Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations

A systematic analysis from the Global Burden of Disease Study 2016

GBD 2016 Healthcare Access and Quality Collaborators, Yohannes Kinfu, John J. McGrath, Mark Andrew Stokes

Research output: Contribution to journalArticle

60 Citations (Scopus)

Abstract

Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods: Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings: In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation: GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.

Original languageEnglish
Pages (from-to)2236-2271
Number of pages36
JournalThe Lancet
Volume391
Issue number10136
DOIs
Publication statusPublished - 2018

Fingerprint

Quality of Health Care
Demography
Universal Coverage
Global Burden of Disease
Health Services Accessibility
Health
Health Services
India
Cause of Death
China
Central African Republic
Guinea-Bissau
Catchment Area (Health)
Somalia
Tibet
Delivery of Health Care
Iceland
Secondary Care
Neoplasms
Southeastern Asia

Cite this

@article{580b6c898d854d22ac64a96c25bbd2ae,
title = "Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: A systematic analysis from the Global Burden of Disease Study 2016",
abstract = "Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods: Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings: In 2016, HAQ Index performance spanned from a high of 97·1 (95{\%} UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation: GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.",
keywords = "Communicable Diseases/epidemiology, Global Burden of Disease, Health Services Accessibility, Humans, Noncommunicable Diseases/epidemiology, Quality of Health Care, Wounds and Injuries/epidemiology",
author = "{GBD 2016 Healthcare Access and Quality Collaborators} and Nancy Fullman and Jamal Yearwood and Abay, {Solomon M.} and Cristiana Abbafati and Foad Abd-Allah and Jemal Abdela and Ahmed Abdelalim and Zegeye Abebe and Abebo, {Teshome Abuka} and Victor Aboyans and Abraha, {Haftom Niguse} and Abreu, {Daisy M.X.} and Abu-Raddad, {Laith J.} and Adane, {Akilew Awoke} and Adedoyin, {Rufus Adesoji} and Olatunji Adetokunboh and Adhikari, {Tara Ballav} and Mohsen Afarideh and Ashkan Afshin and Gina Agarwal and Dominic Agius and Anurag Agrawal and Sutapa Agrawal and {Ahmad Kiadaliri}, Aliasghar and Aichour, {Miloud Taki Eddine} and Mohammed Akibu and Akinyemi, {Rufus Olusola} and Akinyemiju, {Tomi F.} and Nadia Akseer and {Al Lami}, {Faris Hasan} and Fares Alahdab and Ziyad Al-Aly and Khurshid Alam and Tahiya Alam and Deena Alasfoor and Albittar, {Mohammed I.} and Alene, {Kefyalew Addis} and Ayman Al-Eyadhy and Ali, {Syed Danish} and Mehran Alijanzadeh and Aljunid, {Syed M.} and Ala'a Alkerwi and Fran{\cc}ois Alla and Peter Allebeck and Christine Allen and Alomari, {Mahmoud A.} and Rajaa Al-Raddadi and Ubai Alsharif and Altirkawi, {Khalid A.} and Nelson Alvis-Guzman and Amare, {Azmeraw T.} and Kebede Amenu and Walid Ammar and Amoako, {Yaw Ampem} and Nahla Anber and Andrei, {Catalina Liliana} and Sofia Androudi and Antonio, {Carl Abelardo T.} and Ara{\'u}jo, {Valdelaine E.M.} and Olatunde Aremu and Johan {\"A}rnl{\"o}v and Al Artaman and Aryal, {Krishna Kumar} and Hamid Asayesh and Asfaw, {Ephrem Tsegay} and Asgedom, {Solomon Weldegebreal} and Asghar, {Rana Jawad} and Ashebir, {Mengistu Mitiku} and Asseffa, {Netsanet Abera} and Atey, {Tesfay Mehari} and Atre, {Sachin R.} and Atteraya, {Madhu S.} and Leticia Avila-Burgos and Avokpaho, {Euripide Frinel G.Arthur} and Ashish Awasthi and {Ayala Quintanilla}, {Beatriz Paulina} and Ayalew, {Animut Alebel} and Ayele, {Henok Tadesse} and Rakesh Ayer and Ayuk, {Tambe Betrand} and Peter Azzopardi and Natasha Azzopardi-Muscat and Babalola, {Tesleem Kayode} and Hamid Badali and Alaa Badawi and Maciej Banach and Amitava Banerjee and Amrit Banstola and Barber, {Ryan M.} and Barboza, {Miguel A.} and Barker-Collo, {Suzanne L.