Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
Authors: Simon I Hay, Amanuel Alemu Abajobir, Kalkidan Hassen Abate, Cristiana Abbafati, Kaja M Abbas, Foad Abd-Allah, Rizwan Suliankatchi Abdulkader, Abdishakur M Abdulle, Teshome Abuka Abebo, Semaw Ferede Abera, Victor Aboyans, Laith J Abu-Raddad, Ilana N Ackerman, Isaac A Adedeji, Olatunji Adetokunboh, Ashkan Afshin, Rakesh Aggarwal, Sutapa Agrawal, Anurag Agrawal, Muktar Beshir Ahmed, Miloud Taki Eddine Aichour, Amani Nidhal Aichour, Ibtihel Aichour, Sneha Aiyar, Tomi F Akinyemiju, Nadia Akseer, Faris Hasan Al Lami, Fares Alahdab, Ziyad Al-Aly, Khurshid Alam, Noore Alam, Tahiya Alam, Deena Alasfoor, Kefyalew Addis Alene, Raghib Ali, Reza Alizadeh-Navaei, Juma M Alkaabi, Ala'a Alkerwi, François Alla, Peter Allebeck, Christine Allen, Fatma Al-Maskari, Mohammad AbdulAziz AlMazroa, Rajaa Al-Raddadi, Ubai Alsharif, Shirina Alsowaidi, Benjamin M Althouse, Khalid A Altirkawi, Nelson Alvis-Guzman, Azmeraw T Amare, Erfan Amini, Walid Ammar, Yaw Ampem Amoako, Mustafa Geleto Ansha, Carl Abelardo T Antonio, Palwasha Anwari, Johan Ärnlöv, Megha Arora, Al Artaman, Krishna Kumar Aryal, Solomon W Asgedom, Tesfay Mehari Atey, Niguse Tadele Atnafu, Leticia Avila-Burgos, Euripide Frinel G Arthur Avokpaho, Ashish Awasthi, Shally Awasthi, Mahmoud Reza Azarpazhooh, Peter Azzopardi, Tesleem Kayode Babalola, Umar Bacha, Alaa Badawi, Kalpana Balakrishnan, Marlena S Bannick, Aleksandra Barac, Suzanne L Barker-Collo, Till Bärnighausen, Simon Barquera, Lope H Barrero, Sanjay Basu, Robert Battista, Katherine E Battle, Bernhard T Baune, Shahrzad Bazargan-Hejazi, Justin Beardsley, Neeraj Bedi, Yannick Béjot, Bayu Begashaw Bekele, Michelle L Bell, Derrick A Bennett, James R Bennett, Isabela M Bensenor, Jennifer Benson, Adugnaw Berhane, Derbew Fikadu Berhe, Eduardo Bernabé, Balem Demtsu Betsu, Mircea Beuran, Addisu Shunu Beyene, Anil Bhansali, Samir Bhatt, Zulfiqar A Bhutta, Sibhatu Biadgilign, Burcu Kucuk Bicer, Kelly Bienhoff, Boris Bikbov, Charles Birungi, Stan Biryukov, Donal Bisanzio, Habtamu Mellie Bizuayehu, Fiona M Blyth, Dube Jara Boneya, Dipan Bose, Ibrahim R Bou-Orm, Rupert R A Bourne, Michael Brainin, Carol Brayne, Alexandra Brazinova, Nicholas J K Breitborde, Paul S Briant, Gabrielle Britton, Traolach S Brugha, Rachelle Buchbinder, Lemma Negesa Bulto Bulto, Blair R Bumgarner, Zahid A Butt, Lucero Cahuana-Hurtado, Ewan Cameron, Ismael Ricardo Campos-Nonato, Hélène Carabin, Rosario Cárdenas, David O Carpenter, Juan Jesus Carrero, Austin Carter, Felix Carvalho, Daniel Casey, Carlos A Castañeda-Orjuela, Chris D Castle, Ferrán Catalá-López, Jung-Chen Chang, Fiona J Charlson, Pankaj Chaturvedi, Honglei Chen, Mirriam Chibalabala, Chioma Ezinne Chibueze, Vesper Hichilombwe Chisumpa, Abdulaal A Chitheer, Rajiv Chowdhury, Devasahayam Jesudas Christopher, Liliana G Ciobanu, Massimo Cirillo, Danny Colombara, Leslie Trumbull Cooper, Cyrus Cooper, Paolo Angelo Cortesi, Monica Cortinovis, Michael H Criqui, Elizabeth A Cromwell, Marita Cross, John A Crump, Abel Fekadu Dadi, Koustuv Dalal, Albertino Damasceno, Lalit Dandona, Rakhi