Ritu Sadana

Healthy life expectancy in 191 countries, 1999

We describe here the methods used to produce the first estimates of healthy life expectancy (DALE) for 191 countries in 1999. These were based on estimates of the incidence, prevalence, and disability distributions for 109 disease and injury causes by age group, sex, and region of the world, and an analysis of 60 representative health surveys across the world. We used Sullivans method to compute healthy life expectancy for men and women in each WHO member country. Japan had the highest average healthy life expectancy of 74.5 years at birth in 1999. The bottom ten countries are all in sub-Saharan Africa, where the HIV-AIDS epidemic is most prevalent, resulting in DALE at birth of less than 35 years. Years of healthy life lost due to disability represent 18% of total life expectancy in the bottom countries, and decreases to around 8% in the countries with the highest healthy life expectancies. Globally, the male-female gap is lower for DALE than for total life expectancy. Healthy life expectancy increases across countries at a faster rate than total life expectancy, suggesting that reductions in mortality are accompanied by reductions in disability. Although women live longer, they spend a greater amount of time with disability. As average levels of health expenditure per capita increase, healthy life expectancy increases at a greater rate than total life expectancy.

Healthy life expectancy: comparison of OECD countries in 2001

Objectives: To compare average levels of population health for Australia and other OECD countries in 2001.

Knowledge for better health: a conceptual framework and foundation for health research systems

Health research generates knowledge that can be utilized to improve health system performance and, ultimately, health and health equity. We propose a conceptual framework for health research systems (HRSs) that defines their boundaries, components, goals, and functions. The framework adopts a systems perspective towards HRSs and serves as a foundation for constructing a practical approach to describe and analyse HRSs. The analysis of HRSs should, in turn, provide a better understanding of how research contributes to gains in health and health equity. In this framework, the intrinsic goals of the HRS are the advancement of scientific knowledge and the utilization of knowledge to improve health and health equity. Its four principal functions are stewardship, financing, creating and sustaining resources, and producing and using research. The framework, as it is applied in consultation with countries, will provide countries and donor agencies with relevant inputs to policies and strategies for strengthening HRSs and using knowledge for better health.

The World report on ageing and health: a policy framework for healthy ageing

Although populations around the world are rapidly ageing, evidence that increasing longevity is being accompanied by an extended period of good health is scarce. A coherent and focused public health response that spans multiple sectors and stakeholders is urgently needed. To guide this global response, WHO has released the first World report on ageing and health, reviewing current knowledge and gaps and providing a public health framework for action. The report is built around a redefinition of healthy ageing that centres on the notion of functional ability: the combination of the intrinsic capacity of the individual, relevant environmental characteristics, and the interactions between the individual and these characteristics. This Health Policy highlights key findings and recommendations from the report.

Addressing social determinants of health inequities: what can the state and civil society do?

In this Health Policy article, we selected and reviewed evidence synthesised by nine knowledge networks established by WHO to support the Commission on the Social Determinants of Health. We have indicated the part that national governments and civil society can play in reducing health inequity. Government action can take three forms: (1) as provider or guarantor of human rights and essential services; (2) as facilitator of policy frameworks that provide the basis for equitable health improvement; and (3) as gatherer and monitor of data about their populations in ways that generate health information about mortality and morbidity and data about health equity. We use examples from the knowledge networks to illustrate some of the options governments have in fulfilling this role. Civil society takes many forms: here, we have used examples of community groups and social movements. Governments and civil society can have important positive roles in addressing health inequity if political will exists.

Priorities for research on equity and health: towards an equity-focused health research agenda.

Piroska Östlin and colleagues argue that a paradigm shift is needed to keep the focus on health equity within the social determinants of health research agenda.

