4.1. Life expectancy and healthy life years

 

In 1980, male life expectancy was around 70 years as compared to the current rate of about 75. For women the increase was from 77 to 81. The figures are somewhat higher in the EU15 than in the EU27, due to the fact that new Member States countries have much lower life expectancies, showing for males even some drops over the 1980-2005 period. Here males had in 1980, on average, about 67 years to live and currently around 70, while females had 75 and 78 respectively. These figures indicate that the sex difference in life duration is much larger in the 12 new Member States (8 years) than elsewhere in the EU (6 to 7 years). For the future, a further rise in life expectancy is expected.

Whether the extra years of life gained during the last decade are being spent in good or bad health is a crucial question both for individual EU Member States (MS) and the EU as a whole. Over a long period of time, increases in life expectancy at birth (LE₀) were used to infer improvements in the health of populations. This was a plausible assumption whilst infectious diseases represented the main cause of death. As they were replaced by chronic diseases, the risk of becoming ill was not solely linked to the risk of dying but also to the risk of surviving many years with functional restrictions and activity limitations (Riley, 1990). These changes led to the development of indicators of health expectancies, such as disability-free life expectancy (DFLE). These indicators represent the increasing focus on one’s quality of life (life spent in a healthy status) rather than, as previously, on the quantity (life expectancy) by dividing life expectancy into life spent in various states of good and bad health (Robine, Jagger and Euro-REVES, 2003; Robine et al, 2003).

 

Following the adoption of the Lisbon Strategy by the European Council, which, among others, set the target that the employment rate for older workers should reach 50% by 2010, the European Commission introduced in 2004, under the name of “Healthy Life Years” (HLY), a health expectancy indicator among the Structural Indicators. HLY is the first EU Structural Indicator on health and in its 2005 annual report to the Spring European Council, the Commission emphasised that increasing Healthy Life Years is crucial in increasing the employment rate of older workers and in attracting people into employment (Commission of the European Communities, 2005).

 

However, the significant differences in longevity observed across the EU and between genders justifies the importance that is attached to the continued inclusion of life expectancy at birth (and at age 50 and 65) as key health indicators for the EU27 in addition to the new HLY. Moreover, essential information in terms of quality of life is provided by the ratio HLY to LE which measures the proportion of life expectancy lived in good health.

 

In this chapter we present the first HLY estimates for the EU25, review the trends in life expectancy at birth and at 65 in the EU27and the trends in DFLE for the EU15. moreover, we will debate the differences between genders and the interrelationships between life expectancy and HLY as the preliminary means of determining whether longer life implies better health.

 

All calculations where performed online through the European Health Expectancy Monitoring Unit (EHEMU) Information System and are available on the EHEMU website.1 Life expectancy estimates for 2005 were computed using the current EUROSTAT algorithm, and MS death counts and population estimates from the EUROSTAT database,2 except for France and Italy where death counts were unavailable and thus were directly collected at INSEE and ISTAT, respectively. HLY estimates for the EU25 in 2005 were computed with an algorithm developed by EUROSTAT in collaboration with EHEMU3 using the Statistics of Income and Living Conditions (SILC 2005).

 

SILC contains the Minimum European Health Module (MEHM) which was devised by the Euro-REVES group (Robine, Jagger and Euro-REVES, 2003) and is to be a subset of the health module in the European Health Interview Survey (EHIS). The MEHM includes measures of chronic morbidity, perceived health and disability, the latter by means of the GALI (van Oyen et al, 2006). The HLY is based on the disability measure: limitation in activities people usually do, for at least the last 6 months, because of health problems (Robine, Jagger and Euro-REVES, 2003). All data (death counts, population estimates and activity limitation), are for 2005 and were collected or estimated to ensure maximum harmonization for all Member States in 2005.

 

Trends in DFLE for the EU15 were carried out using the European Community Household Panel (ECHP) study run between 1995 and 2001. Relevant questions in the European Community Household Panel (ECHP) explore whether the surveyed individuals have any chronic physical or mental health problem, illness or disability and whether they are hampered in their daily activities by these physical or mental health problems, illnesses or disabilities.

 

LE estimates from 1995 to 2005 for the 27 current MS were also computed with the current EUROSTAT algorithm with death counts and population estimates from the EUROSTAT database, again except for France and Italy in 2005 (see above).