} and Till B{\"a}rnighausen and Simon Barquera and Barrero, {Lope H.} and Quique Bassat and Sanjay Basu and Baune, {Bernhard T.} and Shahrzad Bazargan-Hejazi and Neeraj Bedi and Ettore Beghi and Masoud Behzadifar and Meysam Behzadifar and Bekele, {Bayu Begashaw} and Belachew, {Abate Bekele} and Belay, {Saba Abraham} and Belay, {Yihalem Abebe} and Bell, {Michelle L.} and Bello, {Aminu K.} and Bennett, {Derrick A.} and Bennett, {James R.} and Bensenor, {Isabela M.} and Berhe, {Derbew Fikadu} and Eduardo Bernab{\'e} and Bernstein, {Robert Steven} and Mircea Beuran and Ashish Bhalla and Paurvi Bhatt and Soumyadeep Bhaumik and Bhutta, {Zulfiqar A.} and Belete Biadgo and Ali Bijani and Boris Bikbov and Charles Birungi and Stan Biryukov and Hailemichael Bizuneh and Bolliger, {Ian W.} and Kaylin Bolt and Bou-Orm, {Ibrahim R.} and Kayvan Bozorgmehr and Brady, {Oliver Jerome} and Alexandra Brazinova and Breitborde, {Nicholas J.K.} and Hermann Brenner and Gabrielle Britton and Brugha, {Traolach S.} and Butt, {Zahid A.} and Lucero Cahuana-Hurtado and Campos-Nonato, {Ismael Ricardo} and Campuzano, {Julio Cesar} and Josip Car and Mate Car and Rosario C{\'a}rdenas and Carrero, {Juan Jesus} and Felix Carvalho and Casta{\~n}eda-Orjuela, {Carlos A.} and {Castillo Rivas}, Jacqueline and Ferr{\'a}n Catal{\'a}-L{\'o}pez and Kelly Cercy and Julian Chalek and Chang, {Hsing Yi} and Chang, {Jung Chen} and Aparajita Chattopadhyay and Pankaj Chaturvedi and Chiang, {Peggy Pei Chia} and Chisumpa, {Vesper Hichilombwe} and Choi, {Jee Young J.} and Hanne Christensen and Christopher, {Devasahayam Jesudas} and Chung, {Sheng Chia} and Ciobanu, {Liliana G.} and Massimo Cirillo and Danny Colombara and Sara Conti and Cyrus Cooper and Leslie Cornaby and Cortesi, {Paolo Angelo} and Monica Cortinovis and {Costa Pereira}, Alexandre and Ewerton Cousin and Criqui, {Michael H.} and Cromwell, {Elizabeth A.} and Crowe, {Christopher Stephen} and Crump, {John A.} and Daba, {Alemneh Kabeta} and Dachew, {Berihun Assefa} and Dadi, {Abel Fekadu} and Lalit Dandona and Rakhi Dandona and Dargan, {Paul I.} and Ahmad Daryani and Maryam Daryani and Jai Das and Das, {Siddharth Kumar} and {Das Neves}, Jos{\'e} and {Davis Weaver}, Nicole and Kairat Davletov and {De Courten}, Barbora and {De Leo}, Diego and {De Neve}, {Jan Walter} and Dellavalle, {Robert P.} and Gebre Demoz and Kebede Deribe and {Des Jarlais}, {Don C.} and Subhojit Dey and Dharmaratne, {Samath D.} and Meghnath Dhimal and Shirin Djalalinia and Doku, {David Teye} and Kate Dolan and Dorsey, {E. Ray} and {Dos Santos}, {Kadine Priscila Bender} and Doyle, {Kerrie E.} and Driscoll, {Tim R.} and Manisha Dubey and Eleonora Dubljanin and Duncan, {Bruce Bartholow} and Michelle Echko and Dumessa Edessa and David Edvardsson and Ehrlich, {Joshua R.} and Erika Eldrenkamp and Ziad El-Khatib and Matthias Endres and Endries, {Aman Yesuf} and Babak Eshrati and Sharareh Eskandarieh and Alireza Esteghamati and Mahdi Fakhar and Tamer Farag and Mahbobeh Faramarzi and Faraon, {Emerito Jose Aquino} and Andr{\'e} Faro and Farshad Farzadfar and Adesegun Fatusi and Fazeli, {Mir Sohail} and Feigin, {Valery L.} and Feigl, {Andrea B.} and Netsanet Fentahun and Fereshtehnejad, {Seyed Mohammad} and Eduarda Fernandes and Fernandes, {Jo{\~a}o C.} and Fijabi, {Daniel Obadare} and Irina Filip and Florian Fischer and Christina Fitzmaurice and Flaxman, {Abraham D.} and Flor, {Luisa Sorio} and Nataliya Foigt and Foreman, {Kyle J.} and Frostad, {Joseph J.} and Thomas F{\"u}rst and Futran, {Neal D.} and Emmanuela Gakidou and Silvano Gallus and Ketevan Gambashidze and Amiran Gamkrelidze and Morsaleh Ganji and Yohannes Kinfu and McGrath, {John J.} and Stokes, {Mark Andrew}",
year = "2018",
doi = "10.1016/S0140-6736(18)30994-2",
language = "English",
volume = "391",
pages = "2236--2271",
journal = "Lancet",
issn = "0140-6736",
publisher = "Elsevier Limited",
number = "10136",

