The health-adjusted dependency ratio as a new global measure of the burden of ageing: a population-based study

Background: The old-age dependency ratio (OADR), which is the ratio of older people (aged ≥65 years) to working age people (aged 20–64 years), is the most common way to assess and compare the burden of population ageing in different countries. However, the relationship between chronological age and dependency varies widely across countries. We therefore present the health-adjusted dependency ratio (HADR), a new measure of ageing burden based on the ageing-related health of the adult population. Methods: In this population-based study we used health data for diseases and injuries for 2017 from the Global Burden of Disease project and population data for 2017 from the UN's Population Division to identify the number of adults (aged >20 years) in each country who have the same or higher ageing-related disease burden as the global average 65-year-old. We then calculated the HADR as the ratio of adults who were less healthy than the average 65-year-old (dependent population) to those in better health (supporting population) and compared the HADR with the OADR for 188 countries. We also used cross-sectional, bivariate regression analysis to investigate whether the HADR is a more powerful predictor of changes in per capita health-care expenditure than the OADR as a measure of predictive validity. Findings: Many demographically younger populations have an earlier onset of ageing-related disease, and many demographically older populations have a later onset. For instance, Pakistan has an OADR of 0·09 and an HADR of 0·19, and France has an OADR of 0·35 and an HADR of 0·13. Relative to the OADR, the HADR suggests that Asia, western Europe, and North America have a lower ageing burden, whereas central Asia, southern Asia, and Africa have a greater burden. While Japan and countries in western Europe have the highest OADR, Russia, Papua New Guinea, and countries in southeast Europe have the highest HADR. Relative to the OADR, the HADR suggests that there is much less variation in the burden of ageing across countries than has previously been assumed. HADR was also more closely associated with growth in health spending than the OADR. A 0·1 increase in the HADR was associated with a 2·9 percentage points larger growth rate in per capita spending (p=0·0001), and a 0·1-point increase in the OADR was associated with a 1·8 percentage point larger growth rate. Interpretation: The OADR probably overestimates the burden of population ageing in many demographically older countries and underestimates the ageing burden in many demographically younger countries, which implies that the challenges associated with ageing are more universal than previously thought, and that the world cannot easily be divided in a young and an old groups of nations.