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

• Published in: The Lancet
• Main Authors: Lozano, Rafael, Fullman, Nancy, Mumford, John Everett, Knight, Megan, Barthelemy, Celine M, Abbafati, Cristiana, Abbastabar, Hedayat, Abd-Allah, Foad, Abdollahi, Mohammad, Abedi, Aidin, Abolhassani, Hassan, Abosetugn, Akine Eshete, Abreu, Lucas Guimarães, Abrigo, Michael R M, Abu Haimed, Abdulaziz Khalid, Abushouk, Abdelrahman I, Adabi, Maryam, Adebayo, Oladimeji M, Adekanmbi, Victor, Adelson, Jaimie, Adetokunboh, Olatunji O, Adham, Davoud, Advani, Shailesh M, Afshin, Ashkan, Agarwal, Gina, Agasthi, Pradyumna, Aghamir, Seyed Mohammad Kazem, Agrawal, Anurag, Ahmad, Tauseef, Akinyemi, Rufus Olusola, Alahdab, Fares, Al-Aly, Ziyad, Alam, Khurshid, Albertson, Samuel B, Alemu, Yihun Mulugeta, Alhassan, Robert Kaba, Ali, Muhammad, Ali, Saqib, Alipour, Vahid, Aljunid, Syed Mohamed, Alla, François, Almadi, Majid Abdulrahman Hamad, Almasi, Ali, Almasi-Hashiani, Amir, Almasri, Nihad A, Al-Mekhlafi, Hesham M, Almulhim, Abdulaziz M, Alonso, Jordi, Al-Raddadi, Rajaa M, Altirkawi, Khalid A, Alvis-Guzman, Nelson, Alvis-Zakzuk, Nelson J, Amini, Saeed, Amini-Rarani, Mostafa, Amiri, Fatemeh, Amit, Arianna Maever L, Amugsi, Dickson A, Ancuceanu, Robert, Anderlini, Deanna, Andrei, Catalina Liliana, Androudi, Sofia, Ansari, Fereshteh, Ansari-Moghaddam, Alireza, Antonio, Carl Abelardo T, Antony, Catherine M, Antriyandarti, Ernoiz, Anvari, Davood, Anwer, Razique, Arabloo, Jalal, Arab-Zozani, Morteza, Aravkin, Aleksandr Y, Aremu, Olatunde, Ärnlöv, Johan, Asaad, Malke, Asadi-Aliabadi, Mehran, Asadi-Pooya, Ali A, Ashbaugh, Charlie, Athari, Seyyed Shamsadin, Atout, Maha Moh'd Wahbi, Ausloos, Marcel, Avila-Burgos, Leticia, Ayala Quintanilla, Beatriz Paulina, Ayano, Getinet, Ayanore, Martin Amogre, Aynalem, Yared Asmare, Aynalem, Getie Lake, Ayza, Muluken Altaye, Azari, Samad, Azzopardi, Peter S, B, Darshan B, Babaee, Ebrahim, Badiye, Ashish D, Bahrami, Mohammad Amin, Baig, Atif Amin, Bakhshaei, Mohammad Hossein, Bakhtiari, Ahad, Bakkannavar, Shankar M, Balachandran, Arun, Balassyano, Shelly, Banach, Maciej, Banerjee, Srikanta K, Banik, Palash Chandra, Bante, Agegnehu Bante, Bante, Simachew Animen, Barker-Collo, Suzanne Lyn, Bärnighausen, Till Winfried, Barrero, Lope H, Bassat, Quique, Basu, Sanjay, Baune, Bernhard T, Bayati, Mohsen, Baye, Bayisa Abdissa, Bedi, Neeraj, Beghi, Ettore, Behzadifar, Masoud, Bekuma, Tariku Tesfaye Tesfaye, Bell, Michelle L, Bensenor, Isabela M, Berman, Adam E, Bernabe, Eduardo, Bernstein, Robert S, Bhagavathula, Akshaya