Europe and many other countries in the world are currently facing increasingly complex and systemic societal challenges. Due to health care advances, increased wealth, improved wellbeing and living standards and better diets life expectancy has increased dramatically
]. It is projected that between 2010 and 2060 the number of Europeans aged over 65 will double, from 88 to 153 million, whilst of those over 80 will nearly triple, from 24 to 62 million
]. However, the increased longevity has not always occurred in parallel with improved health and quality of life
]. As demonstrated in Figures
there has been a considerable gap between the extended lifespan and the health expectancies. The ageing of the population has dominated demographic change as one of the most pertinent challenges of present and future.
Life expectancy and healthy life years at birth among males within the European Union and Member States, 2008.
Life expectancy and healthy life years at birth among females within the European Union and Member States, 2008.
In the light of the 1997 WHO Health Report, the Director-General of WHO, Dr. Hiroshi Nakajima stated that increased longevity without quality of life is an empty prize. Health expectancy is more important than life expectancy
. The experience of the European Union (EU) underlines the need to focus on health. Health and healthy population is fundamental to the pursuit of smart, sustainable and inclusive growth and better jobs. More healthy life years mean a healthier workforce, and less retirement on the grounds of ill health. It reduces the burden on formal and informal care structures, leading to less strain on public finances and contributing to the longer-term sustainability of the health and social systems as the population ages
A range of factors impact the health status of ageing populations therefore it cannot be simply assumed how the healthy life expectancy (disability trends) will develop in next decades. For example, rising obesity might cause future increases in unhealthy lifespan, whereas improvements in medical technologies such as joint replacements can contribute towards lower disability rates and higher healthy life years
]. Assumptions, therefore, cannot be made on the development of morbidity and disability in the next decades, and on the interaction between declining mortality, morbidity and disability. Such uncertainty over health and disability trends, combined with current data limitations, entails the need to model different scenarios. For almost 50 years, there has been much debate over whether people will live longer, healthier lives - the compression of morbidity scenario
, longer but more disabled/ ill-health lives - the expansion of morbidity scenario
, or something in between - the dynamic equilibrium scenario
]. In order to examine these different hypotheses, life expectancy per se is not a sufficient indicator and needs to be completed with a level of health status. Lifespan without or with disability/ill-health defines the average number of years a person at a certain age is expected to live in the particular health condition. Health expectancies, combining life expectancy with a concept of health - chronic disease, functional limitations, activity restrictions, physical, mental or social well-being - have become essential indicators of the health of the ageing populations, where the quality of remaining life is considered to be equally important as the quantity
]. There are as many possible health expectancies as relevant health indicators
]. Disability-free life expectancies (DFLE) are commonly used as to refer to a relevant measure of health of the population, and in particular of older cohorts. For the sake of comparability of data and of the more effective measuring of the health status of all Europeans, the European Commission developed a Healthy Life Years (HLY) indicator which is the part of the family of DFLE, being based on a general activity limitation indicator (GALI)
], and introducing a concept of quality of life
]. The HLY was presented in the set of structural indicators selected and defined to help measure progress of the 2000 Lisbon strategy objectives
Realising the importance of health as a determinant and a driver of economic growth and competitiveness, the European Commission decided to include public health policy into its economic Lisbon Agenda
]. HLY indicator was introduced to monitor health as an economic/productivity and societal welfare factor
The Europe 2020 strategy, a successor of the Lisbon Strategy, therefore, highlights the ageing of the EU population as one of pressing societal challenges, calling for actions to foster active and healthy ageing. Health and healthy population is fundamental to the pursuit of smart, sustainable and inclusive growth and better jobs
In one of its flagship initiatives – Innovation Union - Europe 2020 proposed launching a European Innovation Partnership on Active and Healthy Ageing that aims to address the challenge of ageing through innovation
]. The Partnership sets a headline target to increase HLY at birth on EU average by 2 years by 2020. It is an ambitious yet firm health goal that strives to reduce the socio-economic risks associated with demographic change and to underpin quality of life of all Europeans and especially the older Europeans.
The objective of this paper is to provide analytical research that supported the European Commission in setting the target of increasing healthy lifespan of Europeans by 2 years by 2020. Similarly to life expectancy projections predicting an increasing trend for the next few decades, the paper explores the possible effect of continually postponing death on the overall prevalence of morbidity and disability. It explores three scenarios of HLY trends - compression of morbidity, expansion of morbidity, intermediary dynamic equilibrium - which give a range of possible values to be achieved by 2020 on the basis of which the Partnership selected the goal to be pursued.
The first scenario, proposed by Fries
] assumes that life expectancy is reaching its limit, and the period of ill-health and disability before death is shortened. This theory has two parts: delays in the onset of chronic disease/disability in later life, and one stage in the progression of chronic disease
]. Accordingly, morbidity and disability are gradually compressed into the shorter span between the increasing age at onset of morbidity and the age at death, and the number of years spent with diseases or disability decreases over time.
The expansion of morbidity hypothesis, developed by Gruenberg and Kramer
] states that mortality reductions will produce more years with morbidity and related disability. The decline in mortality is largely due to the decreasing fatality rate of diseases, rather than a reduction in their incidence. The final stage of the progress of fatal chronic disease is delayed and mainly due to life-sustaining medical interventions. Consequently, declining mortality from fatal diseases does expand longevity but with a substantial increase in the population at high risk of chronic morbidity and related disability. This induces a shift in the distribution of causes of disability from fatal toward less fatal or nonfatal diseases.
This alternative intermediate hypothesis, suggested by Manton
], states that there exists equilibrium between life expectancy and the health and functioning of the elderly population. In this scenario increased survival does produce an increase in years with morbidity, but years with severe morbidity and disability are relatively constant, because the pace of progression of chronic diseases and disability is reduced. In other words, the proportion of a life span lived with serious illness or disability decreases, whereas the proportion with moderate disability or less severe illness increases. As declines in the rate of disease progression delay the onset of more serious disease states, the dynamic equilibrium scenario implies that mortality reductions will be associated with a redistribution of disease and disability from more to less severe states
The paper does not aim to present complex methodological prediction models. It rather produces a straightforward analysis of HLY projections that helped the European Commission set a firm, politically sound, target. In order to reach that goal, policy makers need to commit to redefining health priorities and goals and developing and implementing relevant strategies and programmes.