Dutch people are living longer and in good health

Life expectancy for the average Dutch person was again higher in 2003 than in the preceding years. Since 1950, average life expectancy has risen by 5.8 years for men and 8.3 years for women, to stand at 76.2 and 80.9 years, respectively. The gap between male and female life spans has gradually been narrowing, following a period of expansion in the 1960s and early 1970s. The diminishing differential comes in spite of the fact that female life expectancy has been increasing again, after the stagnation reported in the previous survey (see figure 1).

Generally speaking, it is healthy years that have been gained. In particular, the number of years spent without disability has risen significantly. Since the 1980s, disability-free life expectancy has increased by between six and seven years, mainly due to reductions in auditory and visual impairment and in loss of mobility.

Figure 1: Life expectancy at birth in the Netherlands between 1950 and 2003 (Source: CBS Mortality Statistics).

Legacy of ill health

Current life expectancy is always a legacy from the past. Illnesses that cause premature death and reduce quality of life are often associated with the lifestyle earlier in life. At present, for example, the burden caused by smoking-related diseases, such as lung cancer and COPD, are in decline among men because they quit tobacco use massively since the 1960s and 1970s. However, smoking has actually become more common among women in recent decades, and the health implications are now becoming evident. Meanwhile, the number of Dutch people who are overweight or obese (seriously overweight) has soared in the last decades, leading to a higher incidence of diabetes.

Among adults and elderly people, conditions associated with unhealthy behaviour, such as cardiovascular disease and cancer, are predominant (see figure 2). Such conditions are less influential among other age groups. The most common causes of death among children are birth complications, congenital abnormalities and accidents. Among juveniles and young adults, the most important causes of death are suicide and road traffic accidents, while mental disorders are the main cause of reduced quality-of-life at that age.

The rise in the incidence of asthma appears gradually to be levelling off. As a matter of fact, the number of children with asthma has actually fallen a little. Death from coronary heart disease has been falling, under the influence of better treatment, such as the pharmaceutical reduction of high blood pressure and elevated cholesterol levels. Cancer-related mortality is also declining, but not so quickly; as a result, cancer will be the predominant cause of death in the years ahead.

Figure 2: Disease burden (DALYs per one thousand individuals) by age and condition (other physical ailments include diabetes, asthma and COPD, visual and auditory impairment).

Health through prosperity

Over the longer term, the steady improvements seen in public health are attributable largely to increased prosperity. Greater prosperity results in improved physical and social circumstances (including better education). In recent decades, economic growth has also increasingly provided a foundation for investment in successful treatments and prevention programmes.

Regional inequalities: considerable scope for improvement

Considerable differences exist between the Netherlands’ 39 municipal health service regions, in terms of health and the prevalence of health risk factors. In the ‘healthiest’ region, healthy life expectancy is nearly twelve years greater than in the ‘least healthy’ region. The percentage of smokers varies from less than 28% to more than 36%, while the percentage of people with obesity ranges from 6 to 16%. Often disadvantageous scores for health and risk factors are directly associated with a region’s lower average socio-economic status. This is particularly the case in the big cities, in the northern Netherlands and in South Limburg (see figure 4). The extent of the inequalities and their geographical distribution has barely changed since the mid-1990s. The magnitude of these differences within the Dutch regions shows how much still can be gained for the overall health status of the Netherlands.

Figure 4: Aggregated public health index, determinant index, prevention index and socio-economic status per municipal health service region.

Present-day lifestyles and obesity: concern for future health status

Just as today’s public health situation is influenced by the way people lived in the past, the future health status of the nation will reflect the lifestyle choices people are making today. Although the picture is not entirely positive, grounds for optimism do exist. After years at a fairly steady level, the percentage of adults who smoke has fallen recently, from about 33% in the 1990s to 28% in 2004. Alcohol consumption among adults has also declined slightly since 2001.

Physical activity levels in the Netherlands have improved only slightly, however. Only half of the Dutch population is currently getting enough physical exercise. The nation’s dietary habits are also far from ideal. The average Dutch person eats too much saturated fat and trans-fatty acid, but too little fruit, vegetables and fish. While consumption of fatty acids is at least decreasing, only 5 to 10% of the Dutch population has what may be described as a healthy diet. Where fruit and vegetables are concerned, the trend is actually towards less healthy consumption.

Overweight results from a combination of excessive calorie intake and insufficient physical activity. In the last quarter-century, the fraction of the adult population that is overweight has risen from a third to nearly half. The percentage of adults who are obese has doubled since 1980, from 5 to 11 percent. Almost all strata of society are affected by this ‘epidemic’. However, there are signs that the trend is levelling off, particularly among the well educated.

