Baum et al. International Journal for Equity in Health (2018) 17:117
https://doi.org/10.1186/s12939-018-0832-y

COMMENTARYOpen Access

Punching above their weight: a network
to understand broader determinants ofincreasing life expectancy
Fran Baum1* , Jennie Popay2, Toni Delany-Crowe1, Toby Freeman1, Connie Musolino1, Carlos Alvarez-Dardet3,
Vinya Ariyaratne4, Kedar Baral5, Paulin Basinga6, Mary Bassett7, David M. Bishai8, Mickey Chopra9, Sharon Friel10,11,
Elsa Giugliani12, Hideki Hashimoto13, James Macinko14, Martin McKee15, Huong Thanh Nguyen16, Nikki Schaay17,
Orielle Solar18, Sundararaman Thiagarajan19 and David Sanders20

Abstract
Background: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any
level of economic development, some countries do better, and some worse, than expected – they either punch
above or below their weight. Why this is the case has been previously researched but no full explanation of thecomplexity of this phenomenon is available.
New research network: In order to advance understanding, the newly formed Punching Above Their Weight
Research Network has developed a model to frame future research. It provides for consideration of the following
influences within a country: political and institutional context and history; economic and social policies; scope fordemocratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles andpower dynamics; the extent of civil society activity and disease burdens.
Conclusion: Further research using this framework has considerable potential to advance effective policies toadvance health and equity.
Keywords: Life expectancy, Health equity, Social determinants of health, Politics of health, Gender equity, Civil
society, Health improvement

Background
In September 2017 the Punching Above Their Weight
Research Network [1] was formed to advance thinking andresearch about why some countries do much better ormuch worse in terms of life expectancy than would be
predicted by their economic status. It builds on previous
research that has focused primarily on health sector performance. Previous attempts have not drawn adequately
on an interdisciplinary approach and have thus failed to
produce a sufficiently nuanced and holistic picture of thepolitical, social, environmental and economic processes
that drive good or poor performance in promoting population health and health equity.
* Correspondence: fran.baum@flinders.edu.au1Southgate Institute for Health, Society & Equity, Flinders University, Adelaide,
South Australia, Australia
Full list of author information is available at the end of the article

The Preston curve has demonstrated that, in general,life expectancy initially improves rapidly with economic
development but the improvement then tails off [2]. Yet,at any level of economic development, some countries
do better, and some worse, than expected. What can welearn from those countries, or regions within countries,
at all levels of development that deviate from the mean
to punch either above or below their weight? (Table 1).
It may be shocking news to many citizens of the UnitedStates that Costa Rica, with a Gross Domestic Product percapita a tenth of the US, outstrips them in life expectancy
by one year [3], but this phenomenon of good health at low
cost was recognised more than three decades ago [4, 5] andrevisited more recently [6]. The two previous ‘good healthat low cost’ studies focused in particular on the role of highquality equitable health care coverage (particularly primary
health care) and disease prevention as well as successful© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Baum et al. International Journal for Equity in Health (2018) 17:117

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Table 1 Top five punching above their weight countries andbottom five at each level of development (2015)

and civil society representatives (all authors). The firstmeeting was held at the Rockefeller Bellagio Centre
in August, 2017. The purpose of the Network is provided in Table 2.
Our discussions focused on the broad structural determinants of health in multiple countries/regions, seeking
to understand the socioeconomic and political contexts
known from research to drive population health andhealth equity. We also drew from the wider literature on
the progress of nations in order to (i) identify issues absent
from earlier studies or in need of further elaboration; and(ii) to develop preliminary research questions that would
direct a broader investigation. The framework that developed from our discussions is shown in Fig. 1.
Our discussions highlighted the need to tease apart andclosely examine the complexities involved in a country/region being able to punch above or below its weight inhealth terms, to determine what factors play a role, in what
contexts, and to what effect. A number of particularly important and/or neglected complexities were identified.

Low income

Middle Income

High Income

Top performers (top row punches most above weight)
Nepal

HondurasJapan

Madagascar

Viet Nam

Spain

RwandaNicaragua

Chile

Liberia

Bangladesh

GreeceEthiopia

Solomon Islands

South Korea

Bottom performers (bottom row punches the most below weight)
Central African Republic

Swaziland

Brunei Darussalam

Mali

Cote d’Ivoire

Saudi Arabia

South Sudan

Nigeria

Trinidad and Tobago

ChadAngolaQatar

Sierra Leone

Equatorial Guinea

KuwaitNote: Performance is defined as the distance from the regression line linking
life expectancy at birth (2015) [28] and gross domestic product (2015) [29]advocacy for social and political support for health. However, neither analysis provided detail of the broader processes that may be implicated. In addition, the Institute for
Health Metrics and Evaluation has published detailed quantitative analysis that shows new countries are emerging as
punching above their weight, and while it identifies policies
that have contributed to improvements, it again does not
explore the wider context in detail [7].
So whilst these existing studies provide tantalising insights into the complex interactions between the characteristics of health care systems and the wider social,economic and political determinants of health that may
underpin the unexpectedly positive (or negative) healthoutcomes achieved by some countries/regions, the picture
is incomplete [8]. It is, therefore, vital to address thesegaps in our knowledge if we are to improve the health andwellbeing of populations across the world. Doing so istimely, because at least nine of the seventeen Sustainable
Development Goals for 2030 [9] require progress in aspects of health that extend beyond the boundaries ofhealth systems, including the alleviation of poverty, hunger, and violence against women, as well as the provisionof access to safe water and sanitation, labour rights, disaster preparedness, and action to combat climate change[10]. Further analysis of the countries that have and/or arepunching above or below their economic weight more
holistically is likely to offer important lessons.