Dandona, José das Neves, Dragos V Davitoiu, Kairat Davletov, Barbora de Courten, Diego De Leo, Hans De Steur, Barthelemy Kuate Defo, Louisa Degenhardt, Selina Deiparine, Robert P Dellavalle, Kebede Deribe, Amare Deribew, Don C Des Jarlais, Subhojit Dey, Samath D Dharmaratne, Preet K Dhillon, Daniel Dicker, Shirin Djalainia, Huyen Phuc Do, Klara Dokova, David Teye Doku, E Ray Dorsey, Kadine Priscila Bender dos Santos, Tim R Driscoll, Manisha Dubey, Bruce Bartholow Duncan, Beth E Ebel, Michelle Echko, Ziad Ziad El-Khatib, Ahmadali Enayati, Aman Yesuf Endries, Sergey Petrovich Ermakov, Holly E Erskine, Setegn Eshetie, Babak Eshrati, Alireza Esteghamati, Kara Estep, Fanuel Belayneh Bekele Fanuel, Tamer Farag, Carla Sofia e Sa Farinha, André Faro, Farshad Farzadfar, Mir Sohail Fazeli, Valery L Feigin, Andrea B Feigl, Seyed-Mohammad Fereshtehnejad, João C Fernandes, Alize J Ferrari, Tesfaye Regassa Feyissa, Irina Filip, Florian Fischer, Christina Fitzmaurice, Abraham D Flaxman, Nataliya Foigt, Kyle J Foreman, Richard C Franklin, Joseph J Frostad, Nancy Fullman, Thomas Fürst, Joao M Furtado, Neal D Futran, Emmanuela Gakidou, Alberto L Garcia-Basteiro, Teshome Gebre, Gebremedhin Berhe Gebregergs, Tsegaye Tewelde Gebrehiwot, Johanna M Geleijnse, Ayele Geleto, Bikila Lencha Gemechu, Hailay Abrha Gesesew, Peter W Gething, Alireza Ghajar, Katherine B Gibney, Richard F Gillum, Ibrahim Abdelmageem Mohamed Ginawi, Melkamu Dedefo Gishu, Giorgia Giussani, William W Godwin, Kashish Goel, Shifalika Goenka, Ellen M Goldberg, Philimon N Gona, Amador Goodridge, Sameer Vali Gopalani, Richard A Gosselin, Carolyn C Gotay, Atsushi Goto, Alessandra Carvalho Goulart, Nicholas Graetz, Harish Chander Gugnani, Prakash C Gupta, Rajeev Gupta, Tanush Gupta, Vipin Gupta, Rahul Gupta, Reyna A Gutiérrez, Vladimir Hachinski, Nima Hafezi-Nejad, Alemayehu Desalegne Hailu, Gessessew Bugssa Hailu, Randah Ribhi Hamadeh, Samer Hamidi, Mouhanad Hammami, Alexis J Handal, Graeme J Hankey, Yuantao Hao, Hilda L Harb, Habtamu Abera Hareri, Josep Maria Haro, Kimani M Harun, James Harvey, Mohammad Sadegh Hassanvand, Rasmus Havmoeller, Roderick J Hay, Mohammad T Hedayati, Delia Hendrie, Nathaniel J Henry, Ileana Beatriz Heredia-Pi, Pouria Heydarpour, Hans W Hoek, Howard J Hoffman, Masako Horino, Nobuyuki Horita, H Dean Hosgood, Sorin Hostiuc, Peter J Hotez, Damian G Hoy, Aung Soe Htet, Guoqing Hu, John J Huang, Chantal Huynh, Kim Moesgaard Iburg, Ehimario Uche Igumbor, Chad Ikeda, Caleb Mackay Salpeter Irvine, Sheikh Mohammed Shariful Islam, Kathryn H Jacobsen, Nader Jahanmehr, Mihajlo B Jakovljevic, Peter James, Simerjot K Jassal, Mehdi Javanbakht, Sudha P Jayaraman, Panniyammakal Jeemon, Paul N Jensen, Vivekanand Jha, Guohong Jiang, Denny John, Catherine O Johnson, Sarah Charlotte Johnson, Jost B Jonas, Mikk Jürisson, Zubair Kabir, Rajendra Kadel, Amaha Kahsay, Ritul Kamal, Chittaranjan Kar, Nadim E Karam, André Karch, Corine Kakizi Karema, Seyed M Karimi, Chante Karimkhani, Amir Kasaeian, Getachew Mullu Kassa, Nigussie Assefa Kassaw, Nicholas J Kassebaum, Anshul Kastor, Srinivasa Vittal Katikireddi, Anil Kaul, Norito