The use of the global activity limitation Indicator and healthy life years by member states and the European Commission

Health expectancies combine information on mortality and morbidity, where the quality of remaining life is as important as the quantity [1]. Increasingly, health expectancies are being used as summary measures of population health, serving as an essential indicator of the health of the ageing populations [2]. Healthy Life Years (HLY), a disability-free life expectancy, measures the expected years lived without participation restriction. In Europe, it has been monitored since 2005 and was selected to help measure progress in strategic European policies such as the 2000 Lisbon strategy and the European strategy on Active and Healthy Ageing [3]. HLY are based on the underlying measure: the Global Activity Limitation Indicator (GALI) which is provided through surveys. The question is: “for at least the past six months, to what extent have you been limited because of a health problem in activities people usually do? Would you say you have been: severely limited? limited but not severely? not limited at all?”. The development of the GALI occurred in the framework of the creation of a coherent set of indicators to monitor health across Europe [4]. The GALI is one of the three questions of the Minimal European Health Module (MEHM) which is a module that was developed to be used in EU social surveys such as the EU Statistics of Income and Living Conditions (EU-SILC) and the Eurobarometer [4]. Eurostat plays an important role in the coordination of the EU-SILC and the calculation of HLY.

A HLY improvement is the main health goal of the EU in order to reduce the social and economic burden with life expectancy lengthening [5]. The European Innovation Partnership on Active and Healthy Ageing is targeting to increase the average HLY of Europeans by two years by 2020 [3, 6]. Additionally, HLY are used as a Sustainable Development Indicator (SDI) in the Europe 2020 strategy, being the headline SDI for the public health theme [7]. The European Commission deployed efforts to harmonise the instruments and methods used in EU Member States to measure HLY and has assessed its uptake in 2006 [8]. They concluded that the use of the HLY indicator was not (yet) widespread, mainly due to limited awareness and understanding of the concept. However, the evaluation only covered the period since the adoption of HLY as a Lisbon Structural Indicator. Nonetheless, the evidence showed that the HLY indicator was seen as important to measure progress towards the Lisbon objectives, in particular because health is a precursor for economic growth and it is an instrument to put health capital higher on the European political agenda [8]. Possible methods to increase the uptake in policy and actions were identified. This included the improvement of dissemination activities by providing easier access to information and by increasing visibility.

Since 2006, no assessment has been carried out to look at the use and uptake of the GALI and HLY in the EU. Despite the EU’s attention, the evolution of the GALI and HLY indicators has not been examined for over 10 years. This study aims to assess the current use of the GALI and HLY indicators by the European Commission and EU Member States. The aim was not to cover a representative sample of potential users, but rather to have a variety of respondents active in the field who could provide a picture of current uses in Member States and the EU.

A questionnaire was sent to experts active in the European Health and Life Expectancy Information System (EHLEIS) project, or working in a relevant public health and/or statistical area, in 28 Member states and two departments of the European Commission [9, 10]. Information was collected from a sample of 22 public health professionals, active in the field of health monitoring, belonging to agencies, such as ministries (n = 2), statistical offices (n = 8), public health institutes (n = 8) and universities (n = 4) that are potential users. Two experts from the European Commission responded to the survey. After purposive sampling, snowball sampling was used. The respondents were asked whether they were the right contact person to respond to the survey. If this was not the case, the respondents were asked to provide contact details for a more suitable contact person and the survey was forwarded to this person. Out of the 30 contacted persons, 23 returned their questionnaire, one suggested other colleagues to be contacted. The questionnaire was sent by email in March 2017 and a reminder was sent after one month. One response to the questionnaire per country was aimed for to provide a picture of current use. Information was complemented with data available from the EHLEIS network and the literature.

The questionnaire (Additional file 1) was developed around four topics: policy implications, use in surveys, dissemination and national capacity in staff. More specifically, the questionnaire inquired if the GALI and HLY had policy implications and was used to assess the current situation or set targets in public policy; in which survey the GALI had been introduced since 2005; how the distribution of the GALI (prevalence of participation restriction by severity level) and HLY were presented, discussed and disseminated at national or regional level; and what the national capacity was to calculate, analyse and follow-up on the GALI and HLY. The questionnaire consisted of six open-ended questions which were analysed qualitatively by using theme coding and frequency analysis. Theme coding was used for the analysis of the first and third topic in which the areas of policy and dissemination type were identified and categorised. The frequency of the use of the different types of surveys and the number of personnel working on HLY or the GALI was investigated.

Twenty-two Member States responded to the questionnaire resulting in a 79% response rate in the Member States and two responded from the European Commission. The majority of Member States respondents were part of a public health institute (n = 8) or a statistical institute (n = 8), but other agencies such as ministries and universities were also covered with respectively two and four respondents. The non-responding Member States were Croatia, Ireland, Luxembourg, Malta, Poland and Portugal. Not all answers addressed the questions completely, however only 3 out of 144 questions were left completely unanswered.