 

All health expectancy calculations were made following the Sullivan approach which was specially designed for estimating disability-free life expectancy from cross-sectional data (Sullivan, 1971). Details on the HLY, Structural Indicators and the Lisbon Strategy can be found on the Europa and EUROSTAT websites. Methodological reports on health expectancies can be found on the EHEMU website. However, it should be pointed out that, due to cultural differences in reporting one’s own health, this indicator is likely to be more appropriate for comparing time trends in health in individual countries than between different countries.

 

Table 4.1.1 shows estimates for 2005 at European level (EU25) per gender: life expectancy (LE), Healthy Life Years (HLY), the expected number of remaining years with moderate activity limitations (LEwML), the expected number of remaining years with severe activity limitations (LEwSL) and the ratio of life expectancy to the Healthy Life Years expressed a percentage (HLY/LE), at birth, at 50 and at 65. It also shows the difference in these quantities between men and women, the gender gaps.

 

Table 4.1.1. Life expectancy (LE) and Healthy Life Years (HLY) at birth, at 50 and at 65, in the European Union (EU25), in 2005, per gender.

 

The number of Healthy Life Years (HLY) lived in 2005 by the inhabitants of the EU25 reached 61.1 years for men and 63.0 years for women. These years represent 81% and 77% of the total life expectancy at birth for men and women, respectively (Table 4.1.1). Although in 2005 the EU life expectancy at birth ranks amongst the highest in the world, at almost 76 years for men and 82 years for women (EU25), for its 461 million inhabitants, too many years are still lived with activity limitations, close to 15 years for men and 19 years for women including 5 to 6 years with severe limitations. Women live on average 6 years longer than men but most of these additional years correspond to years with reported moderate or severe activity limitations. Therefore, the HLY gender gap in favour of women appears to be much smaller, less than 2 years, than the total longevity gap.

 

The number of remaining HLY at 50 is 17.6 years for men and 19.1 years for women representing 62% and 57% of total life expectancy respectively. This provides a good indication of the number of years with good functioning which may be available for work and hence is crucial for monitoring progress towards the EU target of increasing the employment rate of the older workers. Above the age of 50, women live longer than men, 4.9 years on average, but more than two-thirds of these additional years correspond to years lived with activity limitations. Therefore, the HLY gender gap in favour of women at the age of 50 is much smaller, 1.5 years, than the total longevity gap. By the age of 65, the number of remaining HLY still reaches 8.8 years for men and 9.9 years for women, representing 53% and 49% of the total life expectancy for men and women respectively. Men in the EU25 spend a greater proportion of their shorter life expectancy free of activity limitations. At the age of 50, as well as at 65, the gender gaps in the number of expected years with activity limitations are quite substantial in the EU25. For both genders, activity limitations dramatically increase the risk of becoming dependent for everyday tasks and relying on formal or informal care for daily survival.

 

Trends in HLY are not yet available because the European Health Survey System (EHSS) is relatively new. However, the feasibility study for the adoption of the HLY as a Structural Indicator, using survey data coming from the ECHP and run in EU15, gave an idea of likely trends. Table 4.1.2 gives estimates of life expectancy (LE₆₅) and disability-free life expectancy (DFLE₆₅) at 65 as well as the ratio DFLE₆₅/LE₆₅ computed from 1995 to 2001 with the ECHP survey.

 

Table 4.1.2. Life expectancy and Disability-free life expectancy at the age of 65 in EU15

 

In summary, the study suggested a slightly slower increase in the number of years without disability than in total life expectancy, resulting in a slight decrease in the proportion of life free of disability in the EU15. However, there is no obvious single trend of expansion of morbidity among all countries for men and women. If we consider a gain of 5% between 1995 and 2001 to signify compression and a loss of 5% to signify expansion then for men, Austria, Belgium, Finland, Germany and Italy appeared to experience a compression of disability, whilst Denmark, the Netherlands, Sweden and the United Kingdom reported an expansion. For women at the age of 65,  Belgium, Italy and Sweden appeared to experience a compression of disability whilst Germany, Ireland, the Netherlands and Portugal experienced an expansion. Although there is some consistency between genders with Italy and Belgium showing compression for men and women and the Netherlands and Portugal showing expansion for both, there is considerable heterogeneity between genders. These gender differences may be a result of differential reporting of disability or the omission of the institutionalized population (which will adversely affect older women more than older men) (Robine and Michel, 2004).

 

Table 4.1.3 shows 10-year trends in life expectancy at birth (LE₀) in the EU27 by gender. The table also displays the maximum, minimum and range of values estimated each year at MS level within EU27.

