Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.
Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016.
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衡量 195 个国家和地区以及选定的次国家地点的医疗保健可及性和质量指数表现：2016 年全球疾病负担研究的系统分析
DOI：
10.1016/s0140-6736(18)30994-2
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发表时间：
2018-06-02
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通讯作者：
GBD 2016 Healthcare Access and Quality Collaborators
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作者：
GBD 2016 Healthcare Access and Quality Collaborators
实现全民健康覆盖的一个关键组成部分是确保所有人口都能获得优质的医疗保健。检查国家之间和国家内部取得的成果或进展停滞的地方对于指导未来改进的决策和战略至关重要。我们使用 2016 年全球疾病、伤害和风险因素负担研究 (GBD 2016) 来评估 195 个国家和地区以及 7 个国家的次国家地区的医疗保健可及性和质量 (HAQ) 指数，从 1990 年到 2016 年。根据既定方法和 GBD 2016 的最新估计，我们使用了 32 种在存在以下情况时不应发生死亡的原因：有效的护理，以根据地点和时间来估算个人医疗保健的获取和质量。为了更好地将个人医疗保健获取和质量与潜在风险因素模式的潜在影响区分开来，我们按地点年份对非癌症导致的特定原因死亡风险进行了标准化，用全球暴露水平取代了当地环境和行为风险的联合暴露。在 2016 年 GBD 癌症登记数据扩展的支持下，我们使用癌症死亡率与发病率的比率，而不是风险标准化死亡率，来提供更强有力的信号，表明个人医疗保健和获取对癌症生存的影响。我们将每个原因转换为 0-100 的等级，其中 0 为 1990 年至 2016 年间观察到的第一个百分位数（最差），100 为第 99 个百分位数（最好）；我们在国家一级设定这些阈值，然后将其应用于国家以下地区。我们采用主成分分析法，使用所有缩放原因值构建 HAQ 指数，提供随时间推移按位置划分的个人医疗保健获取和质量的 0-100 总分。然后，我们比较了社会人口指数 (SDI) 上的 HAQ 指数水平和趋势（总体发展的汇总衡量标准）。根据更广泛的 GBD 研究和其他数据源，我们研究了国家 HAQ 指数得分与绩效的潜在相关性（例如人均总医疗支出）之间的关系。 2016 年，HAQ 指数表现最高为冰岛 97·1（95% UI 95·8–98·1），其次是挪威 96·6（94·9–97·9）和荷兰 96·1（94·5–97·3），最低为中非共和国 18·6（13·1–24·4）和 19·0索马里 (14·3–23·7)，几内亚比绍 (20·2–26·8) 23·4。 1990 年至 2016 年间取得的进展速度各不相同，撒哈拉以南非洲和东南亚的许多国家在 2000 年至 2016 年间取得了明显更快的进步，而拉丁美洲和其他地区的一些国家在 1990 年至 2000 年间 HAQ 指数取得了长足进步后，进展停滞不前。 2016 年得分最高和最低。在中国，表现范围从北京的 91·5 (89·1–93·6) 到西藏的 48·0 (43·4–53·2)（相差 43·5 分），而印度则出现 30·8 分的差距，从果阿的 64·8 (59·6–68·8) 到 34·0 （30·3–38·1）在阿萨姆邦。 2016 年，日本的地方 HAQ 表现差异最小（4·8 分差异），而 HAQ 指数值最高和最低的地方之间的差异是美国的两倍多，英国的三倍多。从 1990 年到 2016 年，墨西哥 HAQ 指数的州级差距有所缩小（从 20·9 点差异到 17·0 点），而在巴西，在此期间各州之间的差异略有增加（从 17·2 点到 20·4 点差异）。 HAQ 指数的表现显示出与整体发展的密切联系，高和中高 SDI 国家通常在非传染性疾病方面得分较高且进展较快。尽管如此，从 2000 年到 2016 年，各个发展阶段的国家在一些关键卫生服务领域都取得了实质性进展，最引人注目的是疫苗可预防的疾病。总体而言，HAQ 指数的国家表现与较高水平的人均卫生总支出以及卫生系统投入呈正相关，但这些关系相当不同，特别是在中低 SDI 国家中。 GBD 2016 更详细地了解了过去在改善全球个人医疗保健获取和质量方面的成功和当前的挑战。尽管自 2000 年以来取得了巨大进展，但许多低 SDI 和中 SDI 国家仍面临相当大的挑战，除非加强政策行动和投资，重点关注提高关键卫生服务（尤其是非传染性疾病）的医疗保健获取和质量。一些中低到中高 SDI 国家经历的停滞或改善程度很小，可能反映出在千年发展目标的更有限的重点之外重新调整初级和二级卫生保健服务的复杂性。除了加强公共卫生计划的举措外，实现全民健康覆盖还取决于改善全球范围内的获取机会和质量，因此需要采取更全面的观点并随后为所有人口提供优质医疗保健。比尔及梅琳达·盖茨基金会。
A key component of achieving universal health coverage is ensuring that all populations have access to quality health care. Examining where gains have occurred or progress has faltered across and within countries is crucial to guiding decisions and strategies for future improvement. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) to assess personal health-care access and quality with the Healthcare Access and Quality (HAQ) Index for 195 countries and territories, as well as subnational locations in seven countries, from 1990 to 2016. Drawing from established methods and updated estimates from GBD 2016, we used 32 causes from which death should not occur in the presence of effective care to approximate personal health-care access and quality by location and over time. To better isolate potential effects of personal health-care access and quality from underlying risk factor patterns, we risk-standardised cause-specific deaths due to non-cancers by location-year, replacing the local joint exposure of environmental and behavioural risks with the global level of exposure. Supported by the expansion of cancer registry data in GBD 2016, we used mortality-to-incidence ratios for cancers instead of risk-standardised death rates to provide a stronger signal of the effects of personal health care and access on cancer survival. We transformed each cause to a scale of 0–100, with 0 as the first percentile (worst) observed between 1990 and 2016, and 100 as the 99th percentile (best); we