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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

Barthelemy, Celine M.; Abrigo, Michael R.M.; Abushouk, Abdelrahman I.; Adebayo, Oladimeji M.; Adetokunboh, Olatunji O.; Advani, Shailesh M.; Albertson, Samuel B.; Almasri, Nihad A.; Al-Mekhlafi, Hesham M.; Almulhim, Abdulaziz M.; Al-Raddadi, Rajaa M.; Altirkawi, Khalid A.; Alvis-Zakzuk, Nelson J.; Amit, Arianna Maever L.; Amugsi, Dickson A.; Antonio, Carl Abelardo T.; Antony, Catherine M.; Aravkin, Aleksandr Y.; Asadi-Pooya, Ali A.; Atout, Maha Moh d.Wahbi; Azzopardi, Peter S.; B, Darshan B.; Badiye, Ashish D.; Bakkannavar, Shankar M.; Ashbaugh, Charlie; Athari, Seyyed Shamsadin; 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; Babaee, Ebrahim; Bahrami, Mohammad Amin; Baig, Atif Amin; Bakhshaei, Mohammad Hossein; Bakhtiari, Ahad; Balachandran, Arun; Balassyano, Shelly; Banach, Maciej; Ancuceanu, Robert; Anderlini, Deanna; Andrei, Catalina Li...

