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Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

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posted on 09.12.2020, 11:56 by Rafael Lozano, Nancy Fullman, John Everett Mumford, Megan Knight, Celine M Barthelemy, Cristiana Abbafati, Hedayat Abbastabar, Foad Abd-Allah, Mohammad Abdollahi, Aidin Abedi, Hassan Abolhassani, Akine Eshete Abosetugn, Lucas Guimaraes Abreu, Michael RM Abrigo, Abdulaziz Khalid Abu Haimed, Abdelrahman I Abushouk, Maryam Adabi, Oladimeji M Adebayo, Victor Adekanmbi, Jaimie D Adelson, Olatunji O Adetokunboh, Davoud Adham, Shailesh M Advani, Ashkan Afshin, Gina Agarwal, Pradyumna Agasthi, Seyed Mohammad Kazem Aghamir, Anurag Agrawal, Tauseef Ahmad, Rufus Olusola Akinyemi, Fares Alahdab, Ziyad Al-Aly, Khurshid Alam, Samuel B Albertson, Yihun Mulugeta Alemu, Robert Kaba Alhassan, Muhammad Ali, Saqib Ali, Vahid Alipour, Syed Mohamed Aljunid, Francois Alla, Majid Abdulrahman Hamad Almadi, Ali Almasi, Amir Almasi-Hashiani, Nihad A Almasri, Hesham M Al-Mekhlafi, Abdulaziz M Almulhim, Jordi Alonso, Rajaa M Al-Raddadi, Khalid A Altirkawi, Nelson Alvis-Guzman, Nelson J Alvis-Zakzuk, Saeed Amini, Mostafa Amini-Rarani, Fatemeh Amiri, Arianna Maever L Amit, Dickson A Amugsi, Robert Ancuceanu, Deanna Anderlini, Catalina Liliana Andrei, Sofia Androudi, Fereshteh Ansari, Alireza Ansari-Moghaddam, Carl Abelardo T Antonio, Catherine M Antony, Ernoiz Antriyandarti, Davood Anvari, Razique Anwer, Jalal Arabloo, Morteza Arab-Zozani, Aleksandr Y Aravkin, Olatunde Aremu, Johan Arnlov, Malke Asaad, Mehran Asadi-Aliabadi, Ali A Asadi-Pooya, Charlie Ashbaugh, Seyyed Shamsadin Athari, Maha Moh'd Wahbi Atout, Marcel Ausloos, Leticia Avila-Burgos, Beatriz Paulina Ayala Quintanilla, Getinet Ayano, Martin Amogre Ayanore, Getie Lake Aynalem, Yared Asmare Aynalem, Muluken Altaye Ayza, Samad Azari, Peter S Azzopardi, BB Darshan, Ebrahim Babaee, Ashish D Badiye, Mohammad Amin Bahrami, Atif Amin Baig, Mohammad Hossein Bakhshaei, Ahad Bakhtiari, Shankar M Bakkannavar, Arun Balachandran, Shelly Balassyano, Maciej Banach, Srikanta K Banerjee, Palash Chandra Banik, Agegnehu Bante Bante, Simachew Animen Bante, Suzanne Lyn Barker-Collo, Till Winfried Barnighausen, Lope H Barrero, Quique Bassat, Sanjay Basu, Bernhard T Baune, Mohsen Bayati, Bayisa Abdissa Baye, Neeraj Bedi, Ettore Beghi, Masoud Behzadifar, Tariku Tesfaye Tesfaye Bekuma, Michelle L Bell, Isabela M Bensenor, Adam E Berman, Eduardo Bernabe, Robert S Bernstein, Akshaya Srikanth Bhagavathula, Dinesh Bhandari, Pankaj Bhardwaj, Anusha Ganapati Bhat, Krittika Bhattacharyya, Suraj Bhattarai, Zulfiqar A Bhutta, Ali Bijani, Boris Bikbov, Ver Bilano, Antonio Biondi, Binyam Minuye Birihane, Moses John Bockarie, Somayeh Bohlouli, Hunduma Amensisa Bojia, Srinivasa Rao Rao Bolla, Archith Boloor, Oliver J Brady, Dejana Braithwaite, Paul Svitil Briant, Andrew M Briggs, Nikolay Ivanovich Briko, Sharath Burugina Nagaraja, Reinhard Busse, Zahid A Butt, Florentino Luciano Caetano dos Santos, Lucero Cahuana-Hurtado, Luis Alberto Camera, Rosario Cardenas, Giulia Carreras, Juan J Carrero, Felix Carvalho, Joao Mauricio Castaldelli-Maia, Carlos A Castaneda-Orjuela, Giulio Castelpietra, Franz Castro, Ferran Catala-Lopez, Kate Causey, Christopher R Cederroth, Kelly M Cercy, Ester Cerin, Joht Singh Chandan, Angela Y Chang, Jaykaran Charan, Vijay Kumar Chattu, Sarika Chaturvedi, Ken