Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990–2015: a novel analysis from the Global Burden of Disease Study 2015
Authors: Ryan M Barber, Nancy Fullman, Reed J D Sorensen, Thomas Bollyky, Martin McKee, Ellen Nolte, Amanuel Alemu Abajobir, Kalkidan Hassen Abate, Cristiana Abbafati, Kaja M Abbas, Foad Abd-Allah, Abdishakur M Abdulle, Ahmed Abdulahi Abdurahman, Semaw Ferede Abera, Biju Abraham, Girmatsion Fisseha Abreha, Kelemework Adane, Ademola Lukman Adelekan, Ifedayo Morayo O Adetifa, Ashkan Afshin, Arnav Agarwal, Sanjay Kumar Agarwal, Sunilkumar Agarwal, Anurag Agrawal, Aliasghar Ahmad Kiadaliri, Alireza Ahmadi, Kedir Yimam Ahmed, Muktar Beshir Ahmed, Rufus Olusola Akinyemi, Tomi F Akinyemiju, Nadia Akseer, Ziyad Al-Aly, Khurshid Alam, Noore Alam, Sayed Saidul Alam, Zewdie Aderaw Alemu, Kefyalew Addis Alene, Lily Alexander, Raghib Ali, Syed Danish Ali, Reza Alizadeh-Navaei, Ala'a Alkerwi, François Alla, Peter Allebeck, Christine Allen, Rajaa Al-Raddadi, Ubai Alsharif, Khalid A Altirkawi, Elena Alvarez Martin, Nelson Alvis-Guzman, Azmeraw T Amare, Erfan Amini, Walid Ammar, Joshu Amo-Adjei, Yaw Ampem Amoako, Benjamin O Anderson, Sofia Androudi, Hossein Ansari, Mustafa Geleto Ansha, Carl Abelardo T Antonio, Johan Ärnlöv, Al Artaman, Hamid Asayesh, Reza Assadi, Ayalew Astatkie, Tesfay Mehari Atey, Suleman Atique, Niguse Tadele Atnafu, Sachin R Atre, Leticia Avila-Burgos, Euripide Frinel G Arthur Avokpaho, Beatriz Paulina Ayala Quintanilla, Ashish Awasthi, Nebiyu Negussu Ayele, Peter Azzopardi, Huda Omer Ba Saleem, Till Bärnighausen, Umar Bacha, Alaa Badawi, Amitava Banerjee, Aleksandra Barac, Miguel A Barboza, Suzanne L Barker-Collo, Lope H Barrero, Sanjay Basu, Bernhard T Baune, Kaleab Baye, Yibeltal Tebekaw Bayou, Shahrzad Bazargan-Hejazi, Neeraj Bedi, Ettore Beghi, Yannick Béjot, Aminu K Bello, Derrick A Bennett, Isabela M Bensenor, Adugnaw Berhane, Eduardo Bernabé, Oscar Alberto Bernal, Addisu Shunu Beyene, Tariku Jibat Beyene, Zulfiqar A Bhutta, Sibhatu Biadgilign, Boris Bikbov, Sait Mentes Birlik, Charles Birungi, Stan Biryukov, Donal Bisanzio, Habtamu Mellie Bizuayehu, Dipan Bose, Michael Brainin, Michael Brauer, Alexandra Brazinova, Nicholas J K Breitborde, Hermann Brenner, Zahid A Butt, Rosario Cárdenas, Lucero Cahuana-Hurtado, Ismael Ricardo Campos-Nonato, Josip Car, Juan Jesus Carrero, Daniel Casey, Valeria Caso, Carlos A Castañeda-Orjuela, Jacqueline Castillo Rivas, Ferrán Catalá-López, Pedro Cecilio, Kelly Cercy, Fiona J Charlson, Alan Z Chen, Adrienne Chew, Mirriam Chibalabala, Chioma Ezinne Chibueze, Vesper Hichilombwe Chisumpa, Abdulaal A Chitheer, Rajiv Chowdhury, Hanne Christensen, Devasahayam Jesudas Christopher, Liliana G Ciobanu, Massimo Cirillo, Megan S Coggeshall, Leslie Trumbull Cooper, Monica Cortinovis, John A Crump, Koustuv Dalal, Hadi Danawi, Lalit Dandona, Rakhi Dandona, Paul I Dargan, Jose das Neves, Gail Davey, Dragos V Davitoiu, Kairat Davletov, Diego De Leo, Liana C Del Gobbo, Borja del Pozo-Cruz, Robert P Dellavalle, Kebede Deribe, Amare Deribew, Don C Des Jarlais, Subhojit Dey, Samath D Dharmaratne, Daniel Dicker, Eric L Ding, Klara Dokova, E Ray Dorsey, Kerrie E Doyle, Manisha Dubey, Rebecca Ehrenkranz, Christian Lycke Ellingsen, Iqbal Elyazar, Ahmadali Enayati, Sergey Petrovich Ermakov, Babak Eshrati, Alireza Esteghamati, Kara