 

Table 4.1.3. Life expectancy at birth (LE0), in the European Union (EU27), from 1995 to 2005, per gender

 

Over the 10 year period 1995-2005, life expectancy at birth steadily increased in the EU27, by 3 years for men and by 2 years for women, thereby reducing the longevity gender gap by 1 year (Table 4.1.3). Estimates shown in Table 4.1.3 for LE only suggest a very slow reduction in the longevity gaps between the MS since 1995.

 

Table 4.1.4. Minimum and maximum values of life expectancy (LE) and Healthy Life Years (HLY), at birth, at 50 and at 65, among the Member States of the European Union (EU25), in 2005, per gender

 

Table 4.1.4 underlines the significant LE and HLY gaps observed between the Member States in 2005. At MS level, values of life expectancy at birth in 2005 range from 65.3 years to 78.5 years (13.2 years gap) for men and from 76.5 years to 84.0 years (7.5 years gap) for women. The corresponding HLY values range respectively from 48.0 years to 68.5 years (20.5 years gap) for men and from 52.2 years to 70.2 years (18.0 years gap) for women. Table 4.1.4 provides additional information on the LE and HLY gaps observed between the Member States in 2005 at 50 and 65. Indeed at the age of 50, the HLY values range respectively from 9.1 years to 23.6 years (14.5 years gap) for men and from 10.4 years to 24.1 years (13.7 years gap) for women, highlighting that the employment rate for older workers cannot be expected to be the same throughout all MS.

 

Detailed values of life expectancy at birth (LE₀) and healthy life years (HLY₀) in the Member States of the European Union in 2005 (EU25), for men and women, in the different Member States are displayed, respectively, in Figures 4.1.1. and 4.1.2.

 

Figure 4.1.1. Life Expectancy, broken down as Healthy Life Years, Years with Minor Limitations and Years with Severe Limitations, in 2005, Men

 

Figure 4.1.2. Life Expectancy, broken down as Healthy Life Years, Years with Minor Limitations and Years with Severe Limitations, in 2005, Women.

 

 

The calculation of HLY at European level (EU25) and for all MS has disclosed striking gaps in the quantity and quality of life (i.e. between total longevity and years lived free of disability), between men and women and between Member States. Understanding and reducing these gaps will be required for ensuring sustainable economic growth, full employment and greater social cohesion across the EU.

 

In summary. residents of the EU25 can expect to live slightly more than 60 years in good health, as estimated by the HLY in 2005. Around 20% (19% for men and 23% for women) of the life expectancy at birth is lived with some reported activity limitations. Under the current conditions women at birth are expected to live 6 years more than men. They will also live 4 years more with activity limitations, including over one year more with severe limitations. Severe activity limitations dramatically increase the risk of losing independence and requiring long term care. For survivors at the age of 50, the number of remaining HLY still reaches 17.6 years for men and 19.1 years for women, providing possibilities for increasing the employment rate of the older workers. In 2005 the gaps between the MS with the highest and lowest life expectancies at birth is over 13 years for men and over 7 years for women. Gaps in HLY between MS are even wider: over 20 years for men and 18 years for women in total. At 50 the HLY gaps reach 14.5 years for men and 13.7 years for women, highlighting that the labour force participation of older workers cannot be expected to be uniform throughout all MS. Equivalent gaps are evident at 65 but they point more towards long term care (LTC) services than to employment rates.

 

Longevity gaps in the EU27 are much more complex than a simple comparison between Western and eastern countries. A specific analysis made by EHEMU showed that MS experienced a marked convergence in their life expectancy values in the aftermath of the Second World War from a different but generally increasing trend in life expectancy. However, during the 1960s life expectancies began to diverge. In one group of countries, the growth in life expectancy hardly slowed down during the 1960s, and continued to converge towards higher values. These are high convergence countries. A second group, where growth in life expectancy slowed down more in the late 1950s and early 1960s, converged to a level of around two years from the highest EU27 values. These are low convergence countries. The third group includes those countries that at some time ceased to follow the trend of the highest EU27 values. These are divergent countries. It is in this third group that the Baltic and Eastern Europe countries are found as their life expectancies ceased to follow the trend of the highest EU27 values from the 1960s onwards. Denmark is also included though its life expectancy trend varied from the mid-1970s, whilst trends in Norway and the Netherlands diverged from the mid-1980s onwards. These divergences coincided with health crises across the EU27 but their impact varied tremendously from one country to the next (Robine et al 2005).