Lee Chin, Daniel Youngwhan Cho, Jee-Young Jasmine Choi, Hanne Christensen, Dinh-Toi Chu, Michael T Chung, Liliana G Ciobanu, Massimo Cirillo, Haley Comfort, Kelly Compton, Paolo Angelo Cortesi, Vera Marisa Costa, Ewerton Cousin, Saad MA Dahlawi, Giovanni Damiani, Lalit Dandona, Rakhi Dandona, Jiregna Darega Gela, Aso Mohammad Darwesh, Ahmad Daryani, Aditya Prasad Dash, Gail Davey, Claudio Alberto Davila-Cervantes, Kairat Davletov, Jan-Walter De Neve, Edgar Denova-Gutierrez, Kebede Deribe, Nikolaos Dervenis, Rupak Desai, Samath Dhamminda Dharmaratne, Govinda Prasad Dhungana, Mostafa Dianatinasab, Diana Dias da Silva, Daniel Diaz, Ilse N Dippenaar, Thi Do Hoa, Fariba Dorostkar, Leila Doshmangir, Bruce B Duncan, Andre Rodrigues Duraes, Arielle Wilder Eagan, David Edvardsson, Iman El Sayed, Maha El Tantawi, Islam Y Elgendy, Iqbal RF Elyazar, Khalil Eskandari, Sharareh Eskandarieh, Saman Esmaeilnejad, Alireza Esteghamati, Oluchi Ezekannagha, Tamer Farag, Mohammad Farahmand, Emerito Jose A Faraon, Carla Sofia e Sa Farinha, Andrea Farioli, Pawan Sirwan Faris, Andre Faro, Mehdi Fazlzadeh, Valery L Feigin, Eduarda Fernandes, Pietro Ferrara, Garumma Tolu Feyissa, Irina Filip, Florian Fischer, James L Fisher, Luisa Sorio Flor, Nataliya A Foigt, Morenike Oluwatoyin Folayan, Artem Alekseevich Fomenkov, Masoud Foroutan, Joel Msafiri Francis, Weijia Fu, Takeshi Fukumoto, Joao M Furtado, Mohamed M Gad, Abhay Motiramji Gaidhane, Emmanuela Gakidou, Natalie C Galles, Silvano Gallus, William M Gardner, Biniyam Sahiledengle Geberemariyam, Abiyu Mekonnen Gebrehiwot, Gebreamlak Gebremedhn Gebremeskel, Leake G Gebremeskel, Hailay Abrha Gesesew, Keyghobad Ghadiri, Mansour Ghafourifard, Ahmad Ghashghaee, Nermin Ghith, Asadollah Gholamian, Syed Amir Gilani, Paramjit Singh Gill, Tiffany K Gill, Themba G Ginindza, Mojgan Gitimoghaddam, Giorgia Giussani, Mustefa Glagn, Elena V Gnedovskaya, Myron Anthony Godinho, Salime Goharinezhad, Sameer Vali Gopalani, Amir Hossein Goudarzian, Barbara Niegia Garcia Goulart, Mohammed Ibrahim Mohialdeen Gubari, Rafael Alves Guimaraes, Rashid Abdi Guled, Teklemariam Gultie, Yuming Guo, Rahul Gupta, Rajeev Gupta, Nima Hafezi-Nejad, Abdul Hafiz, Teklehaimanot Gereziher Haile, Randah R Hamadeh, Sajid Hameed, Samer Hamidi, Chieh Han, Hannah Han, Demelash Woldeyohannes Handiso, Asif Hanif, Graeme J Hankey, Josep Maria Haro, Ahmed I Hasaballah, Md Mehedi Hasan, Abdiwahab Hashi, Amr Hassan, Shoaib Hassan, Soheil Hassanipour, Hadi Hassankhani, Rasmus J Havmoeller, Simon I Hay, Khezar Hayat, Golnaz Heidari, Reza Heidari-Soureshjani, Delia Hendrie, Claudiu Herteliu, Thomas R Hird, Hung Chak Ho, Michael K Hole, Ramesh Holla, Praveen Hoogar, Kathleen Pillsbury Hopf, Nobuyuki Horita, Naznin Hossain, Mostafa Hosseini, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Mowafa Househ, Vivian Chia-rong Hsieh, Guoqing Hu, Tanvir M Huda, Ayesha Humayun, Bing-Fang Hwang, Ivo Iavicoli, Segun Emmanuel Ibitoye, Nayu Ikeda, Olayinka Stephen Ilesanmi, Irena M Ilic, Milena D Ilic, Leeberk Raja Inbaraj, Usman Iqbal, Seyed Sina Naghibi Irvani, Caleb Mackay Salpeter Irvine, M Mofizul Islam, Sheikh Mohammed Shariful Islam, Farhad Islami, Hiroyasu Iso, Chidozie CD Iwu, Chinwe Juliana Iwu, Jalil Jaafari, Farhad Jadidi-Niaragh, Morteza Jafarinia, Deepa Jahagirdar, Mohammad Ali Jahani, Nader Jahanmehr, Mihajlo Jakovljevic, Hosna Janjani, Tahereh Javaheri, Achala Upendra