Estep, Thomas Fürst, Imad D A Faghmous, Fanuel Belayneh Bekele Fanuel, Emerito Jose Aquino Faraon, Talha A Farid, Carla Sofia e Sa Farinha, Andre Faro, Maryam S Farvid, Farshad Farzadfar, Valery L Feigin, Andrea B Feigl, Seyed-Mohammad Fereshtehnejad, Jefferson G Fernandes, João C Fernandes, Tesfaye Regassa Feyissa, Florian Fischer, Christina Fitzmaurice, Thomas D Fleming, Nataliya Foigt, Kyle J Foreman, Mohammad H Forouzanfar, Richard C Franklin, Joseph Frostad, Tsegaye Tewelde G/hiwot, Emmanuela Gakidou, Ketevan Gambashidze, Amiran Gamkrelidze, Wayne Gao, Alberto L Garcia-Basteiro, Teshome Gebre, Amanuel Tesfay Gebremedhin, Mengistu Welday Gebremichael, Alemseged Aregay Gebru, Amha Admasie Gelaye, Johanna M Geleijnse, Ricard Genova-Maleras, Katherine B Gibney, Ababi Zergaw Giref, Melkamu Dedefo Gishu, Giorgia Giussani, William W Godwin, Audra Gold, Ellen M Goldberg, Philimon N Gona, Amador Goodridge, Sameer Vali Gopalani, Atsushi Goto, Nicholas Graetz, Felix Greaves, Max Griswold, Peter Imre Guban, Harish Chander Gugnani, Prakash C Gupta, Rahul Gupta, Rajeev Gupta, Tanush Gupta, Vipin Gupta, Tesfa Dejenie Habtewold, Nima Hafezi-Nejad, Demewoz Haile, Alemayehu Desalegne Hailu, Gessessew Bugssa Hailu, Alex Hakuzimana, Randah Ribhi Hamadeh, Mitiku Teshome Hambisa, Samer Hamidi, Mouhanad Hammami, Graeme J Hankey, Yuantao Hao, Hilda L Harb, Habtamu Abera Hareri, Josep Maria Haro, Mohammad Sadegh Hassanvand, Rasmus Havmoeller, Roderick J Hay, Simon I Hay, Delia Hendrie, Ileana Beatriz Heredia-Pi, Hans W Hoek, Masako Horino, Nobuyuki Horita, H Dean Hosgood, Aung Soe Htet, Guoqing Hu, Hsiang Huang, John J Huang, Bethany M Huntley, Chantal Huynh, Kim Moesgaard Iburg, Bogdan Vasile Ileanu, Kaire Innos, Asnake Ararsa Irenso, Nader Jahanmehr, Mihajlo B Jakovljevic, Peter James, Spencer Lewis James, Mehdi Javanbakht, Sudha P Jayaraman, Achala Upendra Jayatilleke, Panniyammakal Jeemon, Vivekanand Jha, Denny John, Catherine Johnson, Sarah C Johnson, Jost B Jonas, Knud Juel, Zubair Kabir, Yogeshwar Kalkonde, Ritul Kamal, Haidong Kan, Andre Karch, Corine Kakizi Karema, Seyed M Karimi, Amir Kasaeian, Nicholas J Kassebaum, Anshul Kastor, Srinivasa Vittal Katikireddi, Konstantin Kazanjan, Peter Njenga Keiyoro, Laura Kemmer, Andrew Haddon Kemp, Andre Pascal Kengne, Amene Abebe Kerbo, Maia Kereselidze, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Ibrahim Khalil, Abdur Rahman Khan, Ejaz Ahmad Khan, Gulfaraz Khan, Young-Ho Khang, Abdullah Tawfih Abdullah Khoja, Irma Khonelidze, Jagdish Khubchandani, Getiye Dejenu Kibret, Daniel Kim, Pauline Kim, Yun Jin Kim, Ruth W Kimokoti, Yohannes Kinfu, Niranjan Kissoon, Miia Kivipelto, Yoshihiro Kokubo, Anneli Kolk, Dhaval Kolte, Jacek A Kopec, Soewarta Kosen, Parvaiz A Koul, Ai Koyanagi, Michael Kravchenko, Sanjay Krishnaswami, Kristopher J Krohn, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Ernst J Kuipers, Veena S Kulkarni, G Anil Kumar, Fekede Asefa Kumsa, Michael Kutz, Hmwe H Kyu, Anton Carl Jonas Lager, Aparna Lal, Dharmesh Kumar Lal, Ratilal Lalloo, Tea Lallukka, Qing Lan, Sinead M Langan, Van C Lansingh, Heidi J Larson, Anders Larsson, Dennis Odai Laryea, Asma Abdul Latif, Alicia Elena Beatriz Lawrynowicz, Janet L Leasher, James Leigh, Mall Leinsalu, Cheru Tesema Leshargie, Janni Leung, Ricky Leung, Miriam Levi, Xiaofeng