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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Résumé

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.

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La notice

Revue

The Lancet

Thématique

Healthcare Systems and Reforms

Domaine

Economics, Econometrics and Finance

Établissements canadiens

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Organismes subventionnaires

Division of Human Resource DevelopmentFogarty International CenterNational Institute of General Medical SciencesNational Human Genome Research InstituteNorwegian Institute of Public HealthDipartimento di Medicina e Chirurgia, Università degli Studi di Milano-BicoccaNIHR Nottingham Biomedical Research CentreResearch Management Centre, International Islamic University MalaysiaNIHR Oxford Biomedical Research CentreLee Kong Chian School of Medicine, Nanyang Technological UniversityCenter for International HealthResearch Institute for Endocrine Sciences, Shahid Beheshti University of Medical SciencesGastrointestinal and Liver Diseases Research CenterInstituto de Salud Carlos IIIRussian Academy of SciencesFundação para a Ciência e a TecnologiaMenzies Centre for Australian Studies, King's College London, University of LondonMedical Research CouncilĐại học Quốc gia Hà NộiSchool of Public Health and Family Medicine, University of Cape TownUniwersytet OpolskiUniversidad de Ciencias Aplicadas y AmbientalesUniversity of Veterinary and Animal SciencesUniversidade Federal do Espírito SantoNational Institutes of Biomedical Innovation, Health and NutritionAmbo UniversityBispebjerg HospitalMahatma Gandhi UniversityUniversidad Autónoma de SinaloaFuel Cell Technologies ProgramUniversidade Federal de SergipeARC Centre of Excellence for Children and Families over the Life CourseDuke Kunshan UniversityUniversiti Sultan Zainal AbidinI.M. Sechenov First Moscow State Medical UniversityRazi Vaccine and Serum Research InstituteUniversity of Fort HareLorestan University of Medical SciencesAlborz University of Medical SciencesAfrican Academy of SciencesUniversity Of Nigeria NsukkaAlexandria UniversityNational Center of Neurology and PsychiatryMekelle UniversityInternational Centre for Diarrhoeal Disease Research, BangladeshGeorge Institute for Global HealthUniversity of PeradeniyaXiamen UniversityWuhan University of Science and TechnologyEuropean Social FundTarbiat Modares UniversityTartu ÜlikoolUniversitas Sebelas MaretYoung Researchers and Elite ClubUniversidade Federal de Minas GeraisSecretaria Nacional de Ciencia y TecnologíaInstitute for Social and Economic ChangeChina Medical UniversityUrmia UniversityUniversity of Cape TownSemnan UniversityWachemo UniversityUniversidade Federal de Santa CatarinaNazarbayev UniversityWuhan UniversityUniversitas Muhammadiyah SurakartaUniversidade do PortoUniversity of TabrizUnitatea Executiva pentru Finantarea Invatamantului Superior, a Cercetarii, Dezvoltarii si InovariiUniversity of TsukubaQazvin University of Medical SciencesMinistério da Ciência, Tecnologia e Ensino SuperiorZanjan University of Medical SciencesUniversity of GondarUnited Arab Emirates UniversityBangladesh University of Health SciencesUniversità di BolognaBahir Dar UniversityShahid Beheshti University of Medical SciencesUniversitat de BarcelonaUniversidade Federal de GoiásNational Research University Higher School of EconomicsUniversidad Nacional Autónoma de MéxicoShahroud University of Medical SciencesBabol University of Medical SciencesUniversity of JordanHealth Research Council of New ZealandUniversità degli Studi di PerugiaBinzhou Medical UniversityMaragheh University of Medical SciencesUniwersytet ŁódzkiBHF Centre of Research Excellence, OxfordDanmarks Tekniske UniversitetBirjand University of Medical SciencesGuilan University of Medical SciencesUniversitair Medisch Centrum GroningenUmeå UniversitetHaramaya UniversityUniversità degli Studi di PaviaInyuvesi Yakwazulu-NataliNorth-West UniversityDuke Global Health Institute, Duke UniversityUniversitetet i BergenMinistarstvo Prosvete, Nauke i Tehnološkog RazvojaUniversity College LondonUniversiti Kebangsaan MalaysiaAl-Farabi Kazakh National UniversityUniversity of WaterlooKuwait UniversityTabriz University of Medical SciencesVetenskapsrådetUniversidad Autónoma MetropolitanaSeoul National University HospitalNational Institute of Mental HealthCollege of Environmental Science and Forestry, State University of New YorkFundação de Amparo à Pesquisa do Estado do Rio Grande do SulUniversity of PennsylvaniaTsinghua UniversityEuropean Regional Development FundKarolinska InstitutetConselho Nacional de Desenvolvimento Científico e TecnológicoUniversitat de ValènciaCentral South UniversityMinistero della SaluteUniversidad Nacional de ColombiaChandigarh UniversityWellcome TrustKorea UniversityYonsei UniversitySecretaría Nacional de Ciencia, Tecnología e InnovaciónUniversity of CanberraCairo UniversityFakultet Medicinskih Nauka, Univerziteta U KragujevcuWuhan Polytechnic UniversityShiraz University of Medical SciencesAin Shams UniversityBundesministerium für Bildung und ForschungCoordenação de Aperfeiçoamento de Pessoal de Nível SuperiorJames Cook UniversityMarch of Dimes FoundationCurtin University of TechnologyUniversity of South AustraliaDeakin UniversityRajshahi UniversityAutoritatea Natională pentru Cercetare StiintificăUniversity of New South WalesMinistry of Education, Culture, Sports, Science and TechnologyAmity UniversityApplied Molecular