Many people develop unhealthy habits early in life. Among teenagers of 15-19 years some 45% of boys and 36% of girls smoke: roughly the same as four years ago. Alcohol use among adolescents, and particularly among girls, is increasing. Binge drinking on evenings out has become popular. Only just over a quarter of young people gets enough exercise. It is among children that the prevalence of overweight and obesity is increasing most rapidly. In some age groups, the percentage of overweight children has doubled since 1997 (see figure 5).

Figure 5: Percentages of boys and girls who were overweight and obese in 1997 and in 2002-2004 (Source: Van den Hurk et al., 2006).

Sound lifestyle choices can extend healthy life expectancy with many years

Tobacco use is the largest single cause of morbidity and mortality in the Netherlands. 13% of the total disease burden is directly attributable to tobacco use, with lung cancer, COPD and coronary heart disease as the largest causes. Excessive alcohol consumption is responsible for 4.5% of the disease burden in the Netherlands, mainly in the form of alcohol dependency. Overweight makes a notable contribution to the disease burden, accounting for nearly 10 percent of disease burden. Overweight is an important risk factor for chronic diseases such as diabetes and cardiovascular disease. Disorders associated with smoking, overweight and raised blood pressure also account for considerable amounts of the care budget: 3.7, 2.0 and 3.3%, respectively.

Health promotion: better evaluation and more knowledge sharing required

Health promotion is important, but the initiatives taking place are not being evaluated as well as they might be. This is partly because it is very difficult to measure their effects, particularly over the longer term. Information about the effectiveness of health promotion policies and their implementation needs to be made generally available. This would facilitate the propagation of best practices, tailored to local circumstances wherever possible. It would therefore be helpful to have a central system for the collection, assessment and dissemination of information about health promotion, backed up by continuous interaction between researchers, policy makers and those working in policy implementation.

Many cost-effective prevention measures are not being implemented systematically

Cost-effect analyses performed elsewhere indicate that there are many cost-saving or relatively cheap preventive measures that have yet to be systematically implemented in the Netherlands. In many cases, the measures involve the prevention of disease among high-risk groups or preventing the worsening of the condition of people who are already ill. Various forms of health promotion or protection are actually cost-effective (‘cheap’), such as discouraging tobacco use and specific interventions to reduce the risk of falling among the elderly.

Prevention and care are not separate domains

In countries such as the Netherlands, where health care is funded by a social insurance system, prevention is often more distinct from care than it is in countries where health care is fully funded by the government. This can lead to the neglect of preventive activities in the health care sector. It remains to be seen how the introduction of a new care system in the Netherlands will impact upon this separation. Whatever the outcome may be, it is important that health insurers and care providers are given adequate incentive to develop (‘evidence-based’) preventive activities inside and outside the care domain.

Prevention recommendations made in the last survey report remain valid

Over the last few years, various parties have developed initiatives that have contributed to the incorporation of preventive activities within the care domain and other social policy domains, to the use of settings (school, neighbourhood, work, care) and to broad-based knowledge sharing. As a result, many new preventive activities are underway. However, their coordination still has to be improved. A great deal has been accomplished since the previous survey, but there is still much room for further improvement, such as sustainable programmatic approaches, including durable organisation and funding of the activities, and systematic evaluation of prevention activities in the Netherlands.

In this context, lessons can be learned from other European countries, which are also constantly working to rationalise health policy, e.g. through the creation of far-reaching, integrated programmes aiming at interrelated health objectives. Success factors in this regard include the shared ‘ownership’ of health problems by involved stakeholders, visible governmental stewardship and good communication.

Infectious diseases prepared for predictable and alert to unforeseen events

In the development of an epidemic or pandemic, two factors are decisive: the extent to which the responsible pathogen is transmissible between humans and the infectiousness of carriers in the period prior to diagnosis. In addition, the level of motivation and commitment to the control and prevention required from patients, health workers and the authorities is often a major factor.

Recent developments like SARS and avian flu have shown that infectious diseases can create global problems – from which the Netherlands is not immune. Hence, as well as being ready for developments we can expect, it is important to be alert to the possibility of unforeseen events. It can be crucial, for instance, to monitor any sudden increase in the incidence of an infectious disease as early as possible. There is also a need for flexible response systems, cooperation and information sharing among experts, nationally and internationally.

An aging population will need more and different care

One of the main driving forces shaping future developments in health and care is the demographic build-up of the population. In 2010, the first of the ‘baby boomers’ will reach the age of sixty-five. Thereafter, the ageing of the population will continue, until it is expected to peak in about 2040. Since health problems are more common among the elderly than among younger people, the total disease burden and therefore the demand for care will increase in line with the population ageing. Over the next twenty years, this phenomenon, combined with the effects of present day lifestyle choices and weight problems, will result in increases of 40% or more in some of the chronic illnesses associated with elder age. This will necessitate not only the provision of more care, but also different care, including a further shift from curative care to supportive care.