Authors

Celine M. Barthelemy

Michael R.M. Abrigo

Abdelrahman I. Abushouk

Oladimeji M. Adebayo

Olatunji O. Adetokunboh

Shailesh M. Advani

Samuel B. Albertson

Nihad A. Almasri

Hesham M. Al-Mekhlafi

Abdulaziz M. Almulhim

Rajaa M. Al-Raddadi

Khalid A. Altirkawi

Nelson J. Alvis-Zakzuk

Arianna Maever L. Amit

Dickson A. Amugsi

Carl Abelardo T. Antonio

Catherine M. Antony

Aleksandr Y. Aravkin

Ali A. Asadi-Pooya

Maha Moh d.Wahbi Atout

Peter S. Azzopardi

Darshan B. B

Ashish D. Badiye

Shankar M. Bakkannavar

Charlie Ashbaugh

Seyyed Shamsadin Athari

Marcel Ausloos

Leticia Avila-Burgos

Beatriz Paulina Ayala Quintanilla

Getinet Ayano

Martin Amogre Ayanore

Yared Asmare Aynalem

Getie Lake Aynalem

Muluken Altaye Ayza

Samad Azari

Ebrahim Babaee

Mohammad Amin Bahrami

Atif Amin Baig

Mohammad Hossein Bakhshaei

Ahad Bakhtiari

Arun Balachandran

Shelly Balassyano

Maciej Banach

Robert Ancuceanu

Deanna Anderlini

Catalina Liliana Andrei

Sofia Androudi

Fereshteh Ansari

Alireza Ansari-Moghaddam

Ernoiz Antriyandarti

Davood Anvari

Razique Anwer

Jalal Arabloo

Morteza Arab-Zozani

Olatunde Aremu

Johan Ärnlöv

Malke Asaad

Mehran Asadi-Aliabadi

Ali Almasi

Amir Almasi-Hashiani

Jordi Alonso

Nelson Alvis-Guzman

Saeed Amini

Mostafa Amini-Rarani

Fatemeh Amiri

Robert Kaba Alhassan

Muhammad Ali

Saqib Ali

Vahid Alipour

Syed Mohamed Aljunid

François Alla

Majid Abdulrahman Hamad Almadi

Tauseef Ahmad

Rufus Olusola Akinyemi

Fares Alahdab

Ziyad Al-Aly

Khurshid Alam

Yihun Mulugeta Alemu

Ashkan Afshin

Gina Agarwal

Pradyumna Agasthi

Seyed Mohammad Kazem Aghamir

Anurag Agrawal

Jaimie Adelson

Victor Adekanmbi

Davoud Adham

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 Guimarães Abreu

Michael R M Abrigo

Abdulaziz Khalid Abu Haimed

Abdelrahman I Abushouk

Maryam Adabi

Oladimeji M Adebayo

Victor Adekanmbi

Jaimie 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

François 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 Ärnlöv

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

Yared Asmare Aynalem

Getie Lake Aynalem

Muluken Altaye Ayza

Samad Azari

Peter S Azzopardi

Darshan B B

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 Bärnighausen

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 Cámera

Rosario Cárdenas

Giulia Carreras

Juan J Carrero

Felix Carvalho

Joao Mauricio Castaldelli-Maia

Carlos A Castañeda-Orjuela

Giulio Castelpietra

Franz Castro

Ferrán Catalá-López

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 M A Dahlawi

Giovanni Damiani

Lalit Dandona

Rakhi Dandona

Jiregna Darega Gela

Aso Mohammad Darwesh

Ahmad Daryani

Aditya Prasad Dash

Gail Davey

Claudio Alberto Dávila-Cervantes

Kairat Davletov

Jan-Walter De Neve

Edgar Denova-Gutiérrez

Kebede Deribe

Nikolaos Dervenis

Rupak Desai

Samath Dhamminda Dharmaratne

Govinda Prasad Dhungana

Mostafa Dianatinasab

Diana Dias da Silva

Daniel Diaz

Ilse N Dippenaar

Hoa Thi Do

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 Sá 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

João M Furtado

Mohamed M Gad

Abhay Motiramji Gaidhane

Emmanuela Gakidou

Natalie C Galles

Silvano Gallus

William M Gardner

Biniyam Sahiledengle Geberemariyam

Abiyu Mekonnen Gebrehiwot

Leake G Gebremeskel

Gebreamlak Gebremedhn 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

Bárbara Niegia Garcia Goulart

Mohammed Ibrahim Mohialdeen Gubari

Rafael Alves Guimarães

Rashid Abdi Guled

Teklemariam Gultie

Yuming Guo

Rajeev Gupta

Rahul 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

Shoaib Hassan

Amr 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

Bruce Hollingsworth

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

Chinwe Juliana Iwu

Chidozie C D 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 Jürisson

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

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Mahalaqua Nazli Khatib

Maryam Khayamzadeh

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Alan D Lopez

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Morteza Mahmoudi

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Shokofeh Maleki

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Borhan Mansouri

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Santi Martini

Francisco Rogerlândio Martins-Melo

Ira Martopullo

Benjamin Ballard Massenburg

Claudia I Mastrogiacomo

Manu Raj Mathur

Colm McAlinden

Martin McKee

Carlo Eduardo Medina-Solís

Birhanu Geta Meharie

Man Mohan Mehndiratta

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Babak Moazen

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Abdollah Mohammadian-Hafshejani