Kawakami, Peter Njenga Keiyoro, Laura Kemmer, Andre Pascal Kengne, Andre Keren, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Ibrahim A Khalil, Ejaz Ahmad Khan, Young-Ho Khang, Abdullah T Khoja, Ardeshir Khosravi, Jagdish Khubchandani, Aliasghar Ahmad Kiadaliri, Christian Kieling, Yun Jin Kim, Daniel Kim, Ruth W Kimokoti, Yohannes Kinfu, Adnan Kisa, Katarzyna A Kissimova-Skarbek, Niranjan Kissoon, Mika Kivimaki, Ann Kristin Knudsen, Yoshihiro Kokubo, Dhaval Kolte, Jacek A Kopec, Soewarta Kosen, Georgios A Kotsakis, Parvaiz A Koul, Ai Koyanagi, Michael Kravchenko, Kristopher J Krohn, G Anil Kumar, Pushpendra Kumar, Hmwe H Kyu, Anton Carl Jonas Lager, Dharmesh Kumar Lal, Ratilal Lalloo, Tea Lallukka, Nkurunziza Lambert, Qing Lan, Van C Lansingh, Anders Larsson, Janet L Leasher, Paul H Lee, James Leigh, Cheru Tesema Leshargie, Janni Leung, Ricky Leung, Miriam Levi, Yichong Li, Yongmei Li, Xiaofeng Liang, Misgan Legesse Liben, Stephen S Lim, Shai Linn, Patrick Y Liu, Angela Liu, Shiwei Liu, Yang Liu, Rakesh Lodha, Giancarlo Logroscino, Katharine J Looker, Alan D Lopez, Stefan Lorkowski, Paulo A Lotufo, Rafael Lozano, Timothy C D Lucas, Raimundas Lunevicius, Ronan A Lyons, Erlyn Rachelle King Macarayan, Emilie R Maddison, Hassan Magdy Abd Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Carlos Magis-Rodriguez, Mahdi Mahdavi, Marek Majdan, Reza Majdzadeh, Azeem Majeed, Reza Malekzadeh, Rajesh Malhotra, Deborah Carvalho Malta, Abdullah A Mamun, Helena Manguerra, Treh Manhertz, Lorenzo G Mantovani, Chabila C Mapoma, Lyn M March, Laurie B Marczak, Jose Martinez-Raga, Paulo Henrique Viegas Martins, Francisco Rogerlândio Martins-Melo, Ira Martopullo, Winfried März, Manu Raj Mathur, Mohsen Mazidi, Colm McAlinden, Madeline McGaughey, John J McGrath, Martin McKee, Suresh Mehata, Toni Meier, Kidanu Gebremariam Meles, Peter Memiah, Ziad A Memish, Walter Mendoza, Melkamu Merid Mengesha, Mubarek Abera Mengistie, Desalegn Tadese Mengistu, George A Mensah, Tuomo J Meretoja, Atte Meretoja, Haftay Berhane Mezgebe, Renata Micha, Anoushka Millear, Ted R Miller, Shawn Minnig, Mojde Mirarefin, Erkin M Mirrakhimov, Awoke Misganaw, Shiva Raj Mishra, Philip B Mitchell, Karzan Abdulmuhsin Mohammad, Alireza Mohammadi, Muktar Sano Kedir Mohammed, Kedir Endris Mohammed, Shafiu Mohammed, Murali B V Mohan, Ali H Mokdad, Sarah K Mollenkopf, Lorenzo Monasta, Julio Cesar Montañez Hernandez, Marcella Montico, Maziar Moradi-Lakeh, Paula Moraga, Lidia Morawska, Rintaro Mori, Shane D Morrison, Mark Moses, Cliff Mountjoy-Venning, Kalayu Birhane Mruts, Ulrich O Mueller, Kate Muller, Michele E Murdoch, Gudlavalleti Venkata Satyanarayana Murthy, Srinivas Murthy, Kamarul Imran Musa, Jean B Nachega, Gabriele Nagel, Mohsen Naghavi, Aliya Naheed, Kovin S Naidoo, Vinay Nangia, Jamal T Nasher, Gopalakrishnan Natarajan, Dumessa Edessa Negasa, Ruxandra Irina Negoi, Ionut Negoi, Charles R Newton, Josephine Wanjiku Ngunjiri, Cuong Tat Nguyen, Quyen Le Nguyen, Trang Huyen Nguyen, Grant Nguyen, Minh Nguyen, Emma Nichols, Dina Nur Anggraini Ningrum, Vuong Minh Nong, Ole F Norheim, Bo Norrving, Jean