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Table 2 Punching above or below weight status and selected context and social determinants of health indicators of Ethiopia, Brazil and the United States of America, 1990s-2018

From: 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




United States of America

Life expectancy at birth, 1997




Actual life expectancy at birth, 2018




Expected life expectancy at birth,a 2018




GDP per Capita PPP, 2018




Life expectancy relative to GDP (PAW or PBW) statusb

PAW, + 3.0 years

PAW, + 2.0 years

PBW, − 2.9 years


Country geography and population demographics

East Africa, 1.2mil km2, 100mil people (~ 80% are rural, 82% dependency ratio,c male: female (M: F) ratio is 100:101), land locked

Latin America, 8.5mil km2,~ 210 mil people (~ 80% urban, 43% dependency ratio, M:F ratio of 100:105), home of the largest forest in the world

North America, 9.6mil km2,~ 329 mil people (~ 75% urban, 51% dependency ratio, M:F ratio of 97:100), world’s largest economy

Social Structure Policies and Social Determinants of Health

a) Political, economic policies (trade, national & transnational corporations) and civil societies

From a command economy to a developmental state & agricultural-led economy, fair equity and limited influence of corporates; number of civil society organisations & non-governmental organisations (NGOs) increased substantially; strong political commitment

From a military dictatorship with high debit crisis and income inequalities to a stable democracy, fast economic growth with gradual reduction in income inequalities, active participation in civil societies and NGOs; strong political commitment

A neo-liberal economy, high income inequalities among racial/ethnic groups, low political participation as compared to other OECD countries

b) Education, cultural & societal conditions (gender, race, religion)

Free education in public schools, improved enrolment coverage including for females, gross enrolment ratiod is 100.12%, improved women’s household decision making, enhanced women’s economic participation, improved participation of women in high level positions, paid maternity leave

School enrolment increased from 70 to 96% including females’ education, women’s illiteracy declined from 27% in 1980 to 6.5% in 2016, gross enrolment ratio is 109.8%, gaps between white and non-white men/women is getting close, reducing patriarchalism and increasing gender empowerment, reducing gender discrimination, paid maternity leave, achieved significant milestone in gender participation in high positions

Gross enrolment ratio was 99.4%, significant gender, race and SES gaps/inequalities in education coverage, low political participation of minority groups, significant racial and religious discrimination, significant gender discrimination of religion and racial/ethnic minorities, weak economic participation and political decision making in women, no paid maternity leave on a federal level although few private sectors allow paid maternity leave, 40% of women do not qualify for legislated medical and family leave rights

a) Health system policies and indicators

Strong community health programs and network where primary health care is decentralized to the level of kebele (lowest administrative units, ~  500 households (3500–4000 people), public healthcare expenditure as percentage of GDP is relatively constant (e.g. 4.4% in 2000, 5.5% in 2010, 4% in 2016), improved access to drugs and significant drop in IMR, U5MR & MMR, and universal coverage for HIV treatment (test & treat strategy)

Strong community health programs, access to health services improved through innovative programs, healthcare expenditure as percentage of GDP increased annually (e.g. 6.6% in 2000 to 11.8% in 2016 (45% public)), improved access to drugs and significant drop in IMR, U5MR & MMR, universal coverage for HIV treatment (test & treat strategy)

No universal health coverage, healthcare expenditure as percentage of GDP increased annually (e.g. 12.5% in 2000 to 17.1% in 2016) but sizeable gaps in health coverage, racial disparities in access to health services, IMR, U5MR and MMR decreased in whites but increasing in blacks, MMR increased recently, HIV treatment not free. Some forms of health insurance include mandatory work requirements

 i. Primary Health Care

Access to PHC increased through a community health extension program (urban and rural), services decentralized to health centres & health stations, health facilities coverage increased from 76 health posts and 412 health centres to 1600 and 3500

Access to basic health services increased through Family Health Strategy (Doctors, Community Health Workers and other health professionals), Unified Health System (SUS) and “Mais Médicos” programme

Limited access to PHC with strong focus on specialized medicine due to some social insurance system (private market), difficulty in accessing health care, increasing and associated with voting (most with difficulty in accessing health care voted democrat in 2004)

 ii. Access to drugs

Health budget increased, established health care finance and community-based health insurance, free maternal health services

Unified Health System provides free access to essential medications, Farmacia Popular provides heavily discounted medications, and Bolsa Família (conditional cash transfers) increased family income.

Limited scope and racial disparities of insurance programs (e.g. Affordable Care Act (ACA)), limited insurance and no free access to drugs, including for HIV treatment

 iii. Health indicators

Indicators (1990s to 2017)

1) IMR- 120.2 to 41.0/1000 live births

2) U5MR- 202 to 58.5/1000 live births

3) MMR- 871 to 353/100000 live births

4) HIV Prevalence reduced from 3.2% in 1990 to 0.9% in 2017/8

Indicators (1990s to 2017)

1) IMR – 52.6 to 13.2/1000 livebirths

2) U5MR- 63.1 to 14.8/1000 livebirths

3) MMR- 184 to 58/100000 livebirths

4) HIV prevalence reduced from 3% In 1990 to 0.4% In 2015

Indicators (1990s to 2017)

1) IMR- 9.4 to 5.7/1000 live births

2) U5MR- 11.2 to 6.6/1000 live births

3) MMR- 7.6 to 14/100000 live births

4) HIV prevalence remained 0.34% (850,000 out of 250 mil in 1990 to 1.1 mil out of 323.4 mill in 2016)

b) Agriculture and food supply: Export and localc) consumption

Agriculture as a main source of export, several food security and child nutrition programs as part of SDGs 1&2 (e.g. National Nutrition Program). Overall food security index was 39.4% in 2012 and 36% in 2017 (ranked 100th out of 113 countries).

