TY - JOUR

T1 - Why do some countries do better or worse in life expectancy relative to income?

T2 - An analysis of Brazil, Ethiopia, and the United States of America

AU - Freeman, T.

AU - Gesesew, H.A.

AU - Bambra, C.

AU - Giugliani, E.R.J.

AU - Popay, J.

AU - Sanders, D.

AU - Macinko, J.

AU - Musolino, C.

AU - Baum, F.

PY - 2020/11/10

Y1 - 2020/11/10

N2 - Background: While in general a country’s life expectancy increases with national income, some countries “punch above their weight”, while some “punch below their weight” – achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally. Methods: We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014–2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country. Results: Possible drivers identified for Ethiopia’s extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States’ neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight. Conclusions: The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities. © 2020, The Author(s).

AB - Background: While in general a country’s life expectancy increases with national income, some countries “punch above their weight”, while some “punch below their weight” – achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally. Methods: We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014–2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country. Results: Possible drivers identified for Ethiopia’s extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States’ neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight. Conclusions: The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities. © 2020, The Author(s).

KW - Civil society

KW - Life expectancy

KW - Policy

KW - Population health

KW - Social determinants of health

KW - civil society

KW - female education

KW - health care

KW - life expectancy

KW - political participation

KW - public health

KW - Brazil

KW - Ethiopia

KW - United States

U2 - 10.1186/s12939-020-01315-z

DO - 10.1186/s12939-020-01315-z

M3 - Journal article

VL - 19

JO - International Journal for Equity in Health

JF - International Journal for Equity in Health

SN - 1475-9276

IS - 1

M1 - 202

ER -