INTRODUCTION

To monitor inequities in health and develop international comparisons for policy-making, evaluation, and feedback [1], it is essential to identify major life events and measure population health. Summarizing population health provides the basis for meaningful life indices and for understanding life expectancy [2]. The 1990 Global Burden of Disease (GBD) study represented a major milestone by defining diseases and health conditions as the sum of years of life lost (YLLs) and years lived with disability (YLDs) [3], establishing disability-adjusted life years (DALYs) as the standard indicator for quantifying disease burden. One DALY reflects the loss of 1 year of full health. DALYs combine YLLs resulting from premature mortality with YLDs.

Since the early 1990s, DALYs have been used to summarize population health across 204 countries nationally and 21 countries sub-nationally [4]. Recently, the Institute for Health Metrics and Evaluation (IHME) has led this work by integrating diverse data sources with statistical modeling and regularly refining methodologies and datasets [5]. In Korea, numerous studies have examined the national disease burden since the early 2000s [6], extending through 2024 [7]. Over time, the increasing number of analyzed diseases has enabled more comprehensive national estimates [6-9]. The most recent systematic study, covering 2008 to 2020, demonstrated a persistent upward trend in Korea’s disease burden. In particular, the burden attributable to chronic conditions such as diabetes and low back pain increased substantially compared with earlier years, suggesting that the overall rise in burden is being driven by chronic illnesses.

The Korean National Burden of Disease (KNBD) study previously assessed DALYs from 2008 to 2020. Initiated by the Ministry of Health and Welfare’s Research and Development Project, the study operationalized the GBD methodology for Korean data. However, it did not account for changes during the coronavirus disease 2019 (COVID-19) period, including the extensive lockdowns that continued through 2021. These pandemic-related preventive measures influenced DALYs by reducing healthcare utilization and altering disease burdens related to immobility.

In addition to DALYs, disability-adjusted life expectancy (DALE) is an important policy metric used to establish health objectives aimed at reducing disparities and improving national health by prioritizing interventions targeting risk factors [10]. DALE is a summary measure that estimates the average number of years a person can expect to live in full health at a given age [2,11]. Most KNBD studies have reported DALYs and DALE separately. Although this allows for detailed analysis of each indicator, it limits a multidimensional understanding of Korea’s total disease burden. DALE, in particular, provides a more intuitive depiction of population health than DALYs alone. Therefore, analyzing both measures simultaneously facilitates a more comprehensive assessment of national health.

Accordingly, this study updates the trends in Korea’s disease burden by analyzing DALYs and DALE concurrently from 2008 to 2021. These updated estimates serve as foundational data to support the development of future national health policies.

METHODS

Study Design

DALYs are calculated based on YLDs and YLLs, whereas DALE is derived from YLDs. YLDs and YLLs are estimated for each disease according to a disease classification system. To ensure consistency and continuity in data interpretation, we used the disease classification framework from previous KNBD studies.

YLDs and YLLs can be estimated using prevalence-based or incidence-based methods [12]. In this study, we adopted the incidence-based approach to maintain consistency with earlier KNBD analyses and align with the available data required to estimate YLDs and YLLs.

YLLs represent years lost due to premature mortality and are calculated using cause-of-death data. However, the specific methodology varies depending on how mortality data are structured and classified. For example, some causes of death, such as frailty, are not accepted as valid underlying causes and are reassigned to appropriate disease categories through a redistribution process that uses “garbage codes.” For consistency across diseases, our study applied the same garbage-code redistribution system developed in earlier KNBD research to estimate YLLs [13].

To convert disease burden into a unified YLD metric, we applied condition-specific disability weights (DWs), which reflect the severity and impact of each condition [14]. The selection of DWs depends on the research objective: standardized DWs support global comparability, whereas country-specific DWs reflect national clinical, social, and cultural contexts. Because our objective was to evaluate Korea’s disease burden, we used country-specific DWs previously developed for the Korean population [14].

