Written by Vincent de Wit, Lead Health Specialist
The United Nation’s Millennium Development Goals (MDGs) program was a big success. It kept social development alive amidst a rush for infrastructure and growth. The United Nations is now spearheading a massive movement to define new goals up to 2040, with equity and sustainability as the central themes.
Recently, our colleague Susan Roth presented a conceptual framework of a proposed post 2015 framework linked to work being undertaken by ADB and some UN partners in Asia and the Pacific. One topic that caught my interest was that healthy life expectancy could be the new health goal.
Healthy life expectancy combined life expectancy and absence of morbidity and disability while alive. It would measure inequity as the poor still have shorter lives, and are more often ill. It would be relevant for more developed countries as it would measure mortality and morbidity due to so called “life style” related diseases relating to smoking, alcohol, obesity, lack of activity, and road traffic accidents; and in some countries, like in Russia, due to deteriorating health systems.
In several sub-saharan countries, life expectancy is half of what it could be without HIV. Its not only about money. Some rich countries have much lower life expectancy than some poorer ones. Mark Stibich tells us on About.com that the country with the lowest risk of premature death for men is Iceland, and for women Cyprus. And I always thought it was people living in the mountains because they exercise while walking, drink wine, and eat lots of fruits and nuts!
However, to measure healthy life expectancy is a bit tricky, needing substantial data. Life expectancy is easier but slower to change and less sensitive. Many developing countries have already reached quite a high life expectancy of 65 years or so. After that, life expectancy increases very slowly, up to a maximum of 85 years. So what drives healthy life expectancy?
For centuries, life expectancy remained at about 30-40 years, and even lower at times of epidemics, war and famine. However, those who survived early childhood had a good chance of reaching 50 years and more. It only started improving in the 1900 with the industrial revolution. Studies have shown that life expectancy increased rapidly when child mortality declined with the help of public health. However, when poor countries report a major improvement in life expectancy, this may also be in part due to reduced fertility, which changes the denominator.
The geographical distribution of life expectancy and fertility appear to be quite similar unlike for many other health and non-health indicators, including governance. So there is more going on, for example, reduced fertility results in better survival and education of the children that are born.
Reducing child mortality will hopefully remain a priority in low-income countries as part of the finished and unfinished business of MDGs, For these countries, healthy life expectancy actually captures well the improvements in basic health care, in particular for children, as it also captures malnutrition rates which are stll high and would have a major impact on this indicator unlike on indicators like child mortality or life expectancy. This is something for the experts to look into.
For countries that have achieved a life expectancy of 65 years, increasing healthy life expectancy may also be a useful indicator as it would reflect changes in life style in the medium term that expand or compress morbidity and disability due to chronic diseases. One question is whether countries can actually measure this in a standardized way.
Another question is to what extent governments can influence this indicator. Obesity, smoking and alcohol abuse are linked to many factors. Prevention of life style diseases is for a large part not within the control of the health sector, and will need a fully multisectoral approach including making our cities more livable, regulation of the food industry, and support of the media. Within the health sector, advanced medical technology is becoming increasingly available that can push life expectancy beyond 85 years, but at an initially very high cost. Evidently, improving healthy life expectancy will not be easy, and require multiple policy choices to be made.