522555 research-article2014
SJP0010.1177/1403494814522555Brønnum-HansenShort Title
Scandinavian Journal of Public Health, 2014; 42: 242–244
Short Communication
Ranking health between countries in international comparisons
Henrik Brønnum-Hansen Department of Public Health, University of Copenhagen, Copenhagen, Denmark
Abstract Cross-national comparisons and ranking of summary measures of population health sometimes give rise to inconsistent and diverging conclusions. In order to minimise confusion, international comparative studies ought to be based on wellharmonised data with common standards of definitions and documentation. Calculation methods and results should be communicated clearly and exactly. Key Words: Cross-national comparisons, ranking, summary measures of population health
International comparisons and ranking of countries is a popular endeavour in public health research and great efforts are made to harmonise data. Comparisons by use of summary measures of population health and other health-related indicators could be useful in order to learn from one another and help to put policy making on right track. From time to time, studies comparing health state in several counties are published and the results often have high impact in public media because health issues attract journalistic and political attention. Therefore, it is important that science-based communication is consistent and that diverging and confusing results are minimised. Several composite measures that combine mortality and morbidity or health-related quality of life have been developed and increasingly used in public health. The concept of health expectancy extent the life expectancy indicator by dividing this into years lived in different health states [1]. Healthy life years (HLYs) is one such measure of expected lifetime without activity limitation due to health problems [2]. Healthy life expectancy (HALE) is another concept akin to HLY that estimates average lifetime to be spent in full health [3]. HALE used to rest on health economic traditions and covers related measures that all seek to produce a generic health indicator.
One result that arose from the new Global Burden of Disease (GBD) study published recently in the Lancet ranked Denmark in the next lowest position along with USA with regard to HALE and only exceeded Finland among the 19 countries included in the study [4]. HALE was estimated on the basis of disability weights generated with data from population-based surveys covering populations from different parts of the world [4]. In 2008, the same journal published a study showing a top position for Denmark when comparing 25 European countries with regard to HLYs at age 50 [5]. Both studies were highlighted in Danish and international media and the conclusions were debated in Denmark in newspapers and television. But obviously the opposite positions of Denmark in these comparative studies could hardly both be true. The sensational position for Denmark in the HLY study by Jagger and colleagues [5] was discussed in a short communication in Scandinavian Journal of Public Health [6] as the Lancet refused to publish it. The analysis regarding HLY was based on the global activity limitation question derived from the Minimum European Health Module, which was included in the EU Survey on Income and Living Condition (EU-SILC) [5]. The top position of Denmark was caused by insufficiently harmonised
Correspondence: Henrik Brønnum-Hansen, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark. E-mail: [email protected] (Accepted 10 January 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814522555
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Ranking health between countries 243 Table I. Life expectancy and healthy life expectancy at birth in 2010 for both sexes combined: Global Burden of Disease study. LE
HALE
Health proportion (HALE/LE)
Country
Years
Rank
Country
Years
Rank
Country
%
Rank
Australia Italy Sweden Spain France Norway Canada Austria Netherlands Germany Luxembourg Finland Ireland UK Greece Belgium Portugal Denmark USA
81.5 81.5 81.4 81.4 80.9 80.8 80.6 80.6 80.6 80.2 80.2 80.1 79.9 79.9 79.6 79.5 79.4 78.9 78.2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Spain Italy Australia Sweden Canada France Austria Netherlands Germany Ireland Greece UK Portugal Belgium Luxembourg Norway USA Denmark Finland
70.9 70.2 70.1 69.6 69.6 69.5 69.1 69.1 69.0 68.9 68.7 68.6 68.6 68.5 68.4 68.0 67.9 67.9 67.3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Spain USA Portugal Canada Greece Ireland Belgium Italy Denmark Germany Australia France UK Austria Netherlands Sweden Luxembourg Norway Finland
87.10 86.83 86.40 86.35 86.31 86.23 86.16 86.13 86.06 86.03 86.01 85.91 85.86 85.73 85.73 85.50 85.29 84.16 84.02
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
HALE: healthy life expectancy; LE: life expectancy. Source: Table 1 in Murray et al. [4].