Biosciences UnitPublic Health Foundation of IndiaWestfälische Wilhelms-Universität MünsterIndian Council of Medical ResearchSultan Qaboos UniversityDepartment of Science and Technology, Ministry of Science and Technology, IndiaRoyal College of Surgeons in IrelandSouth African Medical Research CouncilKaiser PermanenteLondon South Bank UniversityStudent Research Committee, Tabriz University of Medical SciencesUniversità degli Studi di Napoli Federico IILa Trobe UniversityUniversidad ICESITehran Heart CenterUniversity of TwenteHealth Services Management Research CenterAustralian Catholic UniversityEmory UniversityUniversità di CataniaThe Wellcome Trust DBT India AllianceUniversity of CalcuttaNational Research FoundationCardiff UniversityCentre for Heart Rhythm Disorders, University of AdelaideJackson State UniversityOhio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research InstituteUniversity of BathSydney Medical SchoolNewcastle UniversityMashhad University of Medical SciencesMassachusetts General HospitalUniwersytet Jagielloński Collegium MedicumShiraz UniversityEscola Nacional de Saúde Pública Sérgio AroucaPublic Health EnglandUniversity of TorontoImperial College LondonKing's College LondonOhio State UniversityUniversity of WarwickMcMaster UniversityUniversity of LeicesterUniversity of East AngliaBritish Heart FoundationUniversity of QueenslandUniversity of Health and Allied SciencesTufts Medical CenterA.T. Still UniversityNational Institute for Health and Care ResearchUniversidade de São PauloTechnische Universität BerlinUniversity of Health Sciences LahoreKrishna Institute Of Medical Sciences Deemed To Be UniversityUniversity of Southern CaliforniaAlexander von Humboldt-StiftungTribhuvan UniversityNational Institutes of HealthSoutheast UniversityBanaras Hindu UniversityWollega UniversityNational University of SingaporeTrường Đại học Nguyễn Tất ThànhMinistério da SaúdeDepartment of Science and Innovation, South AfricaFederation University AustraliaBill and Melinda Gates FoundationInstitució Catalana de Recerca i Estudis AvançatsNational Heart Foundation of AustraliaIstituto di Ricerche Farmacologiche Mario Negri - IRCCSUniversität BaselHögskolan i BoråsUniversiteit StellenboschComunidad de MadridKhalifa University of Science, Technology and ResearchUniversity of OttawaNational Authority for Scientific Research and InnovationAn-Najah National UniversityMadda Walabu UniversityKerman University of Medical SciencesTrường Đại học Duy TânUniverzita Karlova v PrazeTexas Tech UniversityUniversity of Oklahoma Health Sciences CenterUniversità degli Studi di UdineHögskolan DalarnaMurdoch UniversitySheffield Hallam UniversityUniversity of ColomboUniversidade Federal do Rio Grande do SulAgencja Badań MedycznychArabian Gulf UniversityKasturba Medical College, ManipalBirmingham City UniversityOttawa Hospital Research InstituteSeoul National UniversityBurnet InstituteLaboratório Associado para a Química VerdeThomas Jefferson UniversityUniversity of Texas Health Science Center at HoustonQatar UniversityBournemouth UniversityJimma UniversityYale UniversityUniversity of CalgaryFundação de Amparo à Pesquisa do Estado de Minas GeraisNanyang Technological UniversityAuckland University of Technology, New ZealandUniversità degli Studi di MilanoUniversity of OtagoGeorgetown UniversityMazandaran University of Medical SciencesUniversity of AlbertaQuaid-i-Azam UniversityJordan University of Science and TechnologyHamad Bin Khalifa UniversityUniversity of LouisvilleUniversity of Central FloridaDebre Tabor UniversityUniversiteit UtrechtFlinders UniversityMinisterio de Ciencia, Innovación y UniversidadesDepartment of Social Services, Australian GovernmentIran University of Medical SciencesAhvaz Jundishapur University of Medical SciencesGriffith UniversityTulane UniversityNational Health and Medical Research CouncilEuropean Observatory on Health Systems and PoliciesCouncil for the Development of Social Science Research in AfricaInjury Prevention Research CenterHáskólinn í ReykjavíkPfizerRijksuniversiteit GroningenUniversity of ZanjanUniversity of WashingtonHealth Equity Research Center, Washington State UniversityUniversity of GlasgowTehran University of Medical Sciences and Health ServicesUniversity of Technology SydneyYork UniversityTaipei Medical UniversityUniversity College CorkCleveland ClinicSouth Australian Health and Medical Research InstituteCase Western Reserve UniversityHamad Medical CorporationUniversity of MinnesotaCancer Research InstituteInstitute for Physical Activity and NutritionU.S. Department of Veterans AffairsDivision of Mathematical SciencesAksum UniversityNational Rosacea SocietyUniversity of HaifaUniversity of HullUniversity of SulaimaniDepartment of Biotechnology, Ministry of Science and Technology, IndiaAddis Ababa UniversityBall State UniversityUniversity of BernWenzhou Medical UniversityRoyal SocietyFoundation for Advancement of International Medical Education and ResearchSalahaddin University-ErbilTaysEuropean CommissionWayne State UniversityZahedan University of Medical SciencesHarvard UniversityDepartment of Global Health and Population, Harvard T.H. 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Mots-clés

MedicinePopulationEnvironmental healthPercentileScale (ratio)Health careGlobal healthHealth policyPsychological interventionHealth promotionDisease burdenDemographyPublic healthGerontologyEconomic growthGeographyStatisticsNursing

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