Shafiu Mohammed

Jemal Abdu Mohammed

Ali H Mokdad

Lorenzo Monasta

Stefania Mondello

Masoud Moradi

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Rahmatollah Moradzadeh

Paula Moraga

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Abbas Mosapour

Jonathan F Mosser

Amin Mousavi Khaneghah

Moses K Muriithi

Ghulam Mustafa

Ashraf F Nabhan

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Josephine W Ngunjiri

Cuong Tat Nguyen

Diep Ngoc Nguyen

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Chukwudi A Nnaji

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Virginia Nunez-Samudio

Adrian Otoiu

Felix Akpojene Ogbo

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Emmanuel Wandera Okunga

Morteza Oladnabi

Andrew T Olagunju

Jacob Olusegun Olusanya

Bolajoko Olubukunola Olusanya

Mojisola Morenike Oluwasanu

Ahmed Omar Bali

Muktar Omer Omer

Kanyin L Ong

Obinna E Onwujekwe

Doris V V Ortega-Altamirano

Alberto Ortiz

Sergej M Ostojic

Nikita Otstavnov

Stanislav S Otstavnov

Simon Øverland

Mayowa O Owolabi

Jagadish Rao. Padubidri

Smita Pakhale

Raffaele Palladino

Adrian Pana

Songhomitra Panda-Jonas

Helena Ullyartha Pangaribuan

Mona Pathak

George C Patton

Sagun Paudel

Hamidreza Pazoki Toroudi

Spencer A Pease

Amy E Peden

Alyssa Pennini

Emmanuel K Peprah

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Marina Pinheiro

Michael A Piradov

Meghdad Pirsaheb

Khem Narayan Pokhrel

Maarten J Postma

Hadi Pourjafar

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Reza Pourmirza Kalhori

Akram Pourshams

Sergio I Prada

Dimas Ria Angga Pribadi

Elisabetta Pupillo

Zahiruddin Quazi Syed

Amir Radfar

Ata Rafiee

Alireza Rafiei

Alberto Raggi

Fakher Rahim

Muhammad Aziz Rahman

Ali Rajabpour-Sanati

Saleem Muhammad Rana

Chhabi Lal Ranabhat

Sowmya J Rao

Davide Rasella

Vahid Rashedi

Goura Kishor Rath

Priya Rathi

Salman Rawaf

David Laith Rawaf

Lal Rawal

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Vishnu Renjith

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Nima Rezaei

Seyed Mohammad Riahi

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Jennifer Rickard

Nicholas L S Roberts

Leonardo Roever

Michele Romoli

Luca Ronfani

Gholamreza Roshandel

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Godfrey M Rwegerera

Siamak Sabour

Perminder S Sachdev

Basema Saddik

Masoumeh Sadeghi

Ehsan Sadeghi

Yahya Safari

Rajesh Sagar

Amirhossein Sahebkar

Mohammad Ali Sahraian

S. Mohammad Sajadi

Mohammad Reza Salahshoor

Marwa R Rashad Salem

Hosni Salem

Joshua Salomon

Hossein Samadi Kafil

Abdallah M Samy

Juan Sanabria

Milena M Santric-Milicevic

Sivan Yegnanarayana Iyer Saraswathy

Rodrigo Sarmiento-Suárez

Benn Sartorius

Arash Sarveazad

Brijesh Sathian

Thirunavukkarasu Sathish

Davide Sattin

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Deepak Saxena

Alyssa N Sbarra

Lauren E Schaeffer

Silvia Schiavolin

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Aletta Elisabeth Schutte

David C Schwebel

Falk Schwendicke

Soraya Seedat

Feng Sha

Saeed Shahabi

Amira A Shaheen

Masood Ali Shaikh

Morteza Shamsizadeh

Mohammed Shannawaz

Kiomars Sharafi

Fablina Sharara

Hamid Sharifi

David H Shaw

Aziz Sheikh

Abbas Sheikhtaheri

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Kenji Shibuya

Wondimeneh Shibabaw Shiferaw

Mika Shigematsu

Jae Il Shin

Rahman Shiri

Reza Shirkoohi

K M Shivakumar

Mark G Shrime

Kerem Shuval

Soraya Siabani

Radoslaw Sierpinski

Inga Dora Sigfusdottir

Rannveig Sigurvinsdottir

