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. 2017 Sep 16;390(10100):1260-1344.
doi: 10.1016/S0140-6736(17)32130-X.

Global, Regional, and National Disability-Adjusted Life-Years (DALYs) for 333 Diseases and Injuries and Healthy Life Expectancy (HALE) for 195 Countries and Territories, 1990-2016: A Systematic Analysis for the Global Burden of Disease Study 2016

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Global, Regional, and National Disability-Adjusted Life-Years (DALYs) for 333 Diseases and Injuries and Healthy Life Expectancy (HALE) for 195 Countries and Territories, 1990-2016: A Systematic Analysis for the Global Burden of Disease Study 2016

GBD 2016 DALYs and HALE Collaborators. Lancet. .
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Erratum in

  • Department of Error.
    Lancet. 2017 Oct 28;390(10106):e38. doi: 10.1016/S0140-6736(17)32648-X. Epub 2017 Oct 13. Lancet. 2017. PMID: 29032998 Free PMC article. No abstract available.

Abstract

Background: Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI).

Methods: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate.

Findings: The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally.

Interpretation: At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support.

Funding: Bill & Melinda Gates Foundation.

Figures

Figure 1
Figure 1
Trends of total DALYs (A) and age-standardised DALY rates (B) from 1990 to 2016 for GBD Level 1 cause groups by SDI quintile Shaded areas show 95% uncertainty intervals. DALYs=disability-adjusted life-years. GBD=Global Burden of Disease. SDI=Socio-demographic Index.
Figure 2
Figure 2
Leading 30 Level 3 causes of total DALYs for 1990, 2006, and 2016, with percentage change in number of DALYs and all-age and age-standardised DALY rates, overall and by SDI quintile Overall (A). Low SDI (B). Low-middle SDI (C). Middle SDI (D). High-middle SDI (E). High SDI (F). Causes are connected by lines between time periods; solid lines are increases and dashed lines are decreases. For the time period of 1990–2006 and 2006–16, three measures of change are shown: percentage change in the number of DALYs, percentage change in the all-age DALY rate, and percentage change in the age-standardised DALY rate. Statistically significant changes are shown in bold. COPD=chronic obstructive pulmonary disease. DALYs=disability-adjusted life-years. STDs=sexually transmitted diseases.
Figure 2
Figure 2
Leading 30 Level 3 causes of total DALYs for 1990, 2006, and 2016, with percentage change in number of DALYs and all-age and age-standardised DALY rates, overall and by SDI quintile Overall (A). Low SDI (B). Low-middle SDI (C). Middle SDI (D). High-middle SDI (E). High SDI (F). Causes are connected by lines between time periods; solid lines are increases and dashed lines are decreases. For the time period of 1990–2006 and 2006–16, three measures of change are shown: percentage change in the number of DALYs, percentage change in the all-age DALY rate, and percentage change in the age-standardised DALY rate. Statistically significant changes are shown in bold. COPD=chronic obstructive pulmonary disease. DALYs=disability-adjusted life-years. STDs=sexually transmitted diseases.
Figure 2
Figure 2
Leading 30 Level 3 causes of total DALYs for 1990, 2006, and 2016, with percentage change in number of DALYs and all-age and age-standardised DALY rates, overall and by SDI quintile Overall (A). Low SDI (B). Low-middle SDI (C). Middle SDI (D). High-middle SDI (E). High SDI (F). Causes are connected by lines between time periods; solid lines are increases and dashed lines are decreases. For the time period of 1990–2006 and 2006–16, three measures of change are shown: percentage change in the number of DALYs, percentage change in the all-age DALY rate, and percentage change in the age-standardised DALY rate. Statistically significant changes are shown in bold. COPD=chronic obstructive pulmonary disease. DALYs=disability-adjusted life-years. STDs=sexually transmitted diseases.
Figure 3
Figure 3