Srikanth, Bhandari, Dinesh, Bhardwaj, Pankaj, Bhat, Anusha Ganapati, Bhattacharyya, Krittika, Bhattarai, Suraj, Bhutta, Zulfiqar A, Bijani, Ali, Bikbov, Boris, Bilano, Ver, Biondi, Antonio, Birihane, Binyam Minuye, Bockarie, Moses John, Bohlouli, Somayeh, Bojia, Hunduma Amensisa, Bolla, Srinivasa Rao Rao, Boloor, Archith, Brady, Oliver J, Braithwaite, Dejana, Briant, Paul Svitil, Briggs, Andrew M, Briko, Nikolay Ivanovich, Burugina Nagaraja, Sharath, Busse, Reinhard, Butt, Zahid A, Caetano dos Santos, Florentino Luciano, Cahuana-Hurtado, Lucero, Cámera, Luis Alberto, Cárdenas, Rosario, Carreras, Giulia, Carrero, Juan J, Carvalho, Felix, Castaldelli-Maia, Joao Mauricio, Castañeda-Orjuela, Carlos A, Castelpietra, Giulio, Castro, Franz, Catalá-López, Ferrán, Causey, Kate, Cederroth, Christopher R, Cercy, Kelly M, Cerin, Ester, Chandan, Joht Singh, Chang, Angela Y, Charan, Jaykaran, Chattu, Vijay Kumar, Chaturvedi, Sarika, Chin, Ken Lee, Cho, Daniel Youngwhan, Choi, Jee-Young Jasmine, Christensen, Hanne, Chu, Dinh-Toi, Chung, Michael T, Ciobanu, Liliana G, Cirillo, Massimo, Comfort, Haley, Compton, Kelly, Cortesi, Paolo Angelo, Costa, Vera Marisa, Cousin, Ewerton, Dahlawi, Saad M A, Damiani, Giovanni, Dandona, Lalit, Dandona, Rakhi, Darega Gela, Jiregna, Darwesh, Aso Mohammad, Daryani, Ahmad, Dash, Aditya Prasad, Davey, Gail, Dávila-Cervantes, Claudio Alberto, Davletov, Kairat, De Neve, Jan-Walter, Denova-Gutiérrez, Edgar, Deribe, Kebede, Dervenis, Nikolaos, Desai, Rupak, Dharmaratne, Samath Dhamminda, Dhungana, Govinda Prasad, Dianatinasab, Mostafa, Dias da Silva, Diana, Diaz, Daniel, Dippenaar, Ilse N, Do, Hoa Thi, Dorostkar, Fariba, Doshmangir, Leila, Duncan, Bruce B, Duraes, Andre Rodrigues, Eagan, Arielle Wilder, Edvardsson, David, El Sayed, Iman, El Tantawi, Maha, Elgendy, Islam Y, Elyazar, Iqbal RF, Eskandari, Khalil, Eskandarieh, Sharareh, Esmaeilnejad, Saman, Esteghamati, Alireza, Ezekannagha, Oluchi, Farag, Tamer, Farahmand, Mohammad, Faraon, Emerito Jose A, Farinha, Carla Sofia e Sá, Farioli, Andrea, Faris, Pawan Sirwan, Faro, Andre, Fazlzadeh, Mehdi, Feigin, Valery L, Fernandes, Eduarda, Ferrara, Pietro, Feyissa, Garumma Tolu, Filip, Irina, Fischer, Florian, Fisher, James L, Flor, Luisa Sorio, Foigt, Nataliya A, Folayan, Morenike Oluwatoyin, Fomenkov, Artem Alekseevich, Foroutan, Masoud, Francis, Joel Msafiri, Fu, Weijia, Fukumoto, Takeshi, Furtado, João M, Gad, Mohamed M, Gaidhane, Abhay Motiramji, Gakidou, Emmanuela, Galles, Natalie C, Gallus, Silvano, Gardner, William M, Geberemariyam, Biniyam