COVID-19’s disease burden was assessed using prior disease classifications, and incident cases were not ascertained; therefore, YLDs were not estimated [7,8,10]. For mortality, deaths were not coded to COVID-19 as the underlying cause but instead were redistributed to other causes using the same garbage-code methodology applied in estimating YLLs [13].

Data Sources

We used 3 data sources to estimate DALYs and DALE in Korea for 2021. YLLs were calculated using premature mortality data from Statistics Korea’s Cause of Death Statistics. For YLDs, incident case data for communicable, maternal, neonatal, and nutritional disorders and for non-communicable diseases (NCDs) were obtained from the National Health Insurance Service (NHIS) claims database, whereas injury data were derived from the Korea Disease Control and Prevention Agency’s Korean National Hospital Discharge In-depth Injury Survey (Supplemental Material 1). Unlike studies that relied on 2019 injury data to estimate incidence for 2020, we updated the injury dataset to reflect 2020 to ensure greater accuracy in DALY and DALE calculations.

Korea’s single-payer health insurance system, administered by the NHIS, provides universal coverage. Because the system operates under a fee-for-service reimbursement model, claims data provide a reliable basis for evaluating national healthcare use patterns [15]. These data are also suitable for identifying incident cases by assessing whether individuals received care for the same diagnosis within a specified reference period. For this reason, KNBD studies employ an incidence-based approach to measuring disease burden. Our study followed the same disease classification system, case definitions, and washout period used in previous KNBD studies [1].

Disability-adjusted Life Year and Disability-adjusted Life Expectancy Calculations

DALYs are the sum of YLDs and YLLs. YLLs are calculated by subtracting the age at death from the standard life expectancy for that age group and multiplying the result by the number of premature deaths. YLDs are estimated by multiplying the number of incident cases of a disease by the corresponding disability weight and the average disease duration. The basic formula for DALYs is shown in equation (1):

(1)

DALYs=YLLs+YLDs=N cause×L+I cause×DW cause×L cause

where N cause is the number of deaths at a specific age, L is the YLLs due to death at a specific age, I cause is the number of incident cases of a specific disease, DW cause is the disability weight for a specific disease, and L cause is the average disease duration.

We calculated DALE using YLD data together with Sullivan’s method, which estimates life expectancy based on population size and the number of deaths in the population, and then adjusts this using the YLD. Age-specific YLD rates were determined by dividing the number of YLDs by the population in each age group. These YLD rates were then used to estimate the number of years lived in full health (i.e., health-adjusted years) for each age group. The cumulative sum of these health-adjusted years produced the total health-adjusted survival time, which was then divided by the number of survivors in each age group to obtain the final DALE estimate [16].

Statistical Analysis

We used descriptive analysis to estimate DALYs and DALE by year, gender, income level, and region. Income level was determined using NHIS insured data, with health insurance premiums serving as a proxy. Household equivalized income was calculated by dividing the monthly insurance premium by the square root of total household members.

For the regional analysis, we divided Korea into 250 administrative units (si/gun/gu) based on the 2021 administrative structure, which includes 17 metropolitan cities and provinces (si/do) subdivided into 250 si/gun/gu units. Because age-specific mortality data were incomplete at more granular geographic levels, we selected the si/gun/gu level to ensure reliable life expectancy estimates. NHIS insured data were also used for regional classification.

We estimated average morbidity duration using NHIS-derived epidemiological data modeled through DISMOD-II [17]. All data preprocessing and DALY and DALE calculations were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

Ethics Statement

This study was exempted from review by the Institutional Review Board of Korea University (IRB No. KUIRB-2023-0244-01).

RESULTS

Disability-adjusted Life Year Trends From 2008 to 2021

From 2008 to 2021, DALY rates in Korea steadily increased from 2008 to 2019, followed by a marked decline in 2020 (Figure 1). Specifically, the DALY rate rose from 22 361 per 100 000 population in 2008 to 26 069 in 2021, representing a 16.58% increase over the study period. In 2020, the rate declined to 25 254 per 100 000 population, reflecting a temporary decrease from 2019 before climbing again in 2021 to levels comparable to those in 2018. This shift occurred between 2019 and 2020, when COVID-19 first emerged: we observed a sudden decrease in the disease burden immediately after the outbreak, followed by a gradual return toward the prior trajectory. Notably, the decline in DALYs in 2020 was smaller than that reported in previous studies. Disaggregated by component, YLLs showed a persistent decline, decreasing from 4384 per 100 000 in 2008 to 4260 in 2021, whereas YLDs demonstrated a continuous upward trend, increasing from 17 978 per 100 000 in 2008 to 21 809 in 2021.