 

One of the main criteria for the European Structural Indicators is to allow a fair assessment of the EU situation in comparison to that of the United States of America (USA) and Japan, our main economic partners. If HLY does not yet permit direct comparison with these two countries, LE does. Thus Table 4.1.7 presents the values of life expectancy at birth in the EU27, USA and Japan in 1995 and in 2005 and by gender. The US data come from the National Center for Heath Statistics (Anderson et al, 1997; Kung et al, 2007)4 and the Japanese data from the Ministry of Health and Welfare for Japan (Ministry of Health and Welfare, 2006).5

    

 

Table 4.1.5. Life expectancy at birth (LE0) in the European Union (EU27), in the United States of America (USA) and in Japan in 1995 and 2005, per gender

 

Table 4.1.5 shows firstly that by 2005 LE at birth is almost identical for men in the USA and in EU27 but that LE in Japan is four years higher than in both EU27 and USA. Women’s LE at birth is one year higher in the EU27 compared to the USA but three years lower than in Japan. Secondly, the table shows that gender gaps range from 5.2 years in the USA to 7 years in Japan. Finally, the EU27 had the largest increase in male life expectancy over the 10-year period 1995-2005 and the second largest (to Japan) for female life expectancy.

 

Since its introduction in 2004 Healthy Life Years (HLY) have featured significantly throughout European health strategies and the Public Health programme as the means by which improving health of European citizens are measured. Thus the policies and strategies related to increasing healthy life years are those aimed at increasing the health of European citizens. The White Paper “Together for Health: A Strategic Approach for the EU 2008-13” has as the first of its three key objectives that of promoting health and preventing disease in order to counteract the demands on healthcare as a result of population ageing. This could be achieved by improving nutrition and physical activity, reducing the consumption of alcohol, drugs and tobacco and reducing environmental risks and accidents, particularly traffic accidents and accidents in the home, all fields for which specific Community policies have been made. However, the focus of all such actions should be to redress many of the health inequities which currently exist, as shown by the gaps in HLY, and not simply to improve health of all MS equally.

 

Moreover, improving the health of European citizens has wider repercussions than simply reducing the potential burden of an ageing population. Health means wealth and therefore health is fundamental for economic productivity and prosperity. Thus, HLY as the indicator to monitor health within the EU must be recognised and fully exploited across other sectors in the Commission. It is also worth noting that these strategies for the EU have already been promoted within the USA through the development of a nationwide health promotion and disease prevention agenda, known as Healthy People 2010, in which the two overarching national health goals are to increase the quality and years of healthy life and eliminate health disparities. In this framework, the US National Center for Health Statistics (NCHS) developed three summary measures similar to the HLY for monitoring progress toward the goals of Healthy People 2010. Sharing of experiences with HLY and ensuring that common indicators between the EU and the USA are further developed in the future can be seen as a contribution to global health, one of the fundamental principles within the White Paper

 

Significant progress has been made during the last few years in developing sustainable summary measures of population health to meet the EU political agenda. Indeed, after almost 20 years of research on health expectancies (Robine et al, 2003), on both sides of the North Atlantic governmental authorities request these simple and robust indicators to monitor the quality of life and support active ageing and employment in the context of lengthening of life. Drawbacks present in the ECHP are resolved in the health questions in SILC (and further in the EHIS) and a more rigorous translation process to the underlying health concept will minimise cultural differences in the comprehension of the questions. Thus SILC (annually) and EHIS (every 5 years) will provide the required harmonized disability data for the HLY, thus addressing data availability across all Member States (Robine and Jagger, 2007). Several services of the Commission (DG Heath and Consumers Protection, Eurostat, and the Public Health Executive Agency) are working together with the MS to improve the reliability of the HLY through a Task Force on Health Expectancies and through the EHEMU projects (see www.tf-he.eu and www.ehemu.eu).

 

Further political demands on the quality of life of populations will come in the near future and policy makers will have more experience and higher expectations of these indicators. In order to be ready to meet these expectations, the scientific community should work on second generation summary measures, true period indicators (using incidence in place of prevalence), less subjective (using measured in place of self-reported activity limitation) and covering the whole population (rather than excluding those living in institutions such as long-term care establishments). EUROSTAT has already established a Task Force to explore the possibility to compute comparable life tables by socio-economic status (SES) between MS. This is a necessary step for computing HLY by SES.