Recent demographic trends provide a useful basis from which to evaluate the performance of the health systems and needed reforms in Central Asia and Russia. In summary, the population of Central Asia is young, and likely to become younger in some countries. Even though fertility rates have recently declined, population growth remains high. In contrast, the Russian population is aging and has experienced an extraordinary drop in both crude birth rate and fertility, while significant return migration has had an even larger absolute impact on the population. Since 1989, mortality rates have tended to increase, and life expectancy has declined dramatically throughout the region (Klugman and Schieber, 1996). Most of Central Asia experienced significant population increases between 1989 and 1995, while all the Central Asian countries except Turkmenistan had a combination of high natural increase with outmigration.
It is clear, however, that these developments in Central Asia and Russia represent a rapid acceleration of trends that have been evident for several decades. Birth rates have been declining slowly since the 1960s. The flow of Russians and other nationalities into Central Asia began to reverse direction in the mid-1970s. Stagnation and then declines in life expectancy in Russia began in 1965.
Fertility, as measured by either the crude birth rate or the total fertility rate, has generally declined since 1989 (see Table 12-1). Total fertility rates in Central Asia are nonetheless still high relative to Russia (1.4) and Organization for Economic Cooperation and Development (OECD) countries (averaging 1.9). In 2015, Tajikistan, Turkmenistan, and Uzbekistan are still expected to have roughly the same skewed age structures they have today, with more than 40 percent of their populations below age 16 and less than one in ten people above working age.
The outmigration of Russians and other Slavic and European nationalities from Central Asia has had, and will continue to have, an enormous impact on the demographics of the region. The Russian population is older and more urbanized, with birth rates between one-third and one-half those of the titular nationalities and higher death rates, resulting in much lower rates of natural increase. This trend of differential natural growth rates is long-standing, but has become even more marked in recent years. In terms of nationality composition, the Central Asian countries can be classified into two groups: Kazakstan and Kyrgyz Republic with their much larger Russian populations (38 and 22 percent, respectively, in 1989) on the one hand, and the remaining three countries, each less than 10 percent Russian, on the other. Outmigration has played a much more important role in the former group. In Russia, with an overall positive inflow of people from other parts of the former Soviet Union, internal migration and the direction of flows of return migrants have affected the regional distribution of the population; in particular, there have been signifi-