Jacques N Noubiap, Alypio Nyandwi, Carla Makhlouf Obermeyer, Martin J O'Donnell, Felix Akpojene Ogbo, In-Hwan Oh, Anselm Okoro, Olanrewaju Oladimeji, Andrew Toyin Olagunju, Tinuke Oluwasefunmi Olagunju, Helen E Olsen, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, Kanyin Ong, John Nelson Opio, Eyal Oren, Alberto Ortiz, Richard H Osborne, Aaron Osgood-Zimmerman, Majdi Osman, Erika Ota, Mayowa O Owolabi, Mahesh PA, Rosana E Pacella, Basant Kumar Panda, Jeyaraj Durai Pandian, Christina Papachristou, Eun-Kee Park, Charles D Parry, Mahboubeh Parsaeian, Snehal T Patil, Scott B Patten, George C Patton, Deepak Paudel, Katherine Paulson, Neil Pearce, David M Pereira, Krystle Marie Perez, Norberto Perico, Konrad Pesudovs, Carrie Beth Peterson, William Arthur Petri, Max Petzold, Michael Robert Phillips, Geoffrey Phipps, David M Pigott, Julian David Pillay, Christine Pinho, Michael A Piradov, Dietrich Plass, Martin A Pletcher, Svetlana Popova, Richie G Poulton, Farshad Pourmalek, Dorairaj Prabhakaran, Narayan Prasad, Carrie Purcell, Manorama Purwar, Mostafa Qorbani, Beatriz Paulina Ayala Quintanilla, Rynaz H S Rabiee, Amir Radfar, Anwar Rafay, Kazem Rahimi, Afarin Rahimi-Movaghar, Vafa Rahimi-Movaghar, Mohammad Hifz Ur Rahman, Muhammad Aziz Rahman, Mahfuzar Rahman, Rajesh Kumar Rai, Sasa Rajsic, Usha Ram, Chhabi Lal Ranabhat, Thara Rangaswamy, Zane Rankin, Paturi Vishnupriya Rao, Puja C Rao, Salman Rawaf, Sarah E Ray, Robert C Reiner, Nikolas Reinig, Marissa Reitsma, Giuseppe Remuzzi, Andre M N Renzaho, Serge Resnikoff, Satar Rezaei, Antonio L Ribeiro, Jacqueline Castillo Rivas, Hirbo Shore Roba, Stephen R Robinson, David Rojas-Rueda, Mohammad Bagher Rokni, Luca Ronfani, Gholamreza Roshandel, Gregory A Roth, Dietrich Rothenbacher, Ambuj Roy, Enrico Rubagotti, George Mugambage Ruhago, Soheil Saadat, Mahdi Safdarian, Saeid Safiri, Rajesh Sagar, Ramesh Sahathevan, Mohammad Ali Sahraian, Joseph Salama, Muhammad Muhammad Saleh, Joshua A Salomon, Sundeep Santosh Salvi, Abdallah M Samy, Juan Ramon Sanabria, Maria Dolores Sanchez-Niño, Damian Santomauro, João Vasco Santos, Itamar S Santos, Milena M Santric Milicevic, Benn Sartorius, Maheswar Satpathy, Monika Sawhney, Sonia Saxena, Kathryn Schelonka, Maria Inês Schmidt, Ione J C Schneider, Ben Schöttker, Aletta E Schutte, David C Schwebel, Falk Schwendicke, Soraya Seedat, Sadaf G Sepanlou, Edson E Servan-Mori, Amira Shaheen, Masood Ali Shaikh, Mansour Shamsipour, Rajesh Sharma, Jayendra Sharma, Jun She, Peilin Shi, Kenji Shibuya, Chloe Shields, Girma Temam Shifa, Mekonnen Sisay Shiferaw, Mika Shigematsu, Rahman Shiri, Reza Shirkoohi, Shreya Shirude, Kawkab Shishani, Haitham Shoman, Soraya Siabani, Abla Mehio Sibai, Inga Dora Sigfusdottir, Donald H Silberberg, Diego Augusto Santos Silva, João Pedro Silva, Dayane Gabriele Alves Silveira, Jasvinder A Singh, Om Prakash Singh, Narinder Pal Singh, Virendra Singh, Dhirendra Narain Sinha, Eirini Skiadaresi, Erica Leigh Slepak, David L Smith, Mari Smith, Badr H A Sobaih, Eugene Sobngwi, Michael Soljak, Reed J D Sorensen, Tatiane Cristina Moraes Sousa, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Vinay