}

Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations : A systematic analysis from the Global Burden of Disease Study 2016. / GBD 2016 Healthcare Access and Quality Collaborators ; Kinfu, Yohannes; McGrath, John J.; Stokes, Mark Andrew.

In: The Lancet, Vol. 391, No. 10136, 2018, p. 2236-2271.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations

T2 - A systematic analysis from the Global Burden of Disease Study 2016

AU - GBD 2016 Healthcare Access and Quality Collaborators

AU - Fullman, Nancy

AU - Yearwood, Jamal

AU - Abay, Solomon M.

AU - Abbafati, Cristiana

AU - Abd-Allah, Foad

AU - Abdela, Jemal

AU - Abdelalim, Ahmed

AU - Abebe, Zegeye

AU - Abebo, Teshome Abuka

AU - Aboyans, Victor

AU - Abraha, Haftom Niguse

AU - Abreu, Daisy M.X.

AU - Abu-Raddad, Laith J.

AU - Adane, Akilew Awoke

AU - Adedoyin, Rufus Adesoji

AU - Adetokunboh, Olatunji

AU - Adhikari, Tara Ballav

AU - Afarideh, Mohsen

AU - Afshin, Ashkan

AU - Agarwal, Gina

AU - Agius, Dominic

AU - Agrawal, Anurag

AU - Agrawal, Sutapa

AU - Ahmad Kiadaliri, Aliasghar

AU - Aichour, Miloud Taki Eddine

AU - Akibu, Mohammed

AU - Akinyemi, Rufus Olusola

AU - Akinyemiju, Tomi F.

AU - Akseer, Nadia

AU - Al Lami, Faris Hasan

AU - Alahdab, Fares

AU - Al-Aly, Ziyad

AU - Alam, Khurshid

AU - Alam, Tahiya

AU - Alasfoor, Deena

AU - Albittar, Mohammed I.

AU - Alene, Kefyalew Addis

AU - Al-Eyadhy, Ayman

AU - Ali, Syed Danish

AU - Alijanzadeh, Mehran

AU - Aljunid, Syed M.

AU - Alkerwi, Ala'a

AU - Alla, François

AU - Allebeck, Peter

AU - Allen, Christine

AU - Alomari, Mahmoud A.

AU - Al-Raddadi, Rajaa

AU - Alsharif, Ubai

AU - Altirkawi, Khalid A.

AU - Alvis-Guzman, Nelson

AU - Amare, Azmeraw T.

AU - Amenu, Kebede

AU - Ammar, Walid

AU - Amoako, Yaw Ampem

AU - Anber, Nahla

AU - Andrei, Catalina Liliana

AU - Androudi, Sofia

AU - Antonio, Carl Abelardo T.

AU - Araújo, Valdelaine E.M.

