WHO has used healthy life expectancy (HALE)4as a summary measure of level of health that captures the full health experience of the population and not just mortality. HALE was used to assess, in the health system performance analysis published in The world health report 2000, the goal of improving average levels of population health. While there have been several similar composite measures of health in the past, the universal use of HALE – calculated centrally by means of standard methodology using internally consistent estimates of levels of health – is a major advance. HALE is designed to be sensitive to changes over time or
differences between countries in the overall health situation. Nevertheless, HALE based on self-reported health status information may not always be comparable across countries, owing to differences in survey instruments and methods, differences in expectations and norms for health, and cultural differences in reporting health. Internationally comparable measurements of self-reported health-related indicators in population surveys may be difficult, even when reliability and validity have already reached acceptable levels vis-à-vis each specific population.
For example, the meaning that different populations attach to response categories (such as “mild”, “moderate” or “severe”) in self-reported questions can vary.
4 HALE (previously DALE – disability-adjusted life expectancy) adds life expectancy (a composite measure of mortality, i.e. fatal outcome) to estimates of non-fatal outcomes, with adjustment for severity of the latter. It is most easily understood as the lifespan in full health, i.e. without disability. (See also Annex 1 and Annex 2, Table2.)
Fig. 8. Mortality from cancer of the cervix, 1970–1999
EU average CCEE average NIS average
Deaths per 100 000 females
Year
To improve the methodological and empirical basis for measuring population health, WHO has initiated a data collection strategy with Member States. This employs a standardized instrument, together with new statistical methods for adjusting self-reported health measures according to comparable scales. HALE estimates for 2000 for all countries are based on a mix of survey data for some countries (with its own uncertainty due to sampling and systematic biases) and analyses of disability prevalence in the Global Burden of Disease project,5which draws on a wide range of epidemiological and demographic data of varying degrees of uncertainty. The new methods used in the WHO Multi-country Household Survey Study6increase the comparability of self-reported data across countries and represent a major step forward in the use of self-reported data on health. Building on this experience, WHO is developing improved health status measurement techniques for a world health survey to be carried out in 2002.
Worldwide, HALE at birth in 2000 ranged from 39 years for African males and females to almost 66 years for females in the countries of western Europe. Regional HALE at age 60 in 2000 ranged from 8.3 years in Africa to around 16 years for females in Europe, North America and the WHO Western Pacific Region. In the WHO European Region (Fig. 9), HALE at birth in 2000 for males and females combined is 62.9 years, 9.0 years lower than total life expectancy at birth. HALE
Fig. 9. Health-adjusted life expectancy (HALE)
5 MURRAY, C.J.L. & LOPEZ, A.D., ED.The global burden of disease: a comprehensive assessment of mortality and disability, injuries, and risk factors in 1990 and projected to 2020. Boston, MA, Harvard School of Public Health, 1996.
6 ÜSTÜN, T.B. ET AL.WHO Multi-country Survey Study on Health and Responsiveness 2000–2001. Geneva, World Health Organization, 2001 (GPE Discussion Paper 37).
Upper quintile Second quintile Third quintile Fourth quintile Lower quintile No data
at birth for females is 5.9 years greater than that for males; in comparison, total life expectancy at birth is almost 8.2 years higher for females than for males. HALE at birth ranges from 50.3 years for Russian men to 72.2 years for women in the low-mortality countries of western Europe.
Most industrialized western European countries, with a HALE at birth of around 70 years (68 years for males and 72 years for females), are part of a group of countries led by Japan, where women had an estimated average HALE in 2000 of 76.3 years at birth. There is, however, a considerable range of uncertainty in the ranking of countries, with typical 95% uncertainty ranges of around 3 years for developed countries.
In the Russian Federation, HALE is 60.6 for females, 5 years below the European average, but just 50.3 years for males, 9.6 years below the European average. This is one of the widest gender gaps in the world and reflects the sharp increase in adult male mortality in the early 1990s. From 1987 to 1994, the risk of premature death increased by 70% for Russian males. Between 1994 and 1998, male life expectancy improved, but has declined significantly again in the last three years.
Similar rates exist for other countries of the former USSR.
While a lower life expectancy is generally associated with a lower HALE, there are large variations in HALE for any given level of life expectancy. For example, for countries with a life expectancy of 70 years, HALE varies from 57 to 61.5 years, a non-trivial variation. If male and female HALE are considered separately, the range of variation increases to 57–65 years for a total life expectancy of 70 years. These differences partially reflect variations in the impact of health promotion and prevention policies, as well as the levels of performance of the health systems in general.