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Policymakers relying too much on life expectancy in formulating health policy

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In September 2015, all member states of the United Nations made a commitment to collectively work toward achieving the Sustainable Development Goals (SDG) of the 2030 Agenda for Sustainable Development. Fueled by the near-universal support behind the goals and supported by data from large-scale projects like the Global Burden of Disease Study — backed by the Bill and Melinda Gates foundation — health care workers and providers, researchers, and policymakers from institutions around the world came together in an unprecedented collaborative effort to improve public health in the developing world.

While we have made great progress in addressing global health care issues, the first and arguably most important and lofty SDG — “End[ing] poverty in all its forms everywhere” — has hit a massive roadblock: Even in many of the countries where the most health care progress has been made, there have been few notable economic improvements. And new research may help to explain why.

{mosads}A study published earlier in July in the Lancet Global Health illuminates the discrepancies between improved health outcomes and economic wellbeing. The authors developed a new metric for population level measurements, called poverty-free life expectancy (PFLE). Designed to be used in tandem with standard life expectancy measurements, the PFLE incorporates the prevalence of poverty by age and sex from household economic surveys and combines these with mortality rates derived from data from the World Health Organization and the United Nations. The PFLE estimates the average number of poverty-free years a person is expected to live in each country and for each sex.


Ninety countries were analyzed using this novel tool, and researchers found the PFLE range differences between nations are larger than life expectancy range variances. For example, the lowest PFLE is in Malawi, where the average person is expected to live just 9.9 years above the poverty line, and the highest PFLE is in Iceland, where most people are expected to live their entire lives out of poverty — an average PFLE of 83.2 years. According to the study, countries in North America, Europe, and central Asia have the highest PFLE estimates. The lowest values were in sub-Saharan Africa.

Perhaps more striking is that for 67 of the 90 countries, the difference between life expectancy and PFLE was greater for females than males, which means that even though in many countries women live longer, they are more likely to live in poverty than their male counterparts.

The authors of the study argue that traditional benchmarks for health, especially life expectancy, fail to accurately capture societal improvements or problems, and that adding the PFLE to our understanding of global populations would allow policymakers to better consider the “broad consequences of decisions, policies and reforms.” Or, put more simply, if we improve some limited health outcomes and life expectancy, these achievements may be substantially mitigated by the fact that many people in developing countries continue to live in severe poverty.

This problem has important implications for policymakers and for the countries affected by global initiatives. Without using the right measurement for success, success is much more elusive — maybe even impossible.

Critics of the PFLE metric say these measurements do not take into account the heterogeneity in populations or poor quality of data, particularly data from low-income countries, where economic information is deficient. In a commentary published in the same issue of the Lancet Global Health, Dr. Vladimir Canudas Romo states that “the assessment of the PFLE results is complex and must be used cautiously so it does not mislead policy makers.”

Regardless of whether PFLE is the right way to quantify poverty in populations, all can agree that global poverty needs to be addressed aggressively and that policymakers, researchers, and others involved in global health need a multidisciplinary approach that will help them properly tackle health care from every angle, including the relationship between poverty and health. 

These issues have not gone unnoticed. Earlier in July, at the meeting of the High-Level Political Forum of Sustainable Development at the U.N. headquarters in New York, Maria Chatardová, president of the Economic and Social Council, commended the ongoing multinational efforts and but also delivered a grave reminder: a large proportion of the world’s population remains in extreme poverty, and not enough is being done to address this problem, which affects virtually every other aspect of life. “There is progress, but generally not at a sufficient speed to realize the SDGs by 2030,” she said.

And how could they be if policymakers aren’t using the right measures of success and failure? Before the global health care crisis can be solved, everyone involved needs to agree on better methods for evaluating progress, whether that be PFLE or another measure.

Jacquelyn Corley, M.D., (@JacquelynCorley) is a neurological surgery resident at Duke University Medical Center, a research fellow at Harvard’s Program for Global Surgery and Social Change, and a human rights journalist focusing on health-care-related topics.

Tags Global health Health economics life expectancy Public health

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