SILC surveys as regards wording of questions, number of response categories, data collection methods, etc. [6]. The global activity limitation question was ‘For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do?’ However, in the Danish SILC the question was divided into two parts and only participants who reported a long-standing illness were subsequently asked ‘Have you been hampered in your daily activities by this chronic problem or by other health-related problems for longer time-periods within the past 6 months?’ Denmark used only two response categories (yes; no) whereas three levels were used in all other countries (severely limited; limited but not severely; none). Since the HLY paper was published, the harmonisation of the SILC surveys has improved. In particular the Danish SILC survey was revised to better fit the standard of other European SILC surveys. The HLY rank in 2009 of Denmark has changed to a more reasonable sixth highest position among 27 European countries [7]. Until the mid-1990s, life expectancy in Denmark has stagnated for a long time and the Danish life expectancy still lags behind that of many other comparable countries. When low life expectancy is divided into HLYs and unhealthy life years (ULYs), then HLYs and ULYs will, eo ipso, be low too. This is accounted for by measuring the proportion of HLYs estimated by dividing HLYs with life expectancy. Therefore, the proportion of HLYs would rank
Denmark in a more favourable position than measured in terms of absolute HLYs. In the study of Murray et al [4] the Danish rank in 2010 was 18 measured by life expectancy and, thus, it comes as no surprise that the absolute number of life years in a healthy state (i.e. HALE) was low too. By relating HALE to life expectancy, the rank of Denmark moves from 18 to 9, as shown in Table I. The conclusion for Denmark is that the Danish population could not be said to rank highest or almost lowest with regard to expected lifetime in good health but rather in a middle position. Still, the rank as to life expectancy is low compared to many other countries. The European Health and Life Expectancy Information System (EHLEIS) team recently conducted a study with results for 2010 and compared HLYs between 27 European countries [8]. The results from this study and the GBD study [4] ranked health expectancy among the 15 countries that were included in both studies markedly different (Table II). For instance, the HALE rank for Germany was 7 but the HLY rank was 15. Luxembourg had a HALE rank of 13 and a HLY rank of 4. The HALE and HLY ranks for Denmark were 14 and 10 respectively. In fact, the HALE and HLY ranks differed by less than 5 for only six out of the 15 countries (Figure 1). Although the definition of health states is ambiguous and the concepts of HLY and HALE are not coextensive, it is hard to accept that the marked discrepancies between the results of the studies could
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244 Brønnum-Hansen Table II. Healthy life expectancy (GBD study) and healthy life years at birth (EHLEIS study) in 2010 in 15 European countries for both sexes combined. HALE
HLY
Country
Years
Rank
Years
Rank
Spain Italy Sweden France Austria Netherlands Germany Ireland Greece UK Portugal Belgium Luxembourg Denmark Finland
70.9 70.2 69.6 69.5 69.1 69.1 69.0 68.9 68.7 68.6 68.6 68.5 68.4 67.9 67.3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
63.3 62.4 69.7 62.6 59.5 61.2 57.3 64.1 66.4 65.5 57.9 64.5 65.0 61.3 58.6
7 9 1 8 12 11 15 6 2 3 14 5 4 10 13
HLY rank
Sources: Table 1 in Murray et al. [4] and Tables 1 and 2 in Jagger et al. [8].
16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
Portugal
Astria
Finland
Netherlands Denmark Italy France
Ireland Belgium UK
Sweden
0
1
2
3
4
Luxembourg
Greece
5
6
7
8
Conflict of interest There is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References
Germany
Spain
or less diverging results. The main reason for the problem is rather a matter of poorly harmonised data and the question is whether it is wise to publish international comparisons based on incomparable data. Common standards for documentation, sharing of data, and transparency of choice of statistical techniques are needed [9]. Lessons learnt from the GBD and HLY studies are that it is very hard to establish harmonised and cross-national comparable data on health and that using the same names for different summary measures of population health is confusing for the general public. Definitions/descriptions of summary measures of population health should be communicated clearly and exactly.
