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.
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.
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DOI：
10.1016/s0140-6736(20)30750-9
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发表时间：
2020-10-17
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通讯作者：
GBD 2019 Universal Health Coverage Collaborators
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作者：
GBD 2019 Universal Health Coverage Collaborators
实现全民健康覆盖 (UHC) 意味着所有人都能获得所需的高质量卫生服务，且不会遇到经济困难。正如联合国可持续发展目标 (SDG) 和世卫组织第十三个工作总规划 (GPW13) 议程所强调的那样，在全民健康覆盖方面取得进展是各国和全球机构的政策优先事项。衡量卫生系统层面的有效覆盖率对于了解卫生服务是否符合各国的健康概况以及是否具有足够的质量以给所有年龄段的人口带来健康收益非常重要。根据 2019 年全球疾病、伤害和风险因素负担研究 (GBD)，我们评估了 1990 年至 2019 年 204 个国家和地区全民健康覆盖的有效覆盖率。根据世卫组织第 13 次工作总规划磋商制定的衡量框架，我们将 23 个有效覆盖指标映射到一个矩阵，代表卫生服务类型（例如，促进、预防和治疗）和五个人口年龄组（从生殖到生育）。 新生儿到老年人（≥65 岁）。有效的覆盖指标以干预覆盖范围或基于结果的衡量标准为基础，例如死亡率与发病率之比，以大致了解获得优质护理的情况；基于结果的衡量标准根据地点-年份值的第 2·5 个和第 97·5 个百分位数转换为 0-100 范围内的值。我们通过对每个有效覆盖指标相对于其相关的潜在健康收益进行加权来构建全民健康覆盖有效覆盖指数，该指标通过每个地点年份和人口年龄组的残疾调整生命年来衡量。对于三项有效性检验（内容、已知群体和趋同性），全民健康覆盖有效覆盖指数表现普遍优于世卫组织（即关于全民健康覆盖服务覆盖的可持续发展目标指标 3.8.1 的当前指标）、世界银行和 GBD 2017 的其他全民健康覆盖服务覆盖指数。我们根据人均汇总卫生支出量化了全民健康覆盖有效覆盖表现的前沿，代表全民健康覆盖有效覆盖 2019 年相对于国家级政府卫生支出、预付费私人支出和卫生发展援助实现的覆盖指数水平。为了评估当前实现《第十三个工作总规划》全民健康覆盖十亿目标的轨迹（到 2023 年将有 10 亿人受益于全民健康覆盖），我们估算了 2018 年至 2023 年全民健康覆盖有效覆盖的额外人口当量。在全球范围内，全民健康覆盖有效覆盖指数的表现从 1990 年的 45·8（95% 不确定性区间 44·2–47·5）提高到 60·3 (58·7–61·9)，但 2019 年国家级全民健康覆盖有效覆盖率仍从日本和冰岛的 95 或更高，到索马里和中非共和国的低于 25。自 2010 年以来，撒哈拉以南非洲地区的全民健康覆盖有效覆盖指数加速增长（截至 2019 年，每年平均增长 2·6% [1·9–3·3]）；相比之下，与 1990-2010 年相比，大多数其他 GBD 大区域在 2010-2019 年的进展速度有所放缓。尽管非传染性疾病在 2019 年潜在健康收益中所占比例较大，但许多国家在非传染性疾病有效覆盖指标方面的表现仍落后于传染性疾病和孕产妇和儿童健康的指标，这表明许多卫生系统未能跟上不断上升的非传染性疾病负担和相关的人口健康需求。 2019年，全民健康覆盖有效覆盖指数与人均综合医疗支出相关（r=0·79），尽管各个发展阶段国家的全民健康覆盖有效覆盖率远低于相对于其医疗支出可能实现的水平。在将卫生支出转化为全民健康覆盖有效覆盖绩效的最大效率下，各国人均综合卫生支出需要达到 1398 美元（按购买力平价调整的美元），才能实现全民健康覆盖有效覆盖指数 80。从 2018 年到 2023 年，估计将有 3.88·9 百万（358·6-421·3）人口获得全民健康覆盖有效覆盖，远低于第十三个工作总规划期间从全民健康覆盖中受益的人口增加 10 亿的目标。目前的预测表明，到 2023 年，估计仍有 3·10 亿 (3·0–3·2) 人口仍缺乏全民健康覆盖的有效覆盖，其中近三分之一 (968·100 万 [903·5–1040·3]) 居住在南亚。本研究证明了衡量有效覆盖率的实用性及其在支持改善所有人健康结果方面的作用——全民健康覆盖的最终目标及其成就。除非就非传染性疾病采取协调一致的行动并且各国能够更好地将卫生支出转化为绩效的改善，否则全球加速全民健康覆盖服务覆盖进展的雄心越来越不可能实现。重点关注有效覆盖并考虑世界不断变化的健康需求，为更好地了解所有人口从全民健康覆盖中受益的程度或程度奠定了基础。比尔及梅琳达·盖茨基金会。
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. 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. 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. 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. Bill & Melinda Gates Foundation.