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

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 AdelsonOlatunji 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, Yousef Saleh Khader, Mohammad Khammarnia, Maseer Khan, Ejaz Ahmad Khan, Young Ho Khang, Khaled Khatab, Amir M. Khater, Mona M. Khater, Mahalaqua Nazli Khatib, Maryam Khayamzadeh, Jagdish Khubchandani, Neda Kianipour, Young Eun Kim, Yun Jin Kim, Ruth W. Kimokoti, Yohannes Kinfu, Adnan Kisa, Katarzyna Kissimova-Skarbek, Mika Kivimäki, Cameron J. Kneib, Jonathan M. Kocarnik, Sonali Kochhar, Stefan Kohler, Jacek A. Kopec, Anna V. Korotkova, Vladimir Andreevich Korshunov, Soewarta Kosen, Anirudh Kotlo, Parvaiz A. Koul, Ai Koyanagi, Kewal Krishan, Kris J. Krohn, Nuworza Kugbey, Vaman Kulkarni, G. Anil Kumar, Nithin Kumar, Manasi Kumar, Om P. Kurmi, Dian Kusuma, Hmwe Hmwe Kyu, Carlo La Vecchia, Ben Lacey, Dharmesh Kumar Lal, Ratilal Lalloo, Iván Landires, Van Charles Lansingh, Anders O. Larsson, Savita Lasrado, Kathryn Mei Ming Lau, Paolo Lauriola, Jeffrey V. Lazarus, Jorge R. Ledesma, Paul H. Lee, Shaun Wen Huey Lee, Andrew T. Leever, Kate E. LeGrand, James Leigh, Matilde Leonardi, Shanshan Li, Stephen S. Lim, Lee Ling Lim, Xuefeng Liu, Giancarlo Logroscino, Alan D. Lopez, Platon D. Lopukhov, Paulo A. Lotufo, Alton Lu, Jianing Ma, Mohammed Madadin, Phetole Walter Mahasha, Morteza Mahmoudi, Azeem Majeed, Jeadran N. Malagón-Rojas, Shokofeh Maleki, Deborah Carvalho Malta, Borhan Mansouri, Mohammad Ali Mansournia, 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, Entezar Mehrabi Nasab, Fereshteh Mehri, Ravi Mehrotra, Teferi Mekonnen, Addisu Melese, Peter T.N. Memiah, Walter Mendoza, Ritesh G. Menezes, George A. Mensah, Tuomo J. Meretoja, Atte Meretoja, Tomislav Mestrovic, Bartosz Miazgowski, Irmina Maria Michalek, Erkin M. Mirrakhimov, Maryam Mirzaei, Mehdi Mirzaei-Alavijeh, Philip B. Mitchell, Babak Moazen, Masoud Moghadaszadeh, Efat Mohamadi, Yousef Mohammad, Dara K. Mohammad, Naser Mohammad Gholi Mezerji, Abdollah Mohammadian-Hafshejani, Shafiu Mohammed, Jemal Abdu Mohammed, Ali H. Mokdad, Lorenzo Monasta, Stefania Mondello, Masoud Moradi, Maziar Moradi-Lakeh, Rahmatollah Moradzadeh, Paula Moraga, Joana Morgado-da-Costa, Shane Douglas Morrison, Abbas Mosapour, Jonathan F. Mosser, Amin Mousavi Khaneghah, Moses K. Muriithi, Ghulam Mustafa, Ashraf F. Nabhan, Mehdi Naderi, Ahamarshan Jayaraman Nagarajan, Mohsen Naghavi, Behshad Naghshtabrizi, Mukhammad David Naimzada, Vinay Nangia, Jobert Richie Nansseu, Vinod C. Nayak, Javad Nazari, Rawlance Ndejjo, Ionut Negoi, Ruxandra Irina Negoi, Subas Neupane, Kiirithio N. Ngari, Georges Nguefack-Tsague, Josephine W. Ngunjiri, Cuong Tat Nguyen, Diep Ngoc Nguyen, Huong Lan Thi Nguyen, Chukwudi A. Nnaji, Shuhei Nomura, Ole F. Norheim, Jean Jacques Noubiap, Christoph Nowak, Virginia Nunez-Samudio, Adrian Otoiu, Felix Akpojene Ogbo, Onome Bright Oghenetega, In Hwan Oh, 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, Jeevan Pereira, David M. Pigott, Thomas Pilgrim, Tessa M. Pilz, Marina Pinheiro, Michael A. Piradov, Meghdad Pirsaheb, Khem Narayan Pokhrel, Maarten J. Postma, Hadi Pourjafar, Farshad Pourmalek, 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, Reza Rawassizadeh, Christian Razo, Vishnu Renjith, Andre M.N. Renzaho, Bhageerathy Reshmi, Nima Rezaei, Seyed Mohammad Riahi, Daniel Cury Ribeiro, Jennifer Rickard, Nicholas L.S. Roberts, Leonardo Roever, Michele Romoli, Luca Ronfani, Gholamreza Roshandel, Enrico Rubagotti, 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, Miloje Savic, Susan M. Sawyer, Deepak Saxena, Alyssa N. Sbarra, Lauren E. Schaeffer, Silvia Schiavolin, Maria Inês Schmidt, 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, B. Suresh Kumar Shetty, 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, Ireneous N. Soyiri, 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

*Corresponding author for this work

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Abstract

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.

Original languageEnglish
JournalThe Lancet
Volume396
Issue number10258
Pages (from-to)1250-1284
ISSN0140-6736
DOIs
Publication statusPublished - 2020

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