Diego Augusto Santos Silva

João Pedro Silva

Biagio Simonetti

Kyle E Simpson

Jasvinder A Singh

Pushpendra Singh

Dhirendra Narain Sinha

Valentin Yurievich Skryabin

Emma U R Smith

Amin Soheili

Shahin Soltani

Moslem Soofi

Reed J.D. Sorensen

Joan B Soriano

Muluken Bekele Sorrie

Emma Elizabeth Spurlock

Chandrashekhar T Sreeramareddy

Jeffrey D Stanaway

Nicholas Steel

Caroline Stein

Mark A Stokes

Mu'awiyyah Babale Sufiyan

Hafiz Ansar Rasul Suleria

Iyad Sultan

Łukasz Szumowski

Rafael Tabarés-Seisdedos

Takahiro Tabuchi

Santosh Kumar Tadakamadla

Biruk Wogayehu Taddele

Degena Bahrey Tadesse

Amir Taherkhani

Animut Tagele Tamiru

Frank C Tanser

Md Ismail Tareque

Ingan Ukur Tarigan

Whitney L Teagle

Fabrizio Tediosi

Yonas Getaye Getaye Tefera

Freweini Gebrearegay Tela

Zemenu Tadesse Tessema

Bhaskar Thakur

Mariya Vladimirovna Titova

Marcello Tonelli

Roman Topor-Madry

Fotis Topouzis

Marcos Roberto Roberto Tovani-Palone

Bach Xuan Tran

Ravensara Travillian

Christopher E Troeger

Lorainne Tudor Car

Riaz Uddin

Irfan Ullah

Chukwuma David Umeokonkwo

Bhaskaran Unnikrishnan

Era Upadhyay

Olalekan A Uthman

Marco Vacante

Pascual R Valdez

Santosh Varughese

Tommi Juhani Vasankari

Yasser Vasseghian

Narayanaswamy Venketasubramanian

Francesco S Violante

Vasily Vlassov

Stein Emil Vollset

Avina Vongpradith

Theo Vos

Yasir Waheed

Magdalene K Walters

Richard G Wamai

Haidong Wang

Yuan-Pang Wang

Robert G Weintraub

Jordan Weiss

Andrea Werdecker

Ronny Westerman

Lauren B Wilner

Gebremariam Woldu

Charles D A Wolfe

Ai-Min Wu

Sarah Wulf Hanson

Yang Xie

Rixing Xu

Seyed Hossein Yahyazadeh Jabbari

Kazumasa Yamagishi

Yuichiro Yano

Sanni Yaya

Vahid Yazdi-Feyzabadi

Jamal A Yearwood

Yordanos Gizachew Yeshitila

Paul Yip

Naohiro Yonemoto

Mustafa Z Younis

Zabihollah Yousefi

Taraneh Yousefinezhadi

Hasan Yusefzadeh

Siddhesh Zadey

Telma Zahirian Moghadam

Syed Saoud Zaidi

Leila Zaki

Sojib Bin Zaman

Mohammad Zamani

Maryam Zamanian

Hamed Zandian

Mikhail Sergeevich Zastrozhin

Kaleab Alemayehu Zewdie

Yunquan Zhang

Xiu-Ju George Zhao

Yingxi Zhao

Peng Zheng

Cong Zhu

Arash Ziapour

Bianca S Zlavog

Sanjay Zodpey

Christopher J L Murray



Abstract

© 2020 Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license 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.

Citation

Bakhtiari, A., Balachandran, A., Banach, M., Balassyano, S., Baig, A. A., Bakhshaei, M. H., Avila-Burgos, L., Ayala Quintanilla, B. P., Ayano, G., Ayanore, M. A., Aynalem, Y. A., Aynalem, G. L., Ayza, M. A., Azari, S., Babaee, E., Bahrami, M. A., Ashbaugh, C., Athari, S. S., B, D. B., Badiye, A. D., …Murray, C. J. L. (2020). 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. Lancet, https://doi.org/10.1016/S0140-6736%2820%2930750-9

Journal Article Type Article
Acceptance Date Aug 27, 2019
Online Publication Date Aug 27, 2020
Publication Date Jan 1, 2020
Deposit Date Sep 9, 2020
Publicly Available Date Sep 18, 2020
Journal The Lancet
Print ISSN 0140-6736
Publisher Elsevier
Peer Reviewed Peer Reviewed
DOI https://doi.org/10.1016/S0140-6736%2820%2930750-9
Keywords General Medicine
Public URL https://hull-repository.worktribe.com/output/3585062
Publisher URL https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30750-9/fulltext
Related Public URLs https://www.sciencedirect.com/science/article/pii/S0140673620307509

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© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY4.0 license.






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