.ac.uk
ORCID ID: 0000-0003-3640-4405

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