AU - Aremu, Olatunde

AU - Ärnlöv, Johan

AU - Artaman, Al

AU - Aryal, Krishna Kumar

AU - Asayesh, Hamid

AU - Asfaw, Ephrem Tsegay

AU - Asgedom, Solomon Weldegebreal

AU - Asghar, Rana Jawad

AU - Ashebir, Mengistu Mitiku

AU - Asseffa, Netsanet Abera

AU - Atey, Tesfay Mehari

AU - Atre, Sachin R.

AU - Atteraya, Madhu S.

AU - Avila-Burgos, Leticia

AU - Avokpaho, Euripide Frinel G.Arthur

AU - Awasthi, Ashish

AU - Ayala Quintanilla, Beatriz Paulina

AU - Ayalew, Animut Alebel

AU - Ayele, Henok Tadesse

AU - Ayer, Rakesh

AU - Ayuk, Tambe Betrand

AU - Azzopardi, Peter

AU - Azzopardi-Muscat, Natasha

AU - Babalola, Tesleem Kayode

AU - Badali, Hamid

AU - Badawi, Alaa

AU - Banach, Maciej

AU - Banerjee, Amitava

AU - Banstola, Amrit

AU - Barber, Ryan M.

AU - Barboza, Miguel A.

AU - Barker-Collo, Suzanne L.

AU - Bärnighausen, Till

AU - Barquera, Simon

AU - Barrero, Lope H.

AU - Bassat, Quique

AU - Basu, Sanjay

AU - Baune, Bernhard T.

AU - Bazargan-Hejazi, Shahrzad

AU - Bedi, Neeraj

AU - Beghi, Ettore

AU - Behzadifar, Masoud

AU - Behzadifar, Meysam

AU - Bekele, Bayu Begashaw

AU - Belachew, Abate Bekele

AU - Belay, Saba Abraham

AU - Belay, Yihalem Abebe

AU - Bell, Michelle L.

AU - Bello, Aminu K.

AU - Bennett, Derrick A.

AU - Bennett, James R.

AU - Bensenor, Isabela M.

AU - Berhe, Derbew Fikadu

AU - Bernabé, Eduardo

AU - Bernstein, Robert Steven

AU - Beuran, Mircea

AU - Bhalla, Ashish

AU - Bhatt, Paurvi

AU - Bhaumik, Soumyadeep

AU - Bhutta, Zulfiqar A.

AU - Biadgo, Belete

AU - Bijani, Ali

AU - Bikbov, Boris

AU - Birungi, Charles

AU - Biryukov, Stan

AU - Bizuneh, Hailemichael

AU - Bolliger, Ian W.

AU - Bolt, Kaylin

AU - Bou-Orm, Ibrahim R.

AU - Bozorgmehr, Kayvan

AU - Brady, Oliver Jerome

AU - Brazinova, Alexandra

AU - Breitborde, Nicholas J.K.

AU - Brenner, Hermann

AU - Britton, Gabrielle

AU - Brugha, Traolach S.

AU - Butt, Zahid A.

AU - Cahuana-Hurtado, Lucero

AU - Campos-Nonato, Ismael Ricardo

AU - Campuzano, Julio Cesar

AU - Car, Josip

AU - Car, Mate

AU - Cárdenas, Rosario

AU - Carrero, Juan Jesus

AU - Carvalho, Felix

AU - Castañeda-Orjuela, Carlos A.

AU - Castillo Rivas, Jacqueline

AU - Catalá-López, Ferrán

AU - Cercy, Kelly

AU - Chalek, Julian

AU - Chang, Hsing Yi

AU - Chang, Jung Chen

AU - Chattopadhyay, Aparajita

AU - Chaturvedi, Pankaj

AU - Chiang, Peggy Pei Chia

AU - Chisumpa, Vesper Hichilombwe

AU - Choi, Jee Young J.

AU - Christensen, Hanne

AU - Christopher, Devasahayam Jesudas

AU - Chung, Sheng Chia

AU - Ciobanu, Liliana G.

AU - Cirillo, Massimo

AU - Colombara, Danny

AU - Conti, Sara

AU - Cooper, Cyrus

AU - Cornaby, Leslie

AU - Cortesi, Paolo Angelo

AU - Cortinovis, Monica

AU - Costa Pereira, Alexandre

AU - Cousin, Ewerton

AU - Criqui, Michael H.