Srinivasan, Jeffrey D Stanaway, Vasiliki Stathopoulou, Nicholas Steel, Dan J Stein, Caitlyn Steiner, Sabine Steinke, Mark Andrew Stokes, Lars Jacob Stovner, Bryan Strub, Michelle Subart, Muawiyyah Babale Sufiyan, Bruno F Sunguya, Patrick J Sur, Soumya Swaminathan, Bryan L Sykes, Dillon Sylte, Cassandra E I Szoeke, Rafael Tabarés-Seisdedos, Santosh Kumar Tadakamadla, Getachew Redae Taffere, Jukka S Takala, Nikhil Tandon, David Tanne, Yihunie L Tarekegn, Mohammad Tavakkoli, Nuno Taveira, Hugh R Taylor, Teketo Kassaw Tegegne, Arash Tehrani-Banihashemi, Tesfalidet Tekelab, Abdullah Sulieman Terkawi, Dawit Jember Tesfaye, Belay Tesssema, JS Thakur, Ornwipa Thamsuwan, Alice M Theadom, Andrew M Theis, Katie E Thomas, Nihal Thomas, Robert Thompson, Amanda G Thrift, Ruoyan Tobe-Gai, Myriam Tobollik, Marcello Tonelli, Roman Topor-Madry, Miguel Tortajada, Mathilde Touvier, Jefferson Traebert, Bach Xuan Tran, Christopher Troeger, Thomas Truelsen, Derrick Tsoi, Emin Murat Tuzcu, Hayley Tymeson, Stefanos Tyrovolas, Kingsley Nnanna Ukwaja, Eduardo A Undurraga, Chigozie Jesse Uneke, Rachel Updike, Olalekan A Uthman, Benjamin S Chudi Uzochukwu, Job F M van Boven, Santosh Varughese, Tommi Vasankari, Lennert J Veerman, S Venkatesh, Narayanaswamy Venketasubramanian, Ramesh Vidavalur, Lakshmi Vijayakumar, Francesco S Violante, Abhishek Vishnu, Sergey K Vladimirov, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Theo Vos, Fiseha Wadilo, Tolassa Wakayo, Mitchell T Wallin, Yuan-Pang Wang, Scott Weichenthal, Elisabete Weiderpass, Robert G Weintraub, Daniel J Weiss, Andrea Werdecker, Ronny Westerman, Harvey A Whiteford, Tissa Wijeratne, Hywel C Williams, Charles Shey Wiysonge, Belete Getahun Woldeyes, Charles D A Wolfe, Rachel Woodbrook, Anthony D Woolf, Abdulhalik Workicho, Denis Xavier, Gelin Xu, Simon Yadgir, Mohsen Yaghoubi, Bereket Yakob, Lijing L Yan, Yuichiro Yano, Pengpeng Ye, Mahari Gidey Yihdego, Hassen Hamid Yimam, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Marcel Yotebieng, Mustafa Z Younis, Chuanhua Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Elias Asfaw Zegeye, Zerihun Menlkalew Zenebe, Xueying Zhang, Yingfeng Zheng, Maigeng Zhou, Ben Zipkin, Sanjay Zodpey, Leo Zoeckler, Liesl Joanna Zuhlke, Christopher J L Murray
Journal: The Lancet (2017)

Measurement of changes in health across locations is useful to compare and contrast changing epidemiological patterns against health system performance and identify specific needs for resource allocation in research, policy development, and programme decision making. Using the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we drew from two widely used summary measures to monitor such changes in population health: disability-adjusted life-years (DALYs) and healthy life expectancy (HALE). We used these measures to track trends and benchmark progress compared with expected trends on the basis of the Socio-demographic Index (SDI).We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2016. We calculated DALYs by summing years of life lost and years of life lived with disability for