set these thresholds at the country level, and then applied them to subnational locations. We applied a principal components analysis to construct the HAQ Index using all scaled cause values, providing an overall score of 0–100 of personal health-care access and quality by location over time. We then compared HAQ Index levels and trends by quintiles on the Socio-demographic Index (SDI), a summary measure of overall development. As derived from the broader GBD study and other data sources, we examined relationships between national HAQ Index scores and potential correlates of performance, such as total health spending per capita. In 2016, HAQ Index performance spanned from a high of 97·1 (95% UI 95·8–98·1) in Iceland, followed by 96·6 (94·9–97·9) in Norway and 96·1 (94·5–97·3) in the Netherlands, to values as low as 18·6 (13·1–24·4) in the Central African Republic, 19·0 (14·3–23·7) in Somalia, and 23·4 (20·2–26·8) in Guinea-Bissau. The pace of progress achieved between 1990 and 2016 varied, with markedly faster improvements occurring between 2000 and 2016 for many countries in sub-Saharan Africa and southeast Asia, whereas several countries in Latin America and elsewhere saw progress stagnate after experiencing considerable advances in the HAQ Index between 1990 and 2000. Striking subnational disparities emerged in personal health-care access and quality, with China and India having particularly large gaps between locations with the highest and lowest scores in 2016. In China, performance ranged from 91·5 (89·1–93·6) in Beijing to 48·0 (43·4–53·2) in Tibet (a 43·5-point difference), while India saw a 30·8-point disparity, from 64·8 (59·6–68·8) in Goa to 34·0 (30·3–38·1) in Assam. Japan recorded the smallest range in subnational HAQ performance in 2016 (a 4·8-point difference), whereas differences between subnational locations with the highest and lowest HAQ Index values were more than two times as high for the USA and three times as high for England. State-level gaps in the HAQ Index in Mexico somewhat narrowed from 1990 to 2016 (from a 20·9-point to 17·0-point difference), whereas in Brazil, disparities slightly increased across states during this time (a 17·2-point to 20·4-point difference). Performance on the HAQ Index showed strong linkages to overall development, with high and high-middle SDI countries generally having higher scores and faster gains for non-communicable diseases. Nonetheless, countries across the development spectrum saw substantial gains in some key health service areas from 2000 to 2016, most notably vaccine-preventable diseases. Overall, national performance on the HAQ Index was positively associated with higher levels of total health spending per capita, as well as health systems inputs, but these relationships were quite heterogeneous, particularly among low-to-middle SDI countries. GBD 2016 provides a more detailed understanding of past success and current challenges in improving personal health-care access and quality worldwide. Despite substantial gains since 2000, many low-SDI and middle-SDI countries face considerable challenges unless heightened policy action and investments focus on advancing access to and quality of health care across key health services, especially non-communicable diseases. Stagnating or minimal improvements experienced by several low-middle to high-middle SDI countries could reflect the complexities of re-orienting both primary and secondary health-care services beyond the more limited foci of the Millennium Development Goals. Alongside initiatives to strengthen public health programmes, the pursuit of universal health coverage hinges upon improving both access and quality worldwide, and thus requires adopting a more comprehensive view—and subsequent provision—of quality health care for all populations. Bill & Melinda Gates Foundation.