Main export is agriculture & crude petroleum; established School Food Program, conditional cash transfer program (Bolsa Família); overall food security index was 65.8% in 2012 and 68.4% in 2017 (ranked 39th out of 113 countries).

Main export refined petroleum & cars, planes, helicopters & space craft; Significant gap in food supply compared to the Federal Dietary Guidance; Overall food security index was 85.6% in 2012 and 85% in 2017 (ranked 3rd out of 113 countries).

d) Employment: Conditions of work

Relative rate of unemployment and child labour reduced, paid maternity leave, pension scheme for older people through employer contribution

Increased job stability and wages, reduced unemployment, reduced child labour and slavery, paid maternity leave, pension scheme for older people

Significant underemployment and inequalities relative to other OECD countries, no change of federal minimum wage since 1996, lowest paid sickness leave and public pensions compared to other high-income countries (e.g. Sweden)

e) Income: Wealth & poverty levels

Poverty reduced, purchasing power increased, introduction of social security programs such as health care finance & community-based health insurance, relatively equitable access to resources, Gini coefficient was 0.35 in 2015

Improved social welfare, reduced poverty and inequality, government introduced cash transfer program (Bolsa Familia) and Unified Health System (SUS), Gini coefficient was 0.074 in 2014

Weak social security programs, high rate of income inequalities (Gini index rose by 4%, top 1% of population accounts for 40% of nation’s wealth), relative poverty and child poverty (20% of all children estimated to be living in poverty). Gini coefficient was 0.415 in 2016

f) Housing

Improved housing conditions, access to safe water & ratification of public health regulations

Improved sanitation, access to safe water & housing conditions

Low affordability and inequitable access to housing, significant level of homelessness and housing instability, limited coverage of water supply, and loose public health regulations compared to other developed countries

i. Housing supply

Improved housing supply through ‘Condominium’ (a government loan-based housing program), expanded urbanization to address supply shortage, established Urban Development Package (e.g. Integrated Housing Development Program)

Improved housing supply with adequate electricity, sewage disposal, population living in informal settlements decreased from 37% in 1990 to 22% in 2014

Limited affordable housing compared to other OECD countries, significant cost burden among households; underfunding of the National Housing Trust Fund

ii. Access to safe water

Access to drinking water was 65% (increased by 800%), increases in quantity & reduced distance to collect water

Equitable access to safe water coverage increased to 98%

Inequitable access to safe water in low income and minority families, limited scope of the Healthy Hunger-Free Kids Act program

iii. Effective urban planning & healthy infrastructure

Urban Good Governance Package (promoting effective urban planning, improving infrastructure, justice reform and other packages); WHO Framework Convention on Tobacco Control was ratified in 2014; excise tax bill on alcohol and tobacco approved on November 2019

WHO Framework Convention on Tobacco Control was ratified in 2005

Non-ratification of WHO Framework Convention on Tobacco Control, less regulated markets (e.g. uneven restrictions on advertising of unhealthy products)

i. Environment: sustainable practices & pollution

Ethiopian Environmental Protection Authority established in 1994, Climate resilient green economy strategy including the following proclamations: Environment Impact Assessment Proclamation, Pollution Control Proclamation, Industrial Waste Handling

Strong environmental institutions, creation of Special Secretariat of Environment (SEMA), National Environmental System (SISNAMA), the National Environmental Council (CONAMA) and the Brazilian Institute of Environment and Renewable Natural Resources (IBAMA)

Little action towards a sustainable environment, highest per capita C02 emissions and oil use, some limited environmental protection through Environmental Protection Agency, Clean Air Act, and Clean Water Act

  1. FDI foreign direct investments, GDP gross domestic product, HIV human immune-deficiency virus, IMR infant mortality rate, MMR maternal mortality rate, NGOs non-governmental organisations, OECD Organisation for Economic Cooperation and Development, PHC primary health care, PPP purchasing power parity, SDGs sustainable development goals, U5MR under-five mortality rate
  2. aCalculated from a Preston curve with 2018 GDP per capita, International $ PPP and 2018 life expectancy at birth data, where predicted life expectancy = 5.39 x ln(GDP) + 21.8. GDP = Gross Domestic Product, PPP = Purchasing Power Parity
  3. bLife expectancy (LE) relative to GDP status is calculated by subtracting expected LE from actual LE at birth, PAW = Punching Above Weight; PBW = Punching Below Weight
  4. cDependency ratio, an age-population ratio, is the proportion of people who are not in the labour force aged between 0 to 14 and 65+) to people who are in the productive or labour force aged between 15 to 64
  5. dGross enrolment ratio (GER) is the number of students enrolled in a given level of education regardless of age divided by the population of the age group which officially corresponds to the given level of education, and multiplied by 100. A high GER generally indicates a high degree of participation. A GER value approaching or exceeding 100% indicates that a country is, in principle, able to accommodate all of its school-age population