each location, age group, sex, and year. We estimated HALE using age-specific death rates and years of life lived with disability per capita. We explored how DALYs and HALE differed from expected trends when compared with the SDI: the geometric mean of income per person, educational attainment in the population older than age 15 years, and total fertility rate.The highest globally observed HALE at birth for both women and men was in Singapore, at 75·2 years (95% uncertainty interval 71·9-78·6) for females and 72·0 years (68·8-75·1) for males. The lowest for females was in the Central African Republic (45·6 years [42·0-49·5]) and for males was in Lesotho (41·5 years [39·0-44·0]). From 1990 to 2016, global HALE increased by an average of 6·24 years (5·97-6·48) for both sexes combined. Global HALE increased by 6·04 years (5·74-6·27) for males and 6·49 years (6·08-6·77) for females, whereas HALE at age 65 years increased by 1·78 years (1·61-1·93) for males and 1·96 years (1·69-2·13) for females. Total global DALYs remained largely unchanged from 1990 to 2016 (-2·3% [-5·9 to 0·9]), with decreases in communicable, maternal, neonatal, and nutritional (CMNN) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). The exemplars, calculated as the five lowest ratios of observed to expected age-standardised DALY rates in 2016, were Nicaragua, Costa Rica, the Maldives, Peru, and Israel. The leading three causes of DALYs globally were ischaemic heart disease, cerebrovascular disease, and lower respiratory infections, comprising 16·1% of all DALYs. Total DALYs and age-standardised DALY rates due to most CMNN causes decreased from 1990 to 2016. Conversely, the total DALY burden rose for most NCDs; however, age-standardised DALY rates due to NCDs declined globally.At a global level, DALYs and HALE continue to show improvements. At the same time, we observe that many populations are facing growing functional health loss. Rising SDI was associated with increases in cumulative years of life lived with disability and decreases in CMNN DALYs offset by increased NCD DALYs. Relative compression of morbidity highlights the importance of continued health interventions, which has changed in most locations in pace with the gross domestic product per person, education, and family planning. The analysis of DALYs and HALE and their relationship to SDI represents a robust framework with which to benchmark location-specific health performance. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform health policies, health system improvement initiatives, targeted prevention efforts, and development assistance for health, including financial and research investments for all countries, regardless of their level of sociodemographic development. The presence of countries that substantially outperform others suggests the need for increased scrutiny for proven examples of best practices, which can help to extend gains, whereas the presence of underperforming countries suggests the need for devotion of extra attention to health systems that need more robust support.Bill & Melinda Gates Foundation.