9 10 11 12 13 14 15 16
HALE rank
Figure 1. Ranking of 15 European countries according to healthy life expectancy (HALE) and healthy life years (HLY). Source: Table 1 in Murray et al. [4] and Tables 1 and 2 in Jagger et al. [8].
simply reflect differences in goals or research questions. Despite different underlying principles for estimating HALE and HLY (the estimation of HALE is less transparent than the calculation of HLY), methodological differences should not end up with more
[1]
Jagger C and Robine JM. Healthy life expectancy. In: Rogers RG and Crimmins EM, eds, International handbook of adult mortality, International Handbooks of Population 2. Dordrecht: Springer, 2011. pp551–68. [2] Robine JM, Cambois E, Nusselder W, et al. The joint action on healthy life years (JA: EHLEIS). Arch Public Health 2013;71:2. [3] Mullahy J. Live long, live well: quantifying the health of heterogeneous populations. Health Econ 2001;10:429–40. [4] Murray CJL, Richards MA, Newton JN, et al. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet 2013;381:997–1020. [5] Jagger C, Gillies C, Moscone F, et al. Inequalities in healthy life years in the 25 countries of the European Union in 2005: a cross-national meta-regression analysis. Lancet 2008;372:2124–31. [6] Ekholm O and Brønnum-Hansen H. Cross-national comparisons of non-harmonized indicators may lead to more confusion than clarification. Scand J Public Health 2009;37:661–3. [7] Health expectancy in Denmark, EHEMU country reports, issue 5. Advanced research on European health expectancy (eurohex) Available at: http://maryland.mri.cnrs.fr/ehleis/ pdf/CountryReports_Issue5/Denmark_Issue%205.pdf 2012 (accessed January 2014). [8] Jagger C, McKee M, Christensen K, et al. Mind the gap – reaching the European target of a 2-year increase in healthy life years in the next decade. Eur J Public Health 2013;23:829–33. [9] Chan M. From new estimates to better data. Lancet 2012;380:2054.
Downloaded from sjp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on February 26, 2015
SJP0010.1177/1403494814522555Brønnum-HansenShort Title
Scandinavian Journal of Public Health, 2014; 42: 242–244
Short Communication
Ranking health between countries in international comparisons
Henrik Brønnum-Hansen Department of Public Health, University of Copenhagen, Copenhagen, Denmark
Abstract Cross-national comparisons and ranking of summary measures of population health sometimes give rise to inconsistent and diverging conclusions. In order to minimise confusion, international comparative studies ought to be based on wellharmonised data with common standards of definitions and documentation. Calculation methods and results should be communicated clearly and exactly. Key Words: Cross-national comparisons, ranking, summary measures of population health
International comparisons and ranking of countries is a popular endeavour in public health research and great efforts are made to harmonise data. Comparisons by use of summary measures of population health and other health-related indicators could be useful in order to learn from one another and help to put policy making on right track. From time to time, studies comparing health state in several counties are published and the results often have high impact in public media because health issues attract journalistic and political attention. Therefore, it is important that science-based communication is consistent and that diverging and confusing results are minimised. Several composite measures that combine mortality and morbidity or health-related quality of life have been developed and increasingly used in public health. The concept of health expectancy extent the life expectancy indicator by dividing this into years lived in different health states [1]. Healthy life years (HLYs) is one such measure of expected lifetime without activity limitation due to health problems [2]. Healthy life expectancy (HALE) is another concept akin to HLY that estimates average lifetime to be spent in full health [3]. HALE used to rest on health economic traditions and covers related measures that all seek to produce a generic health indicator.