The GALI and HLY are important measures to monitor progress in various policy domains. Since the last evaluation in 2006 [8], the use of the HLY indicator has spread and gained attention and the respondents to our survey reported different uses. Analysis of the HLY have led to policy changes in e.g. Estonia and are discussed in high level political meetings in countries such as France and Italy, and at the European Commission, most recently, in the context of the European Pillar of Social Rights where HLY are a headline indicator. In Lithuania, HLY have even taken over LE as the main evaluation criteria in the program of the government. In contrast with 2006, HLY are now being used to design policies and programmes. The most widespread use of the GALI and HLY are in the area of health, but since health is acknowledged as a precursor of economic growth and important for economic decisions, HLY have gained importance in other policy areas as well. HLY and the GALI are used in at least 5 different Directorate Generals (DGs) of the Commission, including its use in the European Semester. In contrast with the report of Oortwijn et al. [8], Commission Officials do seem to be aware of the HLY indicator as its use has spread. The results from the survey show that HLY are frequently used in the context of sustainability, where HLY are reported and monitored in the strategies of sustainable development of many countries and at the European Commission. This because HLY have gained major importance in discussions on retirement age and pension. In some countries such as Estonia, it is a policy priority to increase HLY in order to increase people’s years of economic activity. The efforts of the European Innovation Partnership on Active and Healthy Aging, the Task Force on GALI and the EHLEIS project may have contributed to countries endeavours to increase HLY. Also in the policy domain of disabilities, HLY have gained political importance. Not all countries have taken up HLY systematically. In the Netherlands, for example, only LE is taken into account for pension age. Methodological issues and fluctuations are other important reasons for its limited use in e.g. Slovenia. At regional level, most recently, the Flemish region in Belgium has used healthy life years in their proposal to address social inequalities in health and wellbeing [23]. However, the policy implications at regional level seem rather limited according to the survey. This should be investigated in more depth to make any conclusive remarks as regional policy-makers were not specifically targeted in this study.

The GALI question is institutionalised in most important health questionnaires through the MEHM such as the EU-SILC, the SHARE and the EHIS [24]. This was initiated by Eurostat to have a health benchmark in all their major surveys including the non-health surveys. Interestingly, in our study, only few countries were aware the GALI was questioned through the SHARE in their country. Overall, the biggest limitation is that survey organisers use their own adaptation of the question. This leads to a variety of wording in different surveys and may limit comparability [25]. Eurostat and EHLEIS have provided support to countries with regards to harmonisation, but continuous efforts will be needed in order for the GALI question not to be altered or removed. Since the capacity has decreased in the European Commission, and the Task Force on GALI and the EHLEIS project have come to an end, it would be interesting to look at the impact of these changes on the use of the GALI and HLY in the future. In this survey, only one country reported to have removed the GALI question from the EHIS. Respondents to the survey also indicated the GALI question is used in various other surveys. Also at regional level and in smaller scale studies, the GALI has been introduced.

HLY are presented in various reports. The country reports produced by EHLEIS are well received by countries and increase the uptake of HLY at national level as the reports are published on countries websites. This is important to improve the understanding of the concept in a unified way and to provide a yearly update. Furthermore, the presentation and dissemination of HLY are most prominent on national statistics websites. Some countries provide data analysis and conclusions on their HLY results increasing the visibility of the GALI and HLY. Other findings on HLY are presented in reports on the EU-SILC and EHIS. The capacity working on the GALI and HLY in the Member States has either remained unchanged or slightly increased over the years. The capacity is usually spread over various institutions being national public health institutes, statistics offices and universities.

At the European Commission, HLY are reported in various health reports such as the Country health profiles and in Health at a glance: Europe report. Also outside the health domain, HLY are used in reports on social protection and inclusion as well as on disability and employment. The production and dissemination of HLY and the GALI follow already established procedures which confirm their institutionalisation, but has a decline in resources and capacity at EU – level as a consequence.

Since only one respondent per country was aimed for in this study, due to resources constraints, the responses may have been incomplete and may not reflect a country wide perspective. Also, the results from the study demonstrated that the areas in which the GALI and HLY are used can be broad and the respondents may only be aware of use in certain areas. However, the respondents were chosen due to their active participation in the EHLEIS network and their expertise in the field. Therefore, they seemed to be suitable to respond to the questionnaire. Participants were also asked to provide another contact person if they did not know the answers to the questionnaire. Various respondents provided links to national reports and websites. Due to the language barrier not all reports could be assessed thoroughly.

In ten years, there has been a real evolution in the use of the GALI and HLY. The use of the GALI and HLY are now widespread in Member States and in the European Commission and has, over the years, become institutionalised. The GALI and HLY are used for policy making (e.g. health promotion and functional capacity of the work force), impact assessment (e.g. impact of healthy life style on health), and monitoring (e.g. trends in social protection). Additionally, HLY are increasingly being used to design policies and programmes. The GALI and HLY are not only used in the policy area of the health sector encompassing disabilities and healthy ageing, but have also gained importance in other fields such as retirement, budgets and sustainable development. The GALI is integrated in major health surveys which support its long-term sustainability. Although the capacity fluctuates between countries, most countries have capacity to evaluate the GALI and HLY. This analysis encourages further documenting for the policy makers how HLY and the GALI are measured and what type of interpretation can be driven from the secular or cross-country comparisons.