Sahiledengle, Gebrehiwot, Abiyu Mekonnen, Gebremeskel, Leake G, Gebremeskel, Gebreamlak Gebremedhn, Gesesew, Hailay Abrha, Ghadiri, Keyghobad, Ghafourifard, Mansour, Ghashghaee, Ahmad, Ghith, Nermin, Gholamian, Asadollah, Gilani, Syed Amir, Gill, Paramjit Singh, Gill, Tiffany K, Ginindza, Themba G, Gitimoghaddam, Mojgan, Giussani, Giorgia, Glagn, Mustefa, Gnedovskaya, Elena V, Godinho, Myron Anthony, Goharinezhad, Salime, Gopalani, Sameer Vali, Goudarzian, Amir Hossein, Goulart, Bárbara Niegia Garcia, Gubari, Mohammed Ibrahim Mohialdeen, Guimarães, Rafael Alves, Guled, Rashid Abdi, Gultie, Teklemariam, Guo, Yuming, Gupta, Rajeev, Gupta, Rahul, Hafezi-Nejad, Nima, Hafiz, Abdul, Haile, Teklehaimanot Gereziher, Hamadeh, Randah R, Hameed, Sajid, Hamidi, Samer, Han, Chieh, Han, Hannah, Handiso, Demelash Woldeyohannes, Hanif, Asif, Hankey, Graeme J, Haro, Josep Maria, Hasaballah, Ahmed I, Hasan, Md Mehedi, Hashi, Abdiwahab, Hassan, Shoaib, Hassan, Amr, Hassanipour, Soheil, Hassankhani, Hadi, Havmoeller, Rasmus J, Hay, Simon I, Hayat, Khezar, Heidari, Golnaz, Heidari-Soureshjani, Reza, Hendrie, Delia, Herteliu, Claudiu, Hird, Thomas R, Ho, Hung Chak, Hole, Michael K, Holla, Ramesh, Hollingsworth, Bruce, Hoogar, Praveen, Hopf, Kathleen Pillsbury, Horita, Nobuyuki, Hossain, Naznin, Hosseini, Mostafa, Hosseinzadeh, Mehdi, Hostiuc, Mihaela, Hostiuc, Sorin, Househ, Mowafa, Hsieh, Vivian Chia-rong, Hu, Guoqing, Huda, Tanvir M, Humayun, Ayesha, Hwang, Bing-Fang, Iavicoli, Ivo, Ibitoye, Segun Emmanuel, Ikeda, Nayu, Ilesanmi, Olayinka Stephen, Ilic, Irena M, Ilic, Milena D, Inbaraj, Leeberk Raja, Iqbal, Usman, Irvani, Seyed Sina Naghibi, Irvine, Caleb Mackay Salpeter, Islam, M Mofizul, Islam, Sheikh Mohammed Shariful, Islami, Farhad, Iso, Hiroyasu, Iwu, Chinwe Juliana, Iwu, Chidozie C D, Jaafari, Jalil, Jadidi-Niaragh, Farhad, Jafarinia, Morteza, Jahagirdar, Deepa, Jahani, Mohammad Ali, Jahanmehr, Nader, Jakovljevic, Mihajlo, Janjani, Hosna, Javaheri, Tahereh, Jayatilleke, Achala Upendra, Jenabi, Ensiyeh, Jha, Ravi Prakash, Jha, Vivekanand, Ji, John S, Jia, Peng, John-Akinola, Yetunde O, Jonas, Jost B, Joukar, Farahnaz, Jozwiak, Jacek Jerzy, Jürisson, Mikk, Kabir, Zubair, Kalankesh, Leila R, Kalhor, Rohollah, Kamath, Aruna M, Kanchan, Tanuj, Kapoor, Neeti, Karami Matin, Behzad, Karanikolos, Marina, Karimi, Seyed M, Kassebaum, Nicholas J, Katikireddi, Srinivasa Vittal, Kayode, Gbenga A, Keiyoro, Peter Njenga, Khader, Yousef Saleh, Khammarnia, Mohammad, Khan, Maseer, Khan, Ejaz Ahmad, Khang, Young-Ho, Khatab, Khaled, Khater, Amir