Liang, Stephen S Lim, Margaret Lind, Shai Linn, Steven E Lipshultz, Patrick Liu, Yang Liu, Loon-Tzian Lo, Giancarlo Logroscino, Alan D Lopez, Scott A Lorch, Paulo A Lotufo, Rafael Lozano, Raimundas Lunevicius, Ronan A Lyons, Erlyn Rachelle King Macarayan, Mark T Mackay, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Mahdi Mahdavi, Azeem Majeed, Reza Malekzadeh, Deborah Carvalho Malta, Lorenzo G Mantovani, Tsegahun Manyazewal, Chabila C Mapoma, Wagner Marcenes, Guy B Marks, Neal Marquez, Jose Martinez-Raga, Melvin Barrientos Marzan, João Massano, Manu Raj Mathur, Pallab K Maulik, Mohsen Mazidi, Colm McAlinden, John J McGrath, Claire McNellan, Peter A Meaney, Alem Mehari, Man Mohan Mehndiratta, Toni Meier, Alemayehu B Mekonnen, Kidanu Gebremariam Meles, Ziad A Memish, Melkamu Merid Mengesha, Desalegn Tadese Mengiste, Mubarek Abera Mengistie, Bereket Gebremichael Menota, George A Mensah, Seid Tiku Mereta, Atte Meretoja, Tuomo J Meretoja, Haftay Berhane Mezgebe, Renata Micha, Anoushka Millear, Edward J Mills, Shawn Minnig, Mojde Mirarefin, Erkin M Mirrakhimov, Charles N Mock, Karzan Abdulmuhsin Mohammad, Shafiu Mohammed, Sanjay K Mohanty, Ali H Mokdad, Glen Liddell D Mola, Mariam Molokhia, Lorenzo Monasta, Marcella Montico, Maziar Moradi-Lakeh, Paula Moraga, Lidia Morawska, Rintaro Mori, Mark Moses, Ulrich O Mueller, Srinivas Murthy, Kamarul Imran Musa, Jean B Nachega, Chie Nagata, Gabriele Nagel, Mohsen Naghavi, Aliya Naheed, Luigi Naldi, Vinay Nangia, Bruno Ramos Nascimento, Ionut Negoi, Sudan Prasad Neupane, Charles R Newton, Marie Ng, Frida Namnyak Ngalesoni, Josephine Wanjiku Ngunjiri, Grant Nguyen, Dina Nur Anggraini Ningrum, Sandra Nolte, Marika Nomura, Ole F Norheim, Bo Norrving, Jean Jacques N Noubiap, Carla Makhlouf Obermeyer, Felix Akpojene Ogbo, In-Hwan Oh, Anselm Okoro, Olanrewaju Oladimeji, Andrew Toyin Olagunju, Pedro R Olivares, Helen E Olsen, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, John Nelson Opio, Eyal Oren, Alberto Ortiz, Richard H Osborne, Majdi Osman, Mayowa O Owolabi, Mahesh PA, Amanda W Pain, Smita Pakhale, Elizabeth Palomares Castillo, Adrian Pana, Christina Papachristou, Mahboubeh Parsaeian, Tejas Patel, George C Patton, Deepak Paudel, Vinod K Paul, Neil Pearce, David M Pereira, Rogelio Perez-Padilla, Fernando Perez-Ruiz, Norberto Perico, Konrad Pesudovs, Max Petzold, Michael Robert Phillips, David M Pigott, Julian David Pillay, Christine Pinho, Suzanne Polinder, Constance D Pond, V Prakash, Manorama Purwar, Mostafa Qorbani, D Alex Quistberg, Amir Radfar, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Mahfuzar Rahman, Mohammad Hifz Ur Rahman, Rajesh Kumar Rai, Usha Ram, Saleem M Rana, Zane Rankin, Paturi Vishnupriya Rao, Puja C Rao, Salman Rawaf, Maria Albertina Santiago Rego, Marissa Reitsma, Giuseppe Remuzzi, Andre M N N Renzaho, Serge Resnikoff, Satar Rezaei, Mohammad Sadegh Rezai, Antonio L Ribeiro, Hirbo Shore Roba, Mohammad Bagher Rokni, Luca Ronfani, Gholamreza Roshandel, Gregory A Roth, Dietrich Rothenbacher, Nawal K Roy, Perminder S Sachdev, Ben Benasco Sackey, Mohammad Yahya Saeedi, Saeid Safiri, Rajesh Sagar, Mohammad Ali Sahraian, Muhammad Muhammad Saleh, Joshua A Salomon, Abdallah M Samy, Juan Ramon Sanabria, Maria Dolores Sanchez-Niño, Logan Sandar, Itamar S Santos, João Vasco Santos, Milena M Santric Milicevic, Rodrigo