Why do some countries do better or worse in life expectancy relative to income? An analysis of Brazil, Ethiopia, and the United States of America

Toby Freeman,James Macinko,Fran Baum,Elsa Regina Justo Giugliani,David Sanders,Jennie Popay,Connie Musolino,Hailay Abrha Gesesew,Clare Bambra

doi:10.1186/s12939-020-01315-z

Abstract

BackgroundWhile 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.MethodsWe 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.ResultsPossible 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.ConclusionsThe 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.

Highlights

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
The research reported in this paper aimed to assess the extent to which existing literature and data can answer the question through scoping reviews of three countries: Ethiopia (PAW), Brazil (PAW), and the United States (PBW)
A country was deemed as punching above their weight” (PAW) if they sat above the Preston Curve, and punching below their weight” (PBW) if they sat below the regression curve

Summary

Introduction

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. Life expectancy ranges from 52 years in Sierra Leone and the Central African Republic to 84 years in Japan and Hong Kong [1] – a staggering gap of 32 years These extreme health inequities partly reflect wealth inequities between countries. Preston [3] found that there was a cross-sectional logarithmic curve relationship between national income per capita and life expectancy, such that life expectancy rapidly increases with national income at first, until it begins to taper off, with higher income countries receiving diminishing returns for increases in national income. Preston speculated on the drivers of countries punching above or below weight, hypothesising that within-country inequities would contribute to punching below weight [3]

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