Leading Level 3 causes of all-age DALY rates by location for females (A) and males (B) in 2016 ATG=Antigua and Barbuda. DALY=disability-adjusted life-year. FSM=Federated States of Micronesia. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines. VUT=Vanuatu. WSM=Samoa.
Figure 4
Figure 4
Ratios of all-age DALY counts from NCDs to those from CMNN diseases by SDI quintile, GBD super-region, and region, for males and females separately, for 1990, 1995, 2000, 2006, 2010, and 2016 Each point represents the ratio of DALYs from NCDs to those from CMNN diseases for each GBD region in a given year by sex. Ratios of more than 1·00 represent a greater number of DALYs from NCDs than from CMNN diseases. CMNN=communicable, maternal, neonatal, and nutritional. DALY=disability-adjusted life-year. GBD=Global Burden of Disease. NCDs=non-communicable diseases. SDI=Socio-demographic Index.
Figure 5
Figure 5
Expected relationship between age-standardised YLL and YLD rates (per 100 000 people) and SDI (A) and all-age YLL and YLD rates (per 100 000 people) and SDI (B) for 21 Level 2 causes These stacked curves represent the average relationship between SDI and YLL and YLD rates for each cause observed across all geographies over the time period 1990–2016. In each figure, the y axis goes from lowest SDI to highest SDI. The left side shows rates for YLLs on a reflected axis and the right side shows rates for YLDs; higher rates are further from the midline in each direction. Differences in patterns between (A) and (B) is the effect of shifts in population age structure in relation to SDI. DALY=disability-adjusted life-year. SDI=Socio-demographic Index. YLDs=years lived with disability. YLLs=years of life lost.
Figure 6
Figure 6
Proportion of all-age DALY counts due to years lived with disability for all ages and both sexes combined for 1990 (A) and 2016 (B) Locations are colour-coded in terms of the magnitude of the ratio. ATG=Antigua and Barbuda. DALY=disability-adjusted life-year. FSM=Federated States of Micronesia. LCA=Saint Lucia. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines.
Figure 7
Figure 7
Ratio of observed to expected age-standardised DALY rates (per 100 000) on the basis of SDI alone for both sexes combined in 2016 Ratios are colour-coded in terms of the magnitude of differences between observed and expected age-standardised DALY rates. Blues indicate much lower observed DALY levels than expected on the basis of SDI, whereas reds reflect observed DALYs that far exceed expected levels given SDI. ATG=Antigua and Barbuda. DALY=disability-adjusted life-year. FSM=Federated States of Micronesia. LCA=Saint Lucia. SDI=Socio-demographic Index. TLS=Timor-Leste. TTO=Trinidad and Tobago. VCT=Saint Vincent and the Grenadines.
Figure 8
Figure 8
Leading ten causes of all-age DALYs with the ratio of observed to expected DALYs on the basis of Socio-demographic Index in 2016, by location The ratio of observed to expected DALYs on the basis of Socio-demographic Index is provided in brackets for each cause and cells are colour-coded by ratio ranges (calculated to place a roughly equal number of cells into each bin). Shades of blue represent much lower observed DALY levels than expected on the basis of Socio-demographic Index, whereas red shows observed DALYs that exceed expected levels. Alcohol=alcohol use disorders. Alzheimer's=Alzheimer's disease and other dementias. Anxiety=anxiety disorders. Back+Neck=low back and neck pain. Cirr alc=cirrhosis due to alcohol use. Cirr HepC=cirrhosis due to hepatitis C. CKD=chronic kidney disease. CMP=cardiomyopathy and myocarditis. Colorect C=colon and rectum cancer. Conflict Terror=conflict and terrorism. Congenital=congenital anomalies. COPD=chronic obstructive pulmonary disease. Depression=depressive disorders. Diabetes=diabetes mellitus. Diarrhoea=diarrhoeal diseases. DR Congo=Democratic Republic of the Congo. Drugs=drug use disorders. HIV=HIV/AIDS. HTN HD=hypertensive heart disease. IHD=ischaemic heart disease. Iron=iron-deficiency anaemia. Liver C=liver cancer. LRI=lower respiratory infections. Lung C=lung, bronchus, and trachea cancers. NN Enceph=neonatal encephalopathy due to birth asphyxia and trauma. NN Preterm=neonatal preterm birth complications. NN Sepsis=neonatal sepsis and other neonatal infections. Oth Cardio=other cardiovascular and circulatory diseases. Oth MSK=other musculoskeletal disorders. Oth NN=Other neonatal disorders. PEM=protein-energy malnutrition. Prostate C=prostate cancer. Road Inj=road injuries. Sense=sense organ diseases. Skin=skin and subcutaneous diseases. STD=sexually transmitted diseases excluding HIV. Stomach C=stomach cancer. Stroke=Cerebrovascular disease. TB=tuberculosis. Violence=interpersonal violence.