In DALY trends by income, the ratio between the lowest-income quintile (first quintile) and the highest-income quintile (fifth quintile) declined from 1.42 in 2008 to 1.31 in 2012, followed by a slight increase to 1.36 in 2019. This ratio rose sharply thereafter, reaching 1.41 in 2020 and 1.47 in 2021 (Figure 2). Meanwhile, DALYs among individuals in the highest-income quintile showed a consistent upward trajectory, increasing from 28 229 per 100 000 population in 2008 to 34 634 in 2021.

Based on the level 2 disease classification, our analysis of Korea’s 2021 DALY distribution shows that NCDs accounted for 89.8% of the national burden, making them the dominant contributor. In particular, diabetes, urogenital, blood, and endocrine diseases and cardiovascular and circulatory diseases accounted for 17.6% and 14.1%, respectively, of total DALYs among men, and 14.5% and 10.7% among women, indicating a substantial burden across genders (Supplemental Material 1). Comparing the leading causes of DALYs in 2008, 2020, and 2021 revealed a growing burden from chronic diseases and a notable decline in injuries, especially transport-related injuries (Figure 3). The decrease in DALYs attributable to transport injuries between 2020 and 2021 was particularly pronounced and exceeded the decline for other injury-related causes during the same period.

Disability-adjusted Life Expectancy Trends From 2008 to 2021

Our analysis of DALE trends from 2008 to 2021 showed a consistent upward trajectory across the total population, both genders, and all income groups (Supplemental Material 2). The overall DALE in Korea rose from 68.89 years in 2008 to 71.57 years in 2021. Among men, DALE increased from 66.47 years to 69.29 years, whereas among women it rose from 71.00 years to 73.62 years. However, in 2012, men and women in the highest-income group experienced a slight decline in DALE. In 2018, DALE in the lowest-income quintile declined from 63.27 to 62.44 years among men and from 68.91 years to 68.23 years among women.

The DALE gap according to gender remained relatively stable, decreasing slightly from 4.53 years in 2008 to 4.33 years in 2021. By contrast, the DALE gap between the highest-income and lowest-income groups widened from 7.94 to 8.54 years over the same period. While DALE increased notably in 2020, a slight decline occurred in 2021.

Overall, women consistently had higher DALE than men. In both genders, those in the lowest-income quintile showed the shortest DALE. The DALE disparity between the highest-income and lowest-income groups was more pronounced among men than among women (Figure 4). Specifically, for men, the gap widened from 8.64 years in 2008 to 9.79 years in 2021, whereas for women it decreased slightly from 6.70 years to 6.47 years. In addition, DALE showed a modest increase in 2020 compared with previous studies.

For regional DALE disparities, the gap between the 5th percentile and 95th percentile regions widened from 4.88 years in 2008 to 6.29 years in 2016. However, this gap gradually narrowed, decreasing to 4.87 years by 2021 (Figure 5). This decline was more pronounced among women. From 2016 to 2021, the regional DALE gap among men decreased from 7.21 years to 6.26 years, whereas that among women declined more sharply (from 5.90 to 4.33 years) indicating a faster reduction in regional inequality in women healthy life expectancy.

DISCUSSION

In updating Korea’s DALY and DALE estimates for 2008 to 2021, our work aligns with Korea’s ongoing efforts to regularly update its national burden of disease statistics [18]. By extending estimates through 2021, we were able to more closely examine the pandemic’s impact on disease burden. Previous studies reported DALY and DALE only up to 2020 [7,19]. Following the emergence of COVID-19, YLDs in Korea declined substantially because of social distancing and reduced access to medical care, while DALE increased notably. However, when examining data through 2021, we found that the earlier reduction in YLDs had diminished, with YLD levels returning to those seen in 2018. We also observed that DALE in 2021 exceeded that of 2019 but remained lower than the peak observed in 2020.

