2.1. Introduction

This Chapter deals with a number of demographic, socio-economic, environmental, scientific, technological and institutional developments and their trends that occurred with large regional variations in the European Community and Union during the last decades of the 20th Century and the first years of the 21^st Century, resulting in major changes of the context in which citizens health has been and will be pursued. These developments had fundamental effects on society, on population size and ageing, family structure, labour market population and minority populations. For example, currently the EU is characterized by low and late fertility, as well as by low and late mortality. Most EU citizens still opt for marriage, although increasingly after a period of non-marital cohabitation. The age at marriage is high in some countries, even after a child is born. Divorce has become kind of normal, but the majority of marriages still end with death. Households are small, also as an effect of population ageing. One person households have become ‘popular’. Moreover, the EU has turned into an immigration continent. These processes started, roughly spoken, in the Northern part of the EU, ‘travelled’ to the Western, and then to the Southern part. After the fall of the Berlin wall, also the Eastern parts ‘adopted’ similar patterns together with the change to a free market economy.

The other fundamental character dominating the world scene is globalization that has substantially changed travel and trade, facilitating contacts and exchanges among parts of the world that were previously isolated. Globalization has increased travel, especially by air, connecting in hours extremes of the world with their different social environments and microbiological ecosystems. Globalisation of trade in food and animals has broadened human exposure to a variety of micro-organisms and made the prevention and control of zoonoses and food borne diseases much more difficult.

At the same time, the national health policies and services of European countries have evolved to meet the growing challenges and health needs; the European (Economic) Community and, then, the European Union were established to provide the opportunity of a new institutional and collaborative context in order to promote health and well being of the European population. Social policies, renowned for their major impact on health outcomes, have become more and more necessary. Interventions need to adopt a health-in-all policies approach. Social protection should ensure access for all to quality healthcare and long-term care and promote prevention, including for those most difficult to reach. A major challenge is how to ensure access for all to technological progress while ensuring sustainability.

While the increasing demand of health implies higher and higher investments, it is very important to keep in mind that health is not only a cost for Society, but may largely contribute to economic outcomes in high-income countries such as the EU Member States through four main channels: (i) higher productivity; (ii) higher labour supply;(iii) improved skills as a result of greater education and training; and (iv) increased savings available for investments in physical and intellectual capital. There is a significant amount of evidence to support the economic importance of health in the labour market in rich countries, while country-level historical studies exploring the role of health in a specific country over one or two centuries have shown that a large share of today’s economic wealth is directly attributable to past achievements in health. In addition to the direct effect of health on economy, there is also an impact of the health system on the economy irrespective of the ways in which the health system affects health. As one of the larger service industries, health represents one of the most important sectors in developed economies, with a current output of about 7% of GDP in the EU15, larger in EU15 than the roughly 5% accounted for by the financial services or the retail trade sector. Around 9% of all workers in the EU25 are employed in the health and social work sector. Moreover, the performance of the health sector will affect the competitiveness of the overall economy via its effects on labour costs, labour market flexibility and the allocation of resources at macroeconomic level (Figure 2.1).

The analysis of the underlying factors which deeply influence the context in which interventions and actions to preserve and improve health take place in the EU is important to understand the existing challenges and constraints. There are several features and trends to be taken into account when addressing the background conditions underlying health developments in the EU. They are considered to be useful background information to help the understanding of the analyses developed in subsequent chapters.