One result that arose from the new Global Burden of Disease (GBD) study published recently in the Lancet ranked Denmark in the next lowest position along with USA with regard to HALE and only exceeded Finland among the 19 countries included in the study [4]. HALE was estimated on the basis of disability weights generated with data from population-based surveys covering populations from different parts of the world [4]. In 2008, the same journal published a study showing a top position for Denmark when comparing 25 European countries with regard to HLYs at age 50 [5]. Both studies were highlighted in Danish and international media and the conclusions were debated in Denmark in newspapers and television. But obviously the opposite positions of Denmark in these comparative studies could hardly both be true. The sensational position for Denmark in the HLY study by Jagger and colleagues [5] was discussed in a short communication in Scandinavian Journal of Public Health [6] as the Lancet refused to publish it. The analysis regarding HLY was based on the global activity limitation question derived from the Minimum European Health Module, which was included in the EU Survey on Income and Living Condition (EU-SILC) [5]. The top position of Denmark was caused by insufficiently harmonised
Correspondence: Henrik Brønnum-Hansen, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark. E-mail: [email protected] (Accepted 10 January 2014) © 2014 the Nordic Societies of Public Health DOI: 10.1177/1403494814522555
Downloaded from sjp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on February 26, 2015
Ranking health between countries 243 Table I. Life expectancy and healthy life expectancy at birth in 2010 for both sexes combined: Global Burden of Disease study. LE
HALE
Health proportion (HALE/LE)
Country
Years
Rank
Country
Years
Rank
Country
%
Rank
Australia Italy Sweden Spain France Norway Canada Austria Netherlands Germany Luxembourg Finland Ireland UK Greece Belgium Portugal Denmark USA
81.5 81.5 81.4 81.4 80.9 80.8 80.6 80.6 80.6 80.2 80.2 80.1 79.9 79.9 79.6 79.5 79.4 78.9 78.2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Spain Italy Australia Sweden Canada France Austria Netherlands Germany Ireland Greece UK Portugal Belgium Luxembourg Norway USA Denmark Finland
70.9 70.2 70.1 69.6 69.6 69.5 69.1 69.1 69.0 68.9 68.7 68.6 68.6 68.5 68.4 68.0 67.9 67.9 67.3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Spain USA Portugal Canada Greece Ireland Belgium Italy Denmark Germany Australia France UK Austria Netherlands Sweden Luxembourg Norway Finland
87.10 86.83 86.40 86.35 86.31 86.23 86.16 86.13 86.06 86.03 86.01 85.91 85.86 85.73 85.73 85.50 85.29 84.16 84.02
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
HALE: healthy life expectancy; LE: life expectancy. Source: Table 1 in Murray et al. [4].
SILC surveys as regards wording of questions, number of response categories, data collection methods, etc. [6]. The global activity limitation question was ‘For at least the past 6 months, to what extent have you been limited because of a health problem in activities people usually do?’ However, in the Danish SILC the question was divided into two parts and only participants who reported a long-standing illness were subsequently asked ‘Have you been hampered in your daily activities by this chronic problem or by other health-related problems for longer time-periods within the past 6 months?’ Denmark used only two response categories (yes; no) whereas three levels were used in all other countries (severely limited; limited but not severely; none). Since the HLY paper was published, the harmonisation of the SILC surveys has improved. In particular the Danish SILC survey was revised to better fit the standard of other European SILC surveys. The HLY rank in 2009 of Denmark has changed to a more reasonable sixth highest position among 27 European countries [7]. Until the mid-1990s, life expectancy in Denmark has stagnated for a long time and the Danish life expectancy still lags behind that of many other comparable countries. When low life expectancy is divided into HLYs and unhealthy life years (ULYs), then HLYs and ULYs will, eo ipso, be low too. This is accounted for by measuring the proportion of HLYs estimated by dividing HLYs with life expectancy. Therefore, the proportion of HLYs would rank
