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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

Adham, Davoud; Aremu, Olatunde; Amini, Saeed; Alvis-Guzman, Nelson; Alonso, Jordi; Almasi-Hashiani, Amir; Almasi, Ali; Asadi-Aliabadi, Mehran; Asaad, Malke; Ärnlöv, Johan; Arab-Zozani, Morteza; Amiri, Fatemeh; Arabloo, Jalal; Anwer, Razique; Anvari, Davood; Antriyandarti, Ernoiz; Ansari-Moghaddam, Alireza; Ansari, Fereshteh; Androudi, Sofia; Andrei, Catalina Liliana; Amini-Rarani, Mostafa; Alhassan, Robert Kaba; Ancuceanu, Robert; Alam, Khurshid; Adekanmbi, Victor; Adelson, Jaimie; Agrawal, Anurag; Aghamir, Seyed Mohammad Kazem; Agasthi, Pradyumna; Agarwal, Gina; Afshin, Ashkan; Alemu, Yihun Mulugeta; Al-Aly, Ziyad; Ali, Muhammad; Alahdab, Fares; Akinyemi, Rufus Olusola; Ahmad, Tauseef; Almadi, Majid Abdulrahman Hamad; Alla, François; Aljunid, Syed Mohamed; Alipour, Vahid; Ali, Saqib; Anderlini, Deanna; Banach, Maciej; Barthelemy, Celine M.; Al-Raddadi, Rajaa M.; Asadi-Pooya, Ali A.; Aravkin, Aleksandr Y.; Antony, Catherine M.; Antonio, Carl Abelardo T.; Amugsi, Dickson A.; Amit, Arianna Maever L.; Alvis-Zakzuk, Nelson J.; Altirkawi, Khalid A.; Almulhim, Abdulaziz M.; Azzopardi, Peter S.; Al-Mekhlafi, Hesham M.; Almasri, Nihad A.; Albertson, Samuel B.; Advani, Shailesh M.; Adetokunboh, Olatunji O.; Adebayo, Oladimeji M.; Abushouk, Abdelrahman I.; Abrigo, Michael R.M.; Atout, Maha Moh d.Wahbi; B, Darshan B.; Balassyano, Shelly; Aynalem, Getie Lake; Balachandran, Arun; Bakhtiari, Ahad; Bakhshaei, Mohammad Hossein; Baig, Atif Amin; Bahrami, Mohammad Amin; Babaee, Ebrahim; Azari, Samad; Ayza, Muluken Altaye; Aynalem, Yared Asmare; Badiye, Ashish D.; Ayanore, Martin Amogre; Ayano, Getinet; Ayala Quintanilla, Beatriz Paulina; Avila-Burgos, Leticia; Ausloos, Marcel; Athari, Seyyed Shamsadin; Ashbaugh, Charlie; Bakkannavar, Shankar M.; Soyiri, Ireneous N


Davoud Adham

Olatunde Aremu

Saeed Amini

Nelson Alvis-Guzman

Jordi Alonso

Amir Almasi-Hashiani

Ali Almasi

Mehran Asadi-Aliabadi

Malke Asaad

Johan Ärnlöv

Morteza Arab-Zozani

Fatemeh Amiri

Jalal Arabloo

Razique Anwer

Davood Anvari

Ernoiz Antriyandarti

Alireza Ansari-Moghaddam

Fereshteh Ansari

Sofia Androudi

Catalina Liliana Andrei

Mostafa Amini-Rarani

Robert Kaba Alhassan

Robert Ancuceanu

Khurshid Alam

Victor Adekanmbi

Jaimie Adelson

Anurag Agrawal

Seyed Mohammad Kazem Aghamir

Pradyumna Agasthi

Gina Agarwal

Ashkan Afshin

Yihun Mulugeta Alemu

Ziyad Al-Aly

Muhammad Ali

Fares Alahdab

Rufus Olusola Akinyemi

Tauseef Ahmad

Majid Abdulrahman Hamad Almadi

François Alla

Syed Mohamed Aljunid

Vahid Alipour

Saqib Ali

Deanna Anderlini

Maciej Banach

Celine M. Barthelemy

Rajaa M. Al-Raddadi

Ali A. Asadi-Pooya

Aleksandr Y. Aravkin

Catherine M. Antony

Carl Abelardo T. Antonio

Dickson A. Amugsi

Arianna Maever L. Amit

Nelson J. Alvis-Zakzuk

Khalid A. Altirkawi

Abdulaziz M. Almulhim

Peter S. Azzopardi

Hesham M. Al-Mekhlafi

Nihad A. Almasri

Samuel B. Albertson

Shailesh M. Advani

Olatunji O. Adetokunboh

Oladimeji M. Adebayo

Abdelrahman I. Abushouk

Michael R.M. Abrigo

Maha Moh d.Wahbi Atout

Darshan B. B

Shelly Balassyano

Getie Lake Aynalem

Arun Balachandran

Ahad Bakhtiari

Mohammad Hossein Bakhshaei

Atif Amin Baig

Mohammad Amin Bahrami

Ebrahim Babaee

Samad Azari

Muluken Altaye Ayza

Yared Asmare Aynalem

Ashish D. Badiye

Martin Amogre Ayanore

Getinet Ayano

Beatriz Paulina Ayala Quintanilla

Leticia Avila-Burgos

Marcel Ausloos

Seyyed Shamsadin Athari

Charlie Ashbaugh

Shankar M. Bakkannavar


© 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.


Bakhtiari, A., Balachandran, A., Banach, M., Balassyano, S., Baig, A. A., Bakhshaei, M. H., …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,

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
Electronic ISSN 1474-547X
Publisher Elsevier
Peer Reviewed Peer Reviewed
Keywords General Medicine
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