Establishment of the punching above their weightresearch network
It was in order to flesh out the contours of a wider conceptual and analytical framework that the international
Punching Above Their Weight Research Network was
established. It comprises researchers, policy actors

Future research agenda
Studies of the political and institutional context and history, a deeper understanding of policies on inequities,
including gender, a more refined picture of disease burdens and improved measures of national performance
were identified as being crucial to a future research
agenda to understand the dynamics of what enables acountry to do well in terms of life expectancy. Each areelaborated on below.
Political and institutional context and history

A full understanding of the geographic, environmental
sustainability, demographic, political, social and culturalcontext of a country is an essential background to understanding why it is ‘over’ or ‘under’ performing in
health terms relative to its economic status. While theCommission on the Social Determinants of Health [11]improved understanding of some of these dynamics,
Table 2 Punching Above Their Weight Research Network Purpose
1. Develop the capacity of members (by sharing knowledge andtechnical skills) to conduct research to understand why countries punch
above or below their weight
2. Cement collaborative relations needed to undertake the researchacross country contexts
3. Develop research questions and specific hypothesis (based on theory
and literature reviews) related to the complex interplay of politicalfactors, governance regimes, civil society action, and specific policies(including the role of the health system) that contribute to the ability ofa country/region to ‘punch above its weight’
4. Develop methodological frameworks to allow investigation of thesequestions including empirical work on the most appropriate way toidentify a diverse sample of countries that have or are punching above
their weight and appropriate ‘matched’ comparators.
5. Disseminate findings of research to international agencies, nationaland regional governments and civil society.

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Fig. 1 Preliminary framework to investigate why some countries punch above their weight in terms of healthfurther work using a complex systems analysis would be
helpful [12]. This approach would enable unpacking of
the relationships between different explanatory variables
and enable whole-of-context understanding. Social determinants interact in complex systems so that “patternsof population health outcomes are an emergent propertyof the system. They arise from a web of causations that
result from interactions among dynamic sets of interconnected systems” [13]. Such research needs to extend
beyond epidemiology to include political science andsociological analysis. Such work must also consider diversity within countries. This is well exemplified by the
Indian states, which have considerable political autonomy and very different health profiles and contexts [14].
More complex time-series work is required to track the
progress of countries over time, allowing greater understanding of the contribution of age, period, and cohort
effects and their causes. Some countries show steady upward progress (e.g. Sweden, Nepal) while others a more
punctuated and gradual gain (e.g. Rwanda, Bangladesh).
Others improve in a sprint and then may even decline(e.g. Zimbabwe). Work by Cardona and Bishai [15] suggests that economic growth is not associated with improved life expectancy when a time series analytical
approach is used.
To understand the influence of context, the role ofcivil society action in raising awareness and creating
democratic demand for improved health should be considered. Particular attention should also be devoted tothe political conditions and dominant power relationships that have given rise to good population health.

Szreter [16, 17] has conducted such research in relation
to nineteenth century England to explain how health improved following the industrial revolution and provides
insight into the political, economic and social insights
required to understand population health. The discussions
at the Bellagio meeting recognised that the political determinants of good health have rarely been unpacked and arestill not adequately understood. The Lancet- University ofOslo Commission added some broad understanding of
the global context and the implications of its work forcountries remains to be determined [7, 18]. Methods tosupport research seeking to understand complex interactions will be multi-disciplinary drawing on social scienceand public health methodologies. They will be a mix ofquantitative and qualitative methods. Quantitative data isrequired to describe the patterns of population healthchange including its distribution across different groups inthe population and how it changes over time and to describe changing social and economic conditions (e.g. unemployment levels and literacy rates). Qualitative data can
describe dynamics such as the distribution of power between groups and the extent to which civil society wasable advocate for health promoting policies in different
political contexts.
Policies affecting socio-economic inequities