Jayatilleke, Ensiyeh Jenabi, Ravi Prakash Jha, Vivekanand Jha, John S Ji, Peng Jia, Yetunde O John-Akinola, Jost B Jonas, Farahnaz Joukar, Jacek Jerzy Jozwiak, Mikk Jurisson, Zubair Kabir, Leila R Kalankesh, Rohollah Kalhor, Aruna M Kamath, Tanuj Kanchan, Neeti Kapoor, Behzad Karami Matin, Marina Karanikolos, Seyed M Karimi, Nicholas J Kassebaum, Srinivasa Vittal Katikireddi, Gbenga A Kayode, Peter Njenga Keiyoro, Yousef Saleh Khader, Mohammad Khammarnia, Ejaz Ahmad Khan, Maseer Khan, Young-Ho Khang, Khaled Khatab, Amir M Khater, Mona M Khater, Mahalaqua Nazli Khatib, Maryam Khayamzadeh, Jagdish Khubchandani, Neda Kianipour, Young-Eun Kim, Yun Jin Kim, Ruth W Kimokoti, Yohannes Kinfu, Adnan Kisa, Katarzyna Kissimova-Skarbek, Mika Kivimaki, Cameron J Kneib, Jonathan M Kocarnik, Sonali Kochhar, Stefan Kohler, Jacek A Kopec, Anna V Korotkova, Vladimir Andreevich Korshunov, Soewarta Kosen, Anirudh Kotlo, Parvaiz A Koul, Ai Koyanagi, Kewal Krishan, Kris J Krohn, Nuworza Kugbey, Vaman Kulkarni, G Anil Kumar, Manasi Kumar, Nithin Kumar, Om P Kurmi, Dian Kusuma, Hmwe Hmwe Kyu, Carlo La Vecchia, Ben Lacey, Dharmesh Kumar Lal, Ratilal Lalloo, Ivan Landires, Van Charles Lansingh, Anders O Larsson, Savita Lasrado, Kathryn Mei-Ming Lau, Paolo Lauriola, Jeffrey V Lazarus, Jorge R Ledesma, Paul H Lee, Shaun Wen Huey Lee, Andrew T Leever, Kate E LeGrand, James Leigh, Matilde Leonardi, Shanshan Li, Lee-Ling Lim, Stephen S Lim, Xuefeng Liu, Giancarlo Logroscino, Alan D Lopez, Platon D Lopukhov, Paulo A Lotufo, Alton Lu, Jianing Ma, Mohammed Madadin, Phetole Walter Mahasha, Morteza Mahmoudi, Azeem Majeed, Jeadran N Malagon-Rojas, Shokofeh Maleki, Deborah Carvalho Malta, Borhan Mansouri, Mohammad Ali Mansournia, Santi Martini, Francisco Rogerlandio Martins-Melo, Ira Martopullo, Benjamin Ballard Massenburg, Claudia I Mastrogiacomo, Manu Raj Mathur, Colm McAlinden, Martin McKee, Carlo Eduardo Medina-Solis, Birhanu Geta Meharie, Man Mohan Mehndiratta, Entezar Mehrabi Nasab, Fereshteh Mehri, Ravi Mehrotra, Teferi Mekonnen, Addisu Melese, Peter TN Memiah, Walter Mendoza, Ritesh G Menezes, George A Mensah, Atte Meretoja, Tuomo J Meretoja, Tomislav Mestrovic, Bartosz Miazgowski, Irmina Maria Michalek, Erkin M Mirrakhimov, Maryam Mirzaei, Mehdi Mirzaei-Alavijeh, Philip B Mitchell, Babak Moazen, Masoud Moghadaszadeh, Efat Mohamadi, Dara K Mohammad, Yousef Mohammad, Naser Mohammad Gholi Mezerji, Abdollah Mohammadian-Hafshejani, Jemal Abdu Mohammed, Shafiu Mohammed, Ali H Mokdad, Lorenzo Monasta, Stefania Mondello, Masoud Moradi, Maziar Moradi-Lakeh, Rahmatollah Moradzadeh, Paula Moraga, Joana Morgado-da-Costa, Shane Douglas Morrison, Abbas Mosapour, Jonathan F Mosser, Amin Mousavi Khaneghah, Moses K Muriithi, Ghulam Mustafa
Background: Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods: Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings: Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation: The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC. Funding: Bill & Melinda Gates Foundation.

History

Citation

The Lancet, Volume 396, Issue 10258, 17–23 October 2020, Pages 1250-1284

Author affiliation

School of Business

Version

VoR (Version of Record)

Published in

LANCET

Volume

396

Issue

10258

Pagination

1250 - 1284 (35)

Publisher

Elsevier

issn

0140-6736

eissn

1474-547X

Copyright date

2020

Available date

27/08/2020

Spatial coverage

England

Language

English