Assessments of countries’ longevity and its variability around the globe often rely on life expectancy (LE) but tend not to differentiate between the years spent in “good” or “less-than-good” health. We explore how the evolution of the healthy and unhealthy components of LE has shaped the composition of LE within countries, and the extent of LE inequality between countries. Using data from the Global Burden of Disease Study, we document the joint evolution of “health-adjusted life expectancy” (HALE) and “unhealthy life expectancy” (UHLE) for 204 countries and territories from 1990 to 2019, the age-specific contributions to changes over time in HALE and UHLE, and the corresponding cause-of-death profiles. We also assess the contribution of HALE and UHLE to “international health inequality” (IHI; i.e., inequality in LE across world countries). Between 1990 and 2019, HALE and UHLE have increased in most world countries, thus lengthening longevity worldwide. Globally, HALE has increased from 58.1 years to 63.4 years, while UHLE has increased from 8.4 years to 9.4 years, but there is a great deal of variation across regions and countries. The fraction HALE/LE has declined in three out of four countries. Over time, IHI followed an inverted U shape, peaking around the year 2000 and declining from that year onwards. IHI levels and trends are mostly explained by trends in HALE. Our findings indicate that global health inequalities are undergoing profound transformations. While health inequalities between countries tend to decline, those within countries tend to increase. In addition, we observe a compositional shift in which the unhealthy component of LE is playing an increasingly important role in explaining (1) further increases in longevity among low-mortality countries and (2) the extent of inequality in LE among world countries. Policies aiming at increasing LE and reducing its variability between countries should increase HALE among the world's least longevous countries.

中文翻译：

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死亡率和发病率之间的竞争：对全球健康分布的影响

对各国寿命及其全球变异性的评估通常依赖于预期寿命（LE），但往往不区分健康状况“良好”或“较差”的年份。我们探讨了 LE 的健康和不健康成分的演变如何影响国家内部LE 的构成，以及国家之间LE 不平等的程度。利用全球疾病负担研究的数据，我们记录了 1990 年至 2019 年 204 个国家和地区“健康调整预期寿命”(HALE) 和“不健康预期寿命”(UHLE) 的联合演变情况。 HALE 和 UHLE 随时间的变化以及相应的死因概况。我们还评估了 HALE 和 UHLE 对“国际健康不平等”（IHI；即世界各国 LE 不平等）的贡献。1990 年至 2019 年间，世界大多数国家的 HALE 和 UHLE 有所增加，从而延长了全球的寿命。在全球范围内，HALE从58.1年增加到63.4年，而UHLE从8.4年增加到9.4年，但不同地区和国家之间存在很大差异。四分之三的国家的 HALE/LE 比例有所下降。随着时间的推移，IHI 呈倒 U 形，在 2000 年左右达到顶峰，并从该年开始下降。IHI 水平和趋势主要由 HALE 趋势来解释。我们的研究结果表明，全球健康不平等正在发生深刻的转变。虽然国家之间的健康不平等趋于缩小，但国家内部的健康不平等却趋于加剧。此外，我们观察到一种构成变化，其中 LE 的不健康成分在解释（1）低死亡率国家的寿命进一步延长和（2）世界各国 LE 的不平等程度方面发挥着越来越重要的作用。旨在提高 LE并减少各国之间差异的政策应该会提高世界上最长寿国家的 HALE。