M, Khater, Mona M, Khatib, Mahalaqua Nazli, Khayamzadeh, Maryam, Khubchandani, Jagdish, Kianipour, Neda, Kim, Young-Eun, Kim, Yun Jin, Kimokoti, Ruth W, Kinfu, Yohannes, Kisa, Adnan, Kissimova-Skarbek, Katarzyna, Kivimäki, Mika, Kneib, Cameron J, Kocarnik, Jonathan M, Kochhar, Sonali, Kohler, Stefan, Kopec, Jacek A, Korotkova, Anna V, Korshunov, Vladimir Andreevich, Kosen, Soewarta, Kotlo, Anirudh, Koul, Parvaiz A, Koyanagi, Ai, Krishan, Kewal, Krohn, Kris J, Kugbey, Nuworza, Kulkarni, Vaman, Kumar, G Anil, Kumar, Nithin, Kumar, Manasi, Kurmi, Om P, Kusuma, Dian, Kyu, Hmwe Hmwe, La Vecchia, Carlo, Lacey, Ben, Lal, Dharmesh Kumar, Lalloo, Ratilal, Landires, Iván, Lansingh, Van Charles, Larsson, Anders O, Lasrado, Savita, Lau, Kathryn Mei-Ming, Lauriola, Paolo, Lazarus, Jeffrey V, Ledesma, Jorge R, Lee, Paul H, Lee, Shaun Wen Huey, Leever, Andrew T, LeGrand, Kate E, Leigh, James, Leonardi, Matilde, Li, Shanshan, Lim, Stephen S, Lim, Lee-Ling, Liu, Xuefeng, Logroscino, Giancarlo, Lopez, Alan D, Lopukhov, Platon D, Lotufo, Paulo A, Lu, Alton, Ma, Jianing, Madadin, Mohammed, Mahasha, Phetole Walter, Mahmoudi, Morteza, Majeed, Azeem, Malagón-Rojas, Jeadran N, Maleki, Shokofeh, Malta, Deborah Carvalho, Mansouri, Borhan, Mansournia, Mohammad Ali, Martini, Santi, Martins-Melo, Francisco Rogerlândio, Martopullo, Ira, Massenburg, Benjamin Ballard, Mastrogiacomo, Claudia I, Mathur, Manu Raj, McAlinden, Colm, McKee, Martin, Medina-Solís, Carlo Eduardo, Meharie, Birhanu Geta, Mehndiratta, Man Mohan, Mehrabi Nasab, Entezar, Mehri, Fereshteh, Mehrotra, Ravi, Mekonnen, Teferi, Melese, Addisu, Memiah, Peter T N, Mendoza, Walter, Menezes, Ritesh G, Mensah, George A, Meretoja, Tuomo J, Meretoja, Atte, Mestrovic, Tomislav, Miazgowski, Bartosz, Michalek, Irmina Maria, Mirrakhimov, Erkin M, Mirzaei, Maryam, Mirzaei-Alavijeh, Mehdi, Mitchell, Philip B, Moazen, Babak, Moghadaszadeh, Masoud, Mohamadi, Efat, Mohammad, Yousef, Mohammad, Dara K, Mohammad Gholi Mezerji, Naser, Mohammadian-Hafshejani, Abdollah, Mohammed, Shafiu, Mohammed, Jemal Abdu, Mokdad, Ali H, Monasta, Lorenzo, Mondello, Stefania, Moradi, Masoud, Moradi-Lakeh, Maziar, Moradzadeh, Rahmatollah, Moraga, Paula, Morgado-da-Costa, Joana, Morrison, Shane Douglas, Mosapour, Abbas, Mosser, Jonathan F, Mousavi Khaneghah, Amin, Muriithi, Moses K, Mustafa, Ghulam, Nabhan, Ashraf F, Naderi, Mehdi, Nagarajan, Ahamarshan Jayaraman, Naghavi, Mohsen, Naghshtabrizi, Behshad, Naimzada, Mukhammad David, Nangia, Vinay, Nansseu, Jobert Richie, Nayak, Vinod