Demographic developments alone may be expected to necessitate a rise in the health care budget, from 57 billion euro in 2003 to nearly 70 billion euro by 2025. Of this increase, just less than 5 billion will result from population growth and 10 billion from changes in the composition of the population (primarily population ageing). These forecasts take no account of the impact of medical technological innovation or changing care demands by the public – factors which to date have had a larger impact than the demographic developments.

Insight into the quality of care

One of the main challenges facing the health care sector is to provide the government and other actors involved, plus the public, with a transparent picture of the quality of care. Health care performance can be measured in a variety of ways. There is increasing interest in performance indicators: statistics that provide insight into the quality of care and other aspects of the health care system, such as accessibility and affordability.

Health care performance assessment is a very dynamic field, and much is expected of it in the near future. However, many obstacles associated with the development and application of performance indicators remain to be overcome; for example, many of the data on which assessment might be based are neither standardized and comparable nor of sufficient quality, and the financial and administrative implications are considerable. Furthermore, the various participants involved tend to have radically different perspectives on performance and performance information and in some cases the expertise to develop indicators is lacking. Finally, performance indicators are not without their shortcomings. They will inevitably focus on particular aspects of a complex process. Much remains to be done before the indicators concept can be optimally applied for the assessment of performance within the Netherlands’ health care system in all its aspects. Nevertheless, it is certainly no longer acceptable not to measure performance.

Care expenditure and phase of life

Age-related patterns of illness in the course of life are reflected in the demand for care. Young and middle-aged people mainly require curative care, while the elderly tend to be increasingly dependent on nursing and supportive care. The cost of preventive activities is more evenly distributed, with vaccinations provided for the very young and programmatic initiatives for the elderly (figure 6).

The need for care is largest in the last year of life. But the amount of care required is age-related. Generally speaking, the older a person is when he or she dies, the lower the cost of care in the final year of life. This has implications for health care expenditure forecasting. As the population ages, the average age in the final year of life will be gradually higher, so the total lifetime cost of care provision will not rise as sharply as many people assume.

Nevertheless, improved public health is more likely to result in more spending on health care than less, since, as people live longer, they develop new care requirement. Simulation models suggest that, if everyone in the Netherlands stopped smoking immediately, the amount spent on medical care over a lifetime would rise by more than 6.5%. Similarly, if everyone maintained a healthy weight and exercised regularly, the lifetime care cost would increase by about 2%. However, in that case many healthy life years are gained.

Figure 6: Health care expenditure in the Netherlands in 2003, broken down by function and by recipient age and gender (Source: Slobbe et al., 2006).

Health care: expenditures but also much ‘production’ of health

An ageing population is not merely a cause of expenditure; first and foremost, it is a triumph of health care. Whereas in the second half of the nineteenth and in the early twentieth century the main factors behind improved public health were increased prosperity and improved public hygiene, nowadays enhanced diagnosis and treatment play an increasingly important role. The rates of mortality associated with infectious and cardiovascular disease in particular have been reduced considerably in recent decades, thanks to medical care and collective prevention. In the case of cancer that contribution has been smaller until now. Research conducted in other countries suggests that the provision of mental health care has substantially reduced the disease burden associated with mental disorders. It is estimated that, to date, the total effect of health care has increased overall life expectancy by 3 to 4 years since the 1950s. It is reasonable to conclude that health care has made a major contribution to the health of the Dutch population, particularly in recent times.

Since the 1980s, the healthy life expectancy has increased by six or seven years, despite the rise in prevalence of chronic illness. This is probably due to the positive influence of medical devices and technologies, such as hearing aids, prosthetic hips and cataract surgery. Chronically ill people suffer less from their disability or are more able to cope with it. Less restriction implies increased self-sufficiency, extended social participation and ultimately less dependence on long-term care.

As indicated in the (Dutch) Health Care Performance Report recently published by the RIVM, the Netherlands has a universally accessible care system, with a performance comparable with other European countries. Nevertheless, much could still be gained by effective prevention, chain care and improved patient safety.

Investment in care has a high return

Macro-economic analyses show that investing in health and care has a high return. Improved public health increases prosperity. It does so in the first place by facilitating economic growth. Health may therefore be regarded as a production factor, which enhances personal and communal prosperity by boosting productivity. Furthermore, health stimulates prosperity by serving as a tradable commodity. People attach considerable value to health, just as they do to material goods. A comparison has been made for the US situation, from which it was concluded that improvements in public health during the twentieth century have contributed as much to prosperity as the growth in personal consumption. Evaluated on this basis, investments in health and care may be considered to have a high economic return.