AU - Cromwell, Elizabeth A.

AU - Crowe, Christopher Stephen

AU - Crump, John A.

AU - Daba, Alemneh Kabeta

AU - Dachew, Berihun Assefa

AU - Dadi, Abel Fekadu

AU - Dandona, Lalit

AU - Dandona, Rakhi

AU - Dargan, Paul I.

AU - Daryani, Ahmad

AU - Daryani, Maryam

AU - Das, Jai

AU - Das, Siddharth Kumar

AU - Das Neves, José

AU - Davis Weaver, Nicole

AU - Davletov, Kairat

AU - De Courten, Barbora

AU - De Leo, Diego

AU - De Neve, Jan Walter

AU - Dellavalle, Robert P.

AU - Demoz, Gebre

AU - Deribe, Kebede

AU - Des Jarlais, Don C.

AU - Dey, Subhojit

AU - Dharmaratne, Samath D.

AU - Dhimal, Meghnath

AU - Djalalinia, Shirin

AU - Doku, David Teye

AU - Dolan, Kate

AU - Dorsey, E. Ray

AU - Dos Santos, Kadine Priscila Bender

AU - Doyle, Kerrie E.

AU - Driscoll, Tim R.

AU - Dubey, Manisha

AU - Dubljanin, Eleonora

AU - Duncan, Bruce Bartholow

AU - Echko, Michelle

AU - Edessa, Dumessa

AU - Edvardsson, David

AU - Ehrlich, Joshua R.

AU - Eldrenkamp, Erika

AU - El-Khatib, Ziad

AU - Endres, Matthias

AU - Endries, Aman Yesuf

AU - Eshrati, Babak

AU - Eskandarieh, Sharareh

AU - Esteghamati, Alireza

AU - Fakhar, Mahdi

AU - Farag, Tamer

AU - Faramarzi, Mahbobeh

AU - Faraon, Emerito Jose Aquino

AU - Faro, André

AU - Farzadfar, Farshad

AU - Fatusi, Adesegun

AU - Fazeli, Mir Sohail

AU - Feigin, Valery L.

AU - Feigl, Andrea B.

AU - Fentahun, Netsanet

AU - Fereshtehnejad, Seyed Mohammad

AU - Fernandes, Eduarda

AU - Fernandes, João C.

AU - Fijabi, Daniel Obadare

AU - Filip, Irina

AU - Fischer, Florian

AU - Fitzmaurice, Christina

AU - Flaxman, Abraham D.

AU - Flor, Luisa Sorio

AU - Foigt, Nataliya

AU - Foreman, Kyle J.

AU - Frostad, Joseph J.

AU - Fürst, Thomas

AU - Futran, Neal D.

AU - Gakidou, Emmanuela

AU - Gallus, Silvano

AU - Gambashidze, Ketevan

AU - Gamkrelidze, Amiran

AU - Ganji, Morsaleh

AU - Kinfu, Yohannes

AU - McGrath, John J.

AU - Stokes, Mark Andrew

PY - 2018

Y1 - 2018

N2 - Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods: Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings: In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation: GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.

AB - Background: A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Methods: Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0-100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0-100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. Findings: In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8-98·1) in Iceland, followed by 96·6 (94·9-97·9) in Norway and 96·1 (94·5-97·3) in the Netherlands, to values as low as 18·6 (13·1-24·4) in the Central African Republic, 19·0 (14·3-23·7) in Somalia, and 23·4 (20·2-26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1-93·6) in Beijing to 48·0 (43·4-53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6-68·8) in Goa to 34·0 (30·3-38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. Interpretation: GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view-and subsequent provision-of quality health care for all populations.

KW - Communicable Diseases/epidemiology

KW - Global Burden of Disease

KW - Health Services Accessibility

KW - Humans

KW - Noncommunicable Diseases/epidemiology

KW - Quality of Health Care

KW - Wounds and Injuries/epidemiology

UR - http://www.scopus.com/inward/record.url?scp=85047728707&partnerID=8YFLogxK

U2 - 10.1016/S0140-6736(18)30994-2

DO - 10.1016/S0140-6736(18)30994-2

M3 - Article

VL - 391

SP - 2236

EP - 2271

JO - Lancet

JF - Lancet

SN - 0140-6736

IS - 10136

ER -