C, Nazari, Javad, Ndejjo, Rawlance, Negoi, Ionut, Negoi, Ruxandra Irina, Neupane, Subas, Ngari, Kiirithio N, Nguefack-Tsague, Georges, Ngunjiri, Josephine W, Nguyen, Cuong Tat, Nguyen, Diep Ngoc, Nguyen, Huong Lan Thi, Nnaji, Chukwudi A, Nomura, Shuhei, Norheim, Ole F, Noubiap, Jean Jacques, Nowak, Christoph, Nunez-Samudio, Virginia, Otoiu, Adrian, Ogbo, Felix Akpojene, Oghenetega, Onome Bright, Oh, In-Hwan, Okunga, Emmanuel Wandera, Oladnabi, Morteza, Olagunju, Andrew T, Olusanya, Jacob Olusegun, Olusanya, Bolajoko Olubukunola, Oluwasanu, Mojisola Morenike, Omar Bali, Ahmed, Omer, Muktar Omer, Ong, Kanyin L, Onwujekwe, Obinna E, Ortega-Altamirano, Doris V V, Ortiz, Alberto, Ostojic, Sergej M, Otstavnov, Nikita, Otstavnov, Stanislav S, Øverland, Simon, Owolabi, Mayowa O, Padubidri, Jagadish Rao., Pakhale, Smita, Palladino, Raffaele, Pana, Adrian, Panda-Jonas, Songhomitra, Pangaribuan, Helena Ullyartha, Pathak, Mona, Patton, George C, Paudel, Sagun, Pazoki Toroudi, Hamidreza, Pease, Spencer A, Peden, Amy E, Pennini, Alyssa, Peprah, Emmanuel K, Pereira, Jeevan, Pigott, David M, Pilgrim, Thomas, Pilz, Tessa M, Pinheiro, Marina, Piradov, Michael A, Pirsaheb, Meghdad, Pokhrel, Khem Narayan, Postma, Maarten J, Pourjafar, Hadi, Pourmalek, Farshad, Pourmirza Kalhori, Reza, Pourshams, Akram, Prada, Sergio I, Pribadi, Dimas Ria Angga, Pupillo, Elisabetta, Quazi Syed, Zahiruddin, Radfar, Amir, Rafiee, Ata, Rafiei, Alireza, Raggi, Alberto, Rahim, Fakher, Rahman, Muhammad Aziz, Rajabpour-Sanati, Ali, Rana, Saleem Muhammad, Ranabhat, Chhabi Lal, Rao, Sowmya J, Rasella, Davide, Rashedi, Vahid, Rath, Goura Kishor, Rathi, Priya, Rawaf, Salman, Rawaf, David Laith, Rawal, Lal, Rawassizadeh, Reza, Razo, Christian, Renjith, Vishnu, Renzaho, Andre M N, Reshmi, Bhageerathy, Rezaei, Nima, Riahi, Seyed Mohammad, Ribeiro, Daniel Cury, Rickard, Jennifer, 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• Format: Article in Journal/Newspaper
• Language: English
• Published: ELSEVIER 2020
• Subjects: WA. 900 Vital Statistics; Iceland
• Online Access: http://eprints.skums.ac.ir/8695/; http://eprints.skums.ac.ir/8695/1/1-s2.0-S0140673620307509-main.pdf; https://reader.elsevier.com/reader/sd/pii/S0140673620307509?token=0FE76717537F020B7B0A7EB9FAD3AA32F53772F99C6377D4D0162FBF55E5DD7FCBA085A1D679816C3AAFC010A77F2F51; https://doi.org/10.1016/S0140-6736(20)30750-9

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. Copyright (C) 2020 The Author(s). Published by Elsevier Ltd. Keywords SUSTAINABLE DEVELOPMENT GOALS; CANCER SURVIVAL; PROGRESS; QUALITY; ACCESS; CARE