Figure 8
Figure 8
Leading ten causes of all-age DALYs with the ratio of observed to expected DALYs on the basis of Socio-demographic Index in 2016, by location The ratio of observed to expected DALYs on the basis of Socio-demographic Index is provided in brackets for each cause and cells are colour-coded by ratio ranges (calculated to place a roughly equal number of cells into each bin). Shades of blue represent much lower observed DALY levels than expected on the basis of Socio-demographic Index, whereas red shows observed DALYs that exceed expected levels. Alcohol=alcohol use disorders. Alzheimer's=Alzheimer's disease and other dementias. Anxiety=anxiety disorders. Back+Neck=low back and neck pain. Cirr alc=cirrhosis due to alcohol use. Cirr HepC=cirrhosis due to hepatitis C. CKD=chronic kidney disease. CMP=cardiomyopathy and myocarditis. Colorect C=colon and rectum cancer. Conflict Terror=conflict and terrorism. Congenital=congenital anomalies. COPD=chronic obstructive pulmonary disease. Depression=depressive disorders. Diabetes=diabetes mellitus. Diarrhoea=diarrhoeal diseases. DR Congo=Democratic Republic of the Congo. Drugs=drug use disorders. HIV=HIV/AIDS. HTN HD=hypertensive heart disease. IHD=ischaemic heart disease. Iron=iron-deficiency anaemia. Liver C=liver cancer. LRI=lower respiratory infections. Lung C=lung, bronchus, and trachea cancers. NN Enceph=neonatal encephalopathy due to birth asphyxia and trauma. NN Preterm=neonatal preterm birth complications. NN Sepsis=neonatal sepsis and other neonatal infections. Oth Cardio=other cardiovascular and circulatory diseases. Oth MSK=other musculoskeletal disorders. Oth NN=Other neonatal disorders. PEM=protein-energy malnutrition. Prostate C=prostate cancer. Road Inj=road injuries. Sense=sense organ diseases. Skin=skin and subcutaneous diseases. STD=sexually transmitted diseases excluding HIV. Stomach C=stomach cancer. Stroke=Cerebrovascular disease. TB=tuberculosis. Violence=interpersonal violence.
Figure 8
Figure 8
Leading ten causes of all-age DALYs with the ratio of observed to expected DALYs on the basis of Socio-demographic Index in 2016, by location The ratio of observed to expected DALYs on the basis of Socio-demographic Index is provided in brackets for each cause and cells are colour-coded by ratio ranges (calculated to place a roughly equal number of cells into each bin). Shades of blue represent much lower observed DALY levels than expected on the basis of Socio-demographic Index, whereas red shows observed DALYs that exceed expected levels. Alcohol=alcohol use disorders. Alzheimer's=Alzheimer's disease and other dementias. Anxiety=anxiety disorders. Back+Neck=low back and neck pain. Cirr alc=cirrhosis due to alcohol use. Cirr HepC=cirrhosis due to hepatitis C. CKD=chronic kidney disease. CMP=cardiomyopathy and myocarditis. Colorect C=colon and rectum cancer. Conflict Terror=conflict and terrorism. Congenital=congenital anomalies. COPD=chronic obstructive pulmonary disease. Depression=depressive disorders. Diabetes=diabetes mellitus. Diarrhoea=diarrhoeal diseases. DR Congo=Democratic Republic of the Congo. Drugs=drug use disorders. HIV=HIV/AIDS. HTN HD=hypertensive heart disease. IHD=ischaemic heart disease. Iron=iron-deficiency anaemia. Liver C=liver cancer. LRI=lower respiratory infections. Lung C=lung, bronchus, and trachea cancers. NN Enceph=neonatal encephalopathy due to birth asphyxia and trauma. NN Preterm=neonatal preterm birth complications. NN Sepsis=neonatal sepsis and other neonatal infections. Oth Cardio=other cardiovascular and circulatory diseases. Oth MSK=other musculoskeletal disorders. Oth NN=Other neonatal disorders. PEM=protein-energy malnutrition. Prostate C=prostate cancer. Road Inj=road injuries. Sense=sense organ diseases. Skin=skin and subcutaneous diseases. STD=sexually transmitted diseases excluding HIV. Stomach C=stomach cancer. Stroke=Cerebrovascular disease. TB=tuberculosis. Violence=interpersonal violence.
