dc.description.abstract | Background
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.
Methods
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.
Findings
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.
Interpretation
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 | en_US |