Denmark in a more favourable position than measured in terms of absolute HLYs. In the study of Murray et al [4] the Danish rank in 2010 was 18 measured by life expectancy and, thus, it comes as no surprise that the absolute number of life years in a healthy state (i.e. HALE) was low too. By relating HALE to life expectancy, the rank of Denmark moves from 18 to 9, as shown in Table I. The conclusion for Denmark is that the Danish population could not be said to rank highest or almost lowest with regard to expected lifetime in good health but rather in a middle position. Still, the rank as to life expectancy is low compared to many other countries. The European Health and Life Expectancy Information System (EHLEIS) team recently conducted a study with results for 2010 and compared HLYs between 27 European countries [8]. The results from this study and the GBD study [4] ranked health expectancy among the 15 countries that were included in both studies markedly different (Table II). For instance, the HALE rank for Germany was 7 but the HLY rank was 15. Luxembourg had a HALE rank of 13 and a HLY rank of 4. The HALE and HLY ranks for Denmark were 14 and 10 respectively. In fact, the HALE and HLY ranks differed by less than 5 for only six out of the 15 countries (Figure 1). Although the definition of health states is ambiguous and the concepts of HLY and HALE are not coextensive, it is hard to accept that the marked discrepancies between the results of the studies could
Downloaded from sjp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on February 26, 2015
244 Brønnum-Hansen Table II. Healthy life expectancy (GBD study) and healthy life years at birth (EHLEIS study) in 2010 in 15 European countries for both sexes combined. HALE
HLY
Country
Years
Rank
Years
Rank
Spain Italy Sweden France Austria Netherlands Germany Ireland Greece UK Portugal Belgium Luxembourg Denmark Finland
70.9 70.2 69.6 69.5 69.1 69.1 69.0 68.9 68.7 68.6 68.6 68.5 68.4 67.9 67.3
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
63.3 62.4 69.7 62.6 59.5 61.2 57.3 64.1 66.4 65.5 57.9 64.5 65.0 61.3 58.6
7 9 1 8 12 11 15 6 2 3 14 5 4 10 13
HLY rank
Sources: Table 1 in Murray et al. [4] and Tables 1 and 2 in Jagger et al. [8].
16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0
Portugal
Astria
Finland
Netherlands Denmark Italy France
Ireland Belgium UK
Sweden
0
1
2
3
4
Luxembourg
Greece
5
6
7
8
Conflict of interest There is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial, or not-forprofit sectors. References
Germany
Spain
or less diverging results. The main reason for the problem is rather a matter of poorly harmonised data and the question is whether it is wise to publish international comparisons based on incomparable data. Common standards for documentation, sharing of data, and transparency of choice of statistical techniques are needed [9]. Lessons learnt from the GBD and HLY studies are that it is very hard to establish harmonised and cross-national comparable data on health and that using the same names for different summary measures of population health is confusing for the general public. Definitions/descriptions of summary measures of population health should be communicated clearly and exactly.
9 10 11 12 13 14 15 16
HALE rank
Figure 1. Ranking of 15 European countries according to healthy life expectancy (HALE) and healthy life years (HLY). Source: Table 1 in Murray et al. [4] and Tables 1 and 2 in Jagger et al. [8].
simply reflect differences in goals or research questions. Despite different underlying principles for estimating HALE and HLY (the estimation of HALE is less transparent than the calculation of HLY), methodological differences should not end up with more
[1]
Jagger C and Robine JM. Healthy life expectancy. In: Rogers RG and Crimmins EM, eds, International handbook of adult mortality, International Handbooks of Population 2. Dordrecht: Springer, 2011. pp551–68. [2] Robine JM, Cambois E, Nusselder W, et al. The joint action on healthy life years (JA: EHLEIS). Arch Public Health 2013;71:2. [3] Mullahy J. Live long, live well: quantifying the health of heterogeneous populations. Health Econ 2001;10:429–40. [4] Murray CJL, Richards MA, Newton JN, et al. UK health performance: findings of the Global Burden of Disease Study 2010. Lancet 2013;381:997–1020. [5] Jagger C, Gillies C, Moscone F, et al. Inequalities in healthy life years in the 25 countries of the European Union in 2005: a cross-national meta-regression analysis. Lancet 2008;372:2124–31. [6] Ekholm O and Brønnum-Hansen H. Cross-national comparisons of non-harmonized indicators may lead to more confusion than clarification. Scand J Public Health 2009;37:661–3. [7] Health expectancy in Denmark, EHEMU country reports, issue 5. Advanced research on European health expectancy (eurohex) Available at: http://maryland.mri.cnrs.fr/ehleis/ pdf/CountryReports_Issue5/Denmark_Issue%205.pdf 2012 (accessed January 2014). [8] Jagger C, McKee M, Christensen K, et al. Mind the gap – reaching the European target of a 2-year increase in healthy life years in the next decade. Eur J Public Health 2013;23:829–33. [9] Chan M. From new estimates to better data. Lancet 2012;380:2054.
Downloaded from sjp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on February 26, 2015