Figure 8
Figure 8
Leading ten causes of all-age DALYs with the ratio of observed to expected DALYs on the basis of Socio-demographic Index in 2016, by location The ratio of observed to expected DALYs on the basis of Socio-demographic Index is provided in brackets for each cause and cells are colour-coded by ratio ranges (calculated to place a roughly equal number of cells into each bin). Shades of blue represent much lower observed DALY levels than expected on the basis of Socio-demographic Index, whereas red shows observed DALYs that exceed expected levels. Alcohol=alcohol use disorders. Alzheimer's=Alzheimer's disease and other dementias. Anxiety=anxiety disorders. Back+Neck=low back and neck pain. Cirr alc=cirrhosis due to alcohol use. Cirr HepC=cirrhosis due to hepatitis C. CKD=chronic kidney disease. CMP=cardiomyopathy and myocarditis. Colorect C=colon and rectum cancer. Conflict Terror=conflict and terrorism. Congenital=congenital anomalies. COPD=chronic obstructive pulmonary disease. Depression=depressive disorders. Diabetes=diabetes mellitus. Diarrhoea=diarrhoeal diseases. DR Congo=Democratic Republic of the Congo. Drugs=drug use disorders. HIV=HIV/AIDS. HTN HD=hypertensive heart disease. IHD=ischaemic heart disease. Iron=iron-deficiency anaemia. Liver C=liver cancer. LRI=lower respiratory infections. Lung C=lung, bronchus, and trachea cancers. NN Enceph=neonatal encephalopathy due to birth asphyxia and trauma. NN Preterm=neonatal preterm birth complications. NN Sepsis=neonatal sepsis and other neonatal infections. Oth Cardio=other cardiovascular and circulatory diseases. Oth MSK=other musculoskeletal disorders. Oth NN=Other neonatal disorders. PEM=protein-energy malnutrition. Prostate C=prostate cancer. Road Inj=road injuries. Sense=sense organ diseases. Skin=skin and subcutaneous diseases. STD=sexually transmitted diseases excluding HIV. Stomach C=stomach cancer. Stroke=Cerebrovascular disease. TB=tuberculosis. Violence=interpersonal violence.
Figure 8
Figure 8
Leading ten causes of all-age DALYs with the ratio of observed to expected DALYs on the basis of Socio-demographic Index in 2016, by location The ratio of observed to expected DALYs on the basis of Socio-demographic Index is provided in brackets for each cause and cells are colour-coded by ratio ranges (calculated to place a roughly equal number of cells into each bin). Shades of blue represent much lower observed DALY levels than expected on the basis of Socio-demographic Index, whereas red shows observed DALYs that exceed expected levels. Alcohol=alcohol use disorders. Alzheimer's=Alzheimer's disease and other dementias. Anxiety=anxiety disorders. Back+Neck=low back and neck pain. Cirr alc=cirrhosis due to alcohol use. Cirr HepC=cirrhosis due to hepatitis C. CKD=chronic kidney disease. CMP=cardiomyopathy and myocarditis. Colorect C=colon and rectum cancer. Conflict Terror=conflict and terrorism. Congenital=congenital anomalies. COPD=chronic obstructive pulmonary disease. Depression=depressive disorders. Diabetes=diabetes mellitus. Diarrhoea=diarrhoeal diseases. DR Congo=Democratic Republic of the Congo. Drugs=drug use disorders. HIV=HIV/AIDS. HTN HD=hypertensive heart disease. IHD=ischaemic heart disease. Iron=iron-deficiency anaemia. Liver C=liver cancer. LRI=lower respiratory infections. Lung C=lung, bronchus, and trachea cancers. NN Enceph=neonatal encephalopathy due to birth asphyxia and trauma. NN Preterm=neonatal preterm birth complications. NN Sepsis=neonatal sepsis and other neonatal infections. Oth Cardio=other cardiovascular and circulatory diseases. Oth MSK=other musculoskeletal disorders. Oth NN=Other neonatal disorders. PEM=protein-energy malnutrition. Prostate C=prostate cancer. Road Inj=road injuries. Sense=sense organ diseases. Skin=skin and subcutaneous diseases. STD=sexually transmitted diseases excluding HIV. Stomach C=stomach cancer. Stroke=Cerebrovascular disease. TB=tuberculosis. Violence=interpersonal violence.