We need a deeper understanding of the role of inequities
in resource distribution on overall population health.
Within populations, there are often large variations inhealth among groups defined by income, wealth, ethnicity,
race, education, and other characteristics. So far, mostBaum et al. International Journal for Equity in Health (2018) 17:117

research has focused on measures of socio-economic position in high-income countries [19, 20] but further
fine-grained analysis of the pathways by which theseeffects occur is required, especially in low andmiddle-income countries.
GenderHomogenous measures of life expectancy need to bebroken down by sex, with further investigation requiredon the role of gendered power dynamics in influencing
wellbeing. This will involve examining how gender roles,
gendered opportunities and gender based discriminationinfluence health outcomes in countries, studying how
these dynamics change over time to produce better orworse health for population groups. Within this analysis,
the complexity of relationships needs to be accommodated to examine, for example, how female empowerment may lead to both positive and negative healthimpacts for women, such as by increasing women’s access to education but also exposing women to culturaland marketing pressures that may increase the likelihoodthat they will engage in unhealthy activities such as
drinking and smoking. It is also important to look at thereasons why life expectancy among men is much lower
than women in some countries.
Disease burdens

Each country has a unique and changing disease burden[21], which reflects many factors, including its context andstage of development. Careful description and analysis of
this burden (types of infectious versus non-communicabledisease) and the responsiveness of particular types of disease to different determinants is required, including themagnitude of effects, and the time scale over which theyoccur. As an example, a significant proportion of the reduction in mortality in children under five in Brazil has been
attributed to the increase in female literacy [22].
New measures

Improved measures of progress that go beyond GDP are
required. More sophisticated measures, such as the
Genuine Progress Indicator (GPI) [23, 24] (which places
more emphasis on things that people value, including
leisure and volunteering and environmental impact) or
the Index of Sustainable Economic Welfare [25] (whichmeasures the depletion of resources) may facilitate understanding of health improvement. While such measures have been developed for high income countries[26, 27] they are also needed for low and middle income
countries, and their association with health requires exploration. In addition, more carefully refined measuresof health are required to consider the distribution ofhealth within populations.

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Conclusion
The Bellagio meeting proposed that while previous research had provided a partial list of ingredients for good
health, the complete recipe, listing all the ingredientsand explaining how best they should be combined was
not yet available. Our Punching Above Their Weight Research Network intends to build on the work describedhere and develop and conduct research within theframework presented in Fig. 1. We consider it essential
to conduct this detailed political, social and economic
analysis because the way research is framed also shapes
the responses of policy makers and political actors topopulation health. Maintaining the current useful, but incomplete, knowledge base will restrict the political andpolicy actions of the future to a limited focus on healthcare reforms (important as these are) leaving the underlying drivers for effective population health action hidden.
Acknowledgements
The Rockefeller Foundation supported the Bellagio meeting at which the
Punching Above Their Weight Research Network was formed.
Funding
Flinders University provided a capacity building grant to support the research
reported in this paper.
Authors’ contributions
Ideas for the paper developed from a meeting in which all authors contributed
to the ideas and framework research and analysis. FB wrote the first draft of thepaper. All authors contributed to redrafting and editing of the paper. All
authors read and approved the final manuscript.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in publishedmaps and institutional affiliations.
Author details
1Southgate Institute for Health, Society & Equity, Flinders University, Adelaide,
South Australia, Australia. 2Institute for Health Research, Lancaster University,
Bailrigg, Lancaster, UK. 3The Observatory of Public Policies and Health, Center
for Research in Epidemiology and Public Health, University of Alicante,
Alicante, Spain. 4Sarvodaya Shramadana Movement, Sarvodaya Headquarters“Damsak Mandira”, Moratuwa, Sri Lanka. 5Department of Community Health
Sciences, Patan Academy of Health Sciences, Kathmandu, Nepal. 6Integrated
Delivery Country Primary Health Care, Bill and Melinda Gates Foundation,
Abuja, Nigeria. 7New York City Department of Health and Mental Hygiene,
Office of General Counsel, Long Island City, New York, USA. 8Population,
Family, and Reproductive Health, Johns Hopkins University Bloomberg
School of Public Health, Baltimore, Maryland, USA. 9World Bank, Washington,
USA. 10School of Regulation and Global Governance (RegNet), Australian
National University, Canberra, Australian Capital Territory, Australia. 11Collegeof Asia and the Pacific, Australian National University, Canberra, Australian
Capital Territory, Australia. 12School of Medicine, Department of Pediatrics
and Child Care, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.
13
Health Economics and Epidemiology Research, School of Public Health,
University of Tokyo, Tokyo, Japan. 14Departments of Health Policy andBaum et al. International Journal for Equity in Health (2018) 17:117

Management and Community Health Sciences, UCLA Fielding School of
Public Health, Los Angeles, California, USA. 15European Public Health, London
School of Hygiene and Tropical Medicine, London, UK. 16Department of
Health Management and Organization, Hanoi Medical University, Hanoi,
Vietnam. 17Faculty of Community and Health, School of Public Health,
University of the Western Cape, Bellville, Republic of South Africa. 18Facultyof Medicine, Programa de Salud Ocupacional, Académico, Escuela de Salud
Pública, Universidad de Chile, Santiago, Chile. 19School of Health Systems
Research, Tata Institute of Social Sciences, Mumbai, India. 20School of Public
Health, University of the Western Cape, Bellville, South Africa.
Received: 16 May 2018 Accepted: 30 July 2018

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