Importance of health research in South Asia

South Asian countries face similar health problems and would benefit from collaboration in health research Research is essential to guide improvements in health systems and develop new initiatives.1 South Asia has a quarter of the worlds population, weak public sector health care, and a staggering disease burden, and thus research is particularly important. Although investment has increased in infrastructure for health research over the past decade, gaps remain in evidence to guide reduction of important problems such as communicable diseases, maternal and perinatal conditions, childhood diseases, and nutritional deficiencies.2 Furthermore, even when technical knowledge is available, political commitment, managerial competencies, and incentives for changing behaviour within health systems are often lacking.3–5 Despite diversity in their geographical, linguistic, and political structures, Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka face common health challenges. Most bear a triple burden of persisting infectious diseases, increasing chronic conditions, and a growing recognition of injuries and violence. Incomplete demographic transitions, HIV and AIDS, massive unplanned urbanisation, and a host of social determinants of health compound these problems.6 Another common characteristic is that national estimates of health mask large variations within countries (fig 1).7 8 Fig 1 Life expectancy and healthy life expectancy by gross domestic product per capita9 Health systems across the region also have to confront challenges such as a lack of evidence based policies and limited social accountability. With no or limited national health insurance schemes and the large role of the private sector, individuals face high out of pocket payments on top of other economic and social consequences of ill health (fig 2).10 In many countries, the devolution of financial responsibility for health services has outpaced capacity and decision making authority, contributing to fragmentation of policies and services.11 Striking …

Measuring reproductive health: review of community-based approaches to assessing morbidity

This article begins by reviewing selected past approaches to estimating the prevalence of a range of morbidities through the use of household or community-based interview surveys in developed and developing countries. Subsequently, it reviews epidemiological studies that have used a range of methods to estimate the prevalence of reproductive morbidities. A detailed review of recent community or hospital based health interview validation studies that compare self-reported, clinical and laboratory measures is presented. Studies from Bangladesh, Bolivia, China, Egypt, India, Indonesia, Nigeria, Philippines and Turkey provide empirical evidence that self-reported morbidity and observed morbidity measure different phenomena and therefore different aspects of reproductive health and illness. Rather than estimating the prevalence of morbidity, interview-based surveys may provide useful information about the disability or burden associated with reproductive health and illness.

Problems and progress in public health education

Further development of public health education is critical to improve population health globally. A debate on the relevance and direction of some 400 schools of public health and many other related institutions around the world is therefore timely. Some argue that most public health schools set up in low-income countries blindly follow their counterparts in high-income countries, reproducing classroom-based teaching, churning out epidemiologists with limited understanding of how to work within a health system to address local needs or how to align multiple partners towards population and equity health objectives. Others argue that schools in high-income countries focus on the science, whereas those in low-income countries plagued with resource constraints focus exclusively on the art. This round table discussion asks deans and directors of schools of public health from around the world to identify innovations in public health training, research and practice that will render schools relevant to health and development challenges.

What Can Public Health Programs Do to Improve Health Equity

Ritu Sadana, ScDa Erik Blas, DrPHb Health inequalities are disparities in health, reflecting either differences in access to a range of promotional, preventive, curative, or palliative health services or differences in outcomes including disability, morbidity, and mortality spanning physical, mental, and social health. The causes of inequalities in health are dynamic and reflect multiple determinants. Health inequities, however, are differences in health that are judged to be avoidable, unfair, and unjust.1 Health inequities are often revealed through systematic patterns or gradients in access or outcomes across populations with different levels of underlying social advantage or disadvantage—that is, wealth, power, prestige, or other markers of social stratification.2 Numerous reviews across low-, middle-, and high-income countries continue to document that health inequalities are related not only to biological or genetic factors, but also to social factors that are amenable to policy and are potentially avoidable given cross-group or cross-population comparisons. Studies most often document differential access to health services based on an individual’s socioeconomic position or place of residence, rather than on need,3–6 although other approaches exist.7 The place in the social hierarchy that individuals and groups occupy, combined with the epidemiological environment, then determines exposure and vulnerability to health-enhancing or health-damaging conditions in daily life (e.g., where people are born, grow, live, work, and age).8 The underlying causes are complex, often reflecting systematic social, political, historical, economic, and environmental factors that also interface with biological factors. The term “social determinants” is often used as shorthand for all of these factors and is relevant to communicable and non-communicable conditions alike.9 An added complexity is that negative or positive impacts of social determinants of health (SDH) can be accumulated during a lifetime, alter health trajectories across the life course, and be transferred across generations.10 Moreover, labeling an inequality as an inequity also reflects a value judgment. This labeling is sometimes made explicit by deliberating on facts, clarifying underlying values, and designing remedial actions. Often, however, there is no