Figure 8
Figure 8
Leading ten causes of all-age DALYs with the ratio of observed to expected DALYs on the basis of Socio-demographic Index in 2016, by location The ratio of observed to expected DALYs on the basis of Socio-demographic Index is provided in brackets for each cause and cells are colour-coded by ratio ranges (calculated to place a roughly equal number of cells into each bin). Shades of blue represent much lower observed DALY levels than expected on the basis of Socio-demographic Index, whereas red shows observed DALYs that exceed expected levels. Alcohol=alcohol use disorders. Alzheimer's=Alzheimer's disease and other dementias. Anxiety=anxiety disorders. Back+Neck=low back and neck pain. Cirr alc=cirrhosis due to alcohol use. Cirr HepC=cirrhosis due to hepatitis C. CKD=chronic kidney disease. CMP=cardiomyopathy and myocarditis. Colorect C=colon and rectum cancer. Conflict Terror=conflict and terrorism. Congenital=congenital anomalies. COPD=chronic obstructive pulmonary disease. Depression=depressive disorders. Diabetes=diabetes mellitus. Diarrhoea=diarrhoeal diseases. DR Congo=Democratic Republic of the Congo. Drugs=drug use disorders. HIV=HIV/AIDS. HTN HD=hypertensive heart disease. IHD=ischaemic heart disease. Iron=iron-deficiency anaemia. Liver C=liver cancer. LRI=lower respiratory infections. Lung C=lung, bronchus, and trachea cancers. NN Enceph=neonatal encephalopathy due to birth asphyxia and trauma. NN Preterm=neonatal preterm birth complications. NN Sepsis=neonatal sepsis and other neonatal infections. Oth Cardio=other cardiovascular and circulatory diseases. Oth MSK=other musculoskeletal disorders. Oth NN=Other neonatal disorders. PEM=protein-energy malnutrition. Prostate C=prostate cancer. Road Inj=road injuries. Sense=sense organ diseases. Skin=skin and subcutaneous diseases. STD=sexually transmitted diseases excluding HIV. Stomach C=stomach cancer. Stroke=Cerebrovascular disease. TB=tuberculosis. Violence=interpersonal violence.
Figure 8
Figure 8
Leading ten causes of all-age DALYs with the ratio of observed to expected DALYs on the basis of Socio-demographic Index in 2016, by location The ratio of observed to expected DALYs on the basis of Socio-demographic Index is provided in brackets for each cause and cells are colour-coded by ratio ranges (calculated to place a roughly equal number of cells into each bin). Shades of blue represent much lower observed DALY levels than expected on the basis of Socio-demographic Index, whereas red shows observed DALYs that exceed expected levels. Alcohol=alcohol use disorders. Alzheimer's=Alzheimer's disease and other dementias. Anxiety=anxiety disorders. Back+Neck=low back and neck pain. Cirr alc=cirrhosis due to alcohol use. Cirr HepC=cirrhosis due to hepatitis C. CKD=chronic kidney disease. CMP=cardiomyopathy and myocarditis. Colorect C=colon and rectum cancer. Conflict Terror=conflict and terrorism. Congenital=congenital anomalies. COPD=chronic obstructive pulmonary disease. Depression=depressive disorders. Diabetes=diabetes mellitus. Diarrhoea=diarrhoeal diseases. DR Congo=Democratic Republic of the Congo. Drugs=drug use disorders. HIV=HIV/AIDS. HTN HD=hypertensive heart disease. IHD=ischaemic heart disease. Iron=iron-deficiency anaemia. Liver C=liver cancer. LRI=lower respiratory infections. Lung C=lung, bronchus, and trachea cancers. NN Enceph=neonatal encephalopathy due to birth asphyxia and trauma. NN Preterm=neonatal preterm birth complications. NN Sepsis=neonatal sepsis and other neonatal infections. Oth Cardio=other cardiovascular and circulatory diseases. Oth MSK=other musculoskeletal disorders. Oth NN=Other neonatal disorders. PEM=protein-energy malnutrition. Prostate C=prostate cancer. Road Inj=road injuries. Sense=sense organ diseases. Skin=skin and subcutaneous diseases. STD=sexually transmitted diseases excluding HIV. Stomach C=stomach cancer. Stroke=Cerebrovascular disease. TB=tuberculosis. Violence=interpersonal violence.

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