Comparing the rankings of major diseases by DALYs between 2019 (pre-pandemic) and 2021 (during the pandemic) enables a more rigorous assessment of how COVID-19 affected disease burden (Figure 3). The decline in the DALY rankings of chronic obstructive pulmonary disease (from 4th to 10th) and asthma (from 14th to 31st) suggests reduced exposure to respiratory infections via improved hand hygiene and widespread mask use. Similarly, decreases in the rankings of falls (from 9th to 11th) and motorized vehicle accidents involving 3 or more wheels (from 13th to 52nd) likely reflect reduced injury risk attributable to social distancing. These findings underscore the value of adopting a broader public health approach—rather than relying solely on treatment-based strategies—when aiming to reduce overall disease burden. Effective strategies should combine high-risk, treatment-focused interventions with population-level approaches that can prevent infectious diseases, injuries, and NCDs [20].

As noted, and unlike previous studies, we reported DALY and DALE metrics together. Summary measures of population health (SMPH), which reflect both mortality and functional health loss, include indicators expressed in life years (such as DALY) and indicators expressed in life expectancy (such as DALE or quality-adjusted life expectancy) [2]. Each type of indicator has strengths and limitations. Indicators expressed in life years are useful for comparing disease-specific priorities and formulating targeted strategies to reduce burden, whereas indicators expressed in life expectancy offer a single, intuitive measure that is easily communicated to the public. Therefore, selecting the appropriate indicator for each situation is necessary for effective healthcare planning. By presenting DALY and DALE together, we aimed to enrich interpretation and provide a dual-purpose SMPH that can inform multiple policy initiatives, including Korea’s 5th National Health Plan (HP2030) [21].

Although Korea’s DALE continues to increase overall, our results indicate that greater attention is needed to address the DALE income gap. Although this disparity improved slightly in 2021 relative to 2020, the DALE gaps remained 9.78 years for men and 6.47 years for women. If current trends persist, Korea may not achieve its HP2030 target of reducing the healthy life expectancy income gap to below 7.6 years by 2030 [22]. To reduce DALE inequality by income, closer examination of DALY income disparities is needed to identify which diseases contribute most to these gaps. Given that the DALE income gap differs by gender, it is likely that the diseases driving inequality also differ, underscoring the need for more detailed analysis of gender-specific DALY patterns [23].

However, it is encouraging that Korea’s regional DALE disparities are decreasing. The regional DALE gap, which was 6.29 years in 2016, declined to 4.87 years in 2021—its lowest level since 2010 (4.68 years). As Korea’s HP2030 prioritizes reducing regional differences in healthy life expectancy, our findings provide a basis for evaluating strategies to meet this goal [22]. Recent national efforts to address the uneven distribution of medical resources include proposing the relevance index (RI), which measures the proportion of medical care received within a resident’s own region [24]. By examining DALY and RI together, policymakers can identify which strategies should be prioritized to both reduce disease burden and establish a more equitable regional medical system. In particular, diseases with high DALY values but low RI may impose disproportionate burdens on local residents that are not fully reflected in DALY alone. Therefore, to reduce regional disease burden, it is essential to evaluate multiple disease burden indicators in combination.

By comparing the DALY rankings by disease in 2008, 2020, and 2021, we can identify which diseases require closer attention. Diabetes ranked first across all 3 years. Accordingly, it is essential to assess whether Korea is implementing appropriate interventions to address the disease burden associated with diabetes [1]. Reducing this burden requires a comprehensive review of primary prevention strategies (e.g., smoking cessation, alcohol abstinence, and increased physical activity) to prevent disease onset; secondary prevention strategies for early detection (e.g., enhanced awareness of blood sugar levels and higher participation in general health checkups); and tertiary prevention strategies to support blood sugar control and prevent complications among patients with diabetes (e.g., improving treatment adherence and expanding regular fundus examinations). Given the substantial disease burden from diabetes, Korea should consider providing financial support comparable to or exceeding that allocated to cancer or emergency diseases [25]. Interventions targeting diabetes are also expected to reduce the burden of ischemic stroke—the third leading cause of DALYs in 2021—and ischemic heart disease, which ranked fifth.