Sarmiento-Suarez, Benn Sartorius, Maheswar Satpathy, Miloje Savic, Monika Sawhney, Mete I Saylan, Ben Schöttker, Aletta E Schutte, David C Schwebel, Soraya Seedat, Abdulbasit Musa Seid, Canaan Negash Seifu, Sadaf G Sepanlou, Berrin Serdar, Edson E Servan-Mori, Tesfaye Setegn, Katya Anne Shackelford, Amira Shaheen, Saeid Shahraz, Masood Ali Shaikh, Marina Shakh-Nazarova, Mansour Shamsipour, Sheikh Mohammed Shariful Islam, Jayendra Sharma, Rajesh Sharma, Jun She, Sara Sheikhbahaei, Jiabin Shen, Peilin Shi, Mika Shigematsu, Min-Jeong Shin, Rahman Shiri, Haitham Shoman, Mark G Shrime, Ephrem Lejore Sibamo Sibamo, Inga Dora Sigfusdottir, Diego Augusto Santos Silva, Dayane Gabriele Alves Silveira, Shireen Sindi, Abhishek Singh, Jasvinder A Singh, Om Prakash Singh, Prashant Kumar Singh, Virendra Singh, Abiy Hiruye Sinke, Aklilu Endalamaw Sinshaw, Vegard Skirbekk, Karen Sliwa, Alison Smith, Eugene Sobngwi, Samir Soneji, Joan B Soriano, Tatiane Cristina Moraes Sousa, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Vasiliki Stathopoulou, Nicholas Steel, Caitlyn Steiner, Sabine Steinke, Mark Andrew Stokes, Saverio Stranges, Mark Strong, Konstantinos Stroumpoulis, Lela Sturua, Muawiyyah Babale Sufiyan, Rizwan Abdulkader Suliankatchi, Jiandong Sun, Patrick Sur, Soumya Swaminathan, Bryan L Sykes, Rafael Tabarés-Seisdedos, Karen M Tabb, Getachew Redae Taffere, Roberto Tchio Talongwa, Musharaf Tarajia, Mohammad Tavakkoli, Nuno Taveira, Stephanie Teeple, Teketo Kassaw Tegegne, Arash Tehrani-Banihashemi, Tesfalidet Tekelab, Dejen Yemane Tekle, Girma Temam Shifa, Abdullah Sulieman Terkawi, Azeb Gebresilassie Tesema, JS Thakur, Alan J Thomson, Taavi Tillmann, Tenaw Yimer Tiruye, Ruoyan Tobe-Gai, Marcello Tonelli, Roman Topor-Madry, Miguel Tortajada, Christopher Troeger, Thomas Truelsen, Abera Kenay Tura, Uche S Uchendu, Kingsley N Ukwaja, Eduardo A Undurraga, Chigozie Jesse Uneke, Olalekan A Uthman, Job F M van Boven, Rita Van Dingenen, Santosh Varughese, Tommi Vasankari, Narayanaswamy Venketasubramanian, Francesco S Violante, Sergey K Vladimirov, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Theo Vos, Joseph A Wagner, Tolassa Wakayo, Stephen G Waller, Judd L Walson, Haidong Wang, Yuan-Pang Wang, David A Watkins, Elisabete Weiderpass, Robert G Weintraub, Chi-Pang Wen, Andrea Werdecker, Joshua Wesana, Ronny Westerman, Harvey A Whiteford, James D Wilkinson, Charles Shey Wiysonge, Belete Getahun Woldeyes, Charles D A Wolfe, Sungho Won, Abdulhalik Workicho, Shimelash Bitew Workie, Mamo Wubshet, Denis Xavier, Gelin Xu, Ajit Kumar Yadav, Mohsen Yaghoubi, Bereket Yakob, Lijing L Yan, Yuichiro Yano, Mehdi Yaseri, Hassen Hamid Yimam, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Mustafa Z Younis, Chuanhua Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Carlos Zambrana-Torrelio, Tomas Zapata, Zerihun Menlkalew Zenebe, Sanjay Zodpey, Leo Zoeckler, Liesl Joanna Zuhlke, Christopher J L Murray
Journal: The Lancet (2017)

National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015.We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time.Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0-42·8) in 1990 to 53·7 (52·2-55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015.This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world.Bill & Melinda Gates Foundation.