Korea also needs strategies to reduce the DALYs attributable to low back pain, which consistently ranked high across comparison years [26]. Although low back pain is well recognized in burden of disease studies, public awareness and social attention remain limited. Low back pain decreases mobility and work capacity, imposing substantial burdens on individuals, families, and society [27]. Yet Korea lacks systematic strategies to mitigate this burden compared with other major conditions. The issue has often been framed narrowly as a treatment matter between medical staff and patients, leading to excessive imaging and use of treatment methods with uncertain efficacy [28]. Thus, strategies must emphasize not only regular exercise, weight management, and smoking cessation to alleviate symptoms, but also improvements in occupational and ergonomic environments that contribute to low back pain [29]. More detailed analyses of the burden of low back pain by gender, age group, and occupation could help establish tailored strategies targeting specific subpopulations.

Although this study contributes by extending DALY and DALE estimates through 2021 and presenting both metrics together, several limitations warrant discussion. First, we did not include COVID-19 as a direct cause of disease because our estimates extended only to 2021. Future research covering a longer measurement period should consider explicitly incorporating COVID-19 as a disease entity. Second, although our analysis examined DALY and DALE through 2021 to assess pandemic impacts, we could not evaluate the long-term effects of COVID-19. Expanded analyses using data through 2023 would allow for better identification of prolonged impacts. Third, we calculated DALYs using an incidence-based approach, whereas the GBD adopts a prevalence-based approach. Thus, direct comparisons with GBD estimates must be made cautiously. Given the advantages and disadvantages of each approach [12], future Korean burden of disease studies should also calculate prevalence-based DALYs to enhance comparability and methodological robustness.

In this study, we updated DALY and DALE estimates, which are key summary measures of population health, in Korea from 2008 to 2021. The patterns of DALY and DALE by gender, income level, and region can guide systematic strategies to reduce the national burden of disease. The usefulness of DALY and DALE in policy-making depends on our collective ability to decrease DALYs and increase DALE by improving health risk factors. Continued efforts are needed to refine burden-of-disease measurement, enhance accuracy, and expand the domains included in future estimates. In combination with regular updates of DALY and DALE, such improvements can ultimately contribute to strategies that enhance the health of Koreans by enabling more precise assessments of disease burdens across diverse conditions.

Supplemental Materials

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

This study was supported by the National R&D Program for Cancer Control through the National Cancer Center, funded by the Ministry of Health & Welfare, Republic of Korea (RS-2025-02213322).

Acknowledgements

None.

Author Contributions

Conceptualization: Kim CN, Ock M, Yoon SJ. Data curation: Kim CN, Urgi D, Kim YE, Jung YS, Choi Y, Ock M, Yoon SJ. Formal analysis: Kim CN, Urgi D, Kim YE, Jung YS, Choi Y. Funding acquisition: Yoon SJ. Visualization: Kim CN, Ock M, Yoon SJ. Writing – original draft: Kim CN, Urgi D, Ock M. Writing – review & editing: Kim CN, Urgi D, Kim YE, Jung YS, Choi Y, Ock M, Yoon SJ.

Figure. 1.

Trends in the burden of disease in Korea from 2008 to 2021. YLL, years of life lost; YLD, years lived with disability; DALY, disability-adjusted life year.

Figure. 2.

Trends in the burden of disease by income quintile from 2008 to 2021. DALY, disability-adjusted life year.

Figure. 3.

Shifts in the leading causes of the disease burden in 2008, 2020, and 2021.

Figure. 4.

Trends in disability-adjusted life expectancy (DALE) by gender (A: men, B: women) and income level from 2008 to 2021.

Figure. 5.

Trends in disparities in disability-adjusted life expectancy (DALE) by gender and region from 2008 to 2021.

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Figure & Data

References

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