Lancet Healthcare Quality Journal

Articles
Healthcare Access and Quality Index based on mortality from

causes amenable to personal health care in 195 countries and
territories, 19902015: a novel analysis from the Global
Burden of Disease Study 2015
GBD 2015 Healthcare Access and Quality Collaborators*
Summary
Background National levels of personal health-care access and quality can be approximated by measuring mortality Published Online
rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous May 18, 2017
http://dx.doi.org/10.1016/
analyses of mortality amenable to health care only focused on high-income countries and faced several methodological S0140-6736(17)30818-8
challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated
See Online/Comment
through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the http://dx.doi.org/10.1016/
quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. S0140-6736(17)31289-8
*Collaborators listed at the end
Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and of the Article
McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications Correspondence to:
Prof Christopher J L Murray,
through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate
Institute for Health Metrics and
the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each Evaluation, University of
geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the Washington, 2301 5th Avenue,
global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a Suite 600, Seattle, WA 98121,
USA
single, interpretable summary measurethe Healthcare Quality and Access (HAQ) Indexon a scale of 0 to 100.
cjlm@uw.edu
The HAQ Index showed strong convergence validity as compared with other health-system indicators, including
health expenditure per capita (r=088), an index of 11 universal health coverage interventions (r=083), and human
resources for health per 1000 (r=077). 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 286 to 946. 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 407
(95% uncertainty interval, 390428) in 1990 to 537 (522554) 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 212 in 1990 to 201 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 738 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
www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 1

Articles
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.
Funding Bill & Melinda Gates Foundation.
Copyright The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.
Introduction dimensions of health-system performance and to identify

Quantifying how much personal health care can untapped potential for advancing personal health-care
improve population health and ultimately health-system access and quality.912 Much debate exists concerning the
performance is a crucial undertaking, particularly relative contributions of personal health care, population-
following the inclusion of universal health coverage (UHC) level health initiatives, and social determinants to
in the Sustainable Development Goals (SDGs).1 Mortality population health.1316 Studies show that access to high-
from causes considered amenable to personal health care quality health care substantially improves many health
serve as an important proxy of health-care access and outcomes, including infectious diseases (eg, tuberculosis
quality (panel),4,68 and thus can be used to benchmark and measles);1719 maternal and neonatal disorders;20,21
Research in context
Evidence before this study designated to so-called garbage codes, or causes of death that
In the last several decades, various studies have used measures of could not or should not be classified as underlying causes of
amenable mortality, or deaths that could be avoided in the death. Second, we draw on GBDs comparative risk assessment
presence of high-quality personal health care, to garner signals analyses to risk-standardise national cause-specific mortality
about health-system delivery, effectiveness, and performance. rates to global levels of risk exposure; this step helps to remove
Rutstein and colleagues developed an initial list of conditions variations in death rates due to risk exposure rather than
from which death was unnecessary and untimely during the differences in personal health-care access and quality. Third, we
late 1970s, while Charlton and colleagues were the first to apply construct the Healthcare Access and Quality (HAQ) Index based
this concept to population-level analyses in England and Wales. on risk-standardised cause-specific death rates to facilitate
Although variations of amenable cause lists exist today, the most comparisons over time and by geography. Finally, we produced a
widely used cause list of 33 conditions was developed and further HAQ Index frontier to enable a better understanding of the
honed by Nolte and McKee during the early-to-mid 2000s. Such maximum observed levels of the HAQ Index across the
analyses of health-care access and quality, as approximated by development spectrum, and what untapped potential for
amenable mortality, have been limited to Europe, Organisation improving personal health-care access and quality may exist
for Economic Co-operation and Development (OECD) countries, given a country or territorys current resources.
and country-specific assessments, including the USA, Australia,
Implications of all the available evidence
and New Zealand. These studies acknowledge several
Our results point to substantive gains for advancing personal
methodological challenges that may impede the policy utility
health-care access and quality throughout the world since 1990.
and applications of their results. Heterogeneity in cause of death
However, the gap between places with the highest and lowest
certification and misclassification, even for countries with
HAQ Index in 1990 increased by 2015, suggesting that
complete vital registration systems, can hinder comparability of
geographic inequalities in personal health-care access and quality
results over time and place. Further, researchers commonly
might be on the rise. In 2015, countries in western Europe
acknowledge that variations in measured amenable mortality
generally had the highest HAQ Index values while geographies in
rates may be more reflective of differences in underlying risk
sub-Saharan Africa and Oceania mainly saw the lowest, further
factor exposure rather than true differences in personal
emphasising these disparities. A number of countries achieved
health-care access and quality.
improvements in the HAQ Index that exceeded the average
Added value of this study found for their development level, identifying possible success
The Global Burden of Diseases, Injuries, and Risk Factors Study stories in markedly advancing personal health-care access and
(GBD) provides an appropriate analytic framework through quality at the national level. Based on our frontier analysis, many
which these main challenges in approximating personal countries and territories currently experience untapped potential
health-care access and quality can be addressed. First, the for improving health-care access and quality, on the basis of their
extensive cause of death data processing and standardisation development, a finding that could be transformative for
that occur within GBD allow for the systematic identification and prioritising particular health-sector reforms, pinpointing
redress of cause of death certification errors or misclassification. cause-specific therapeutic areas that require more policy
These adjustments are conducted across all geographies and attention, and monitoring overall progress toward universal
over time, accounting for known misclassification patterns and health coverage.
applying well established redistribution algorithms for causes
2 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

Articles
several cancers (eg, testicular, skin, and cervical cancers);22,23

and many non-communicable diseases (NCDs) such as Panel: Context and definitions
cerebrovascular disease (stroke),24 diabetes,25 and chronic With the present analysis, we use the Global Burden of Diseases, Injuries, and Risk Factors
kidney disease.26 Consequently, assessing mortality rates Study (GBD) to approximate average levels of personal health-care access and quality for
from these conditions, which are considered amenable to 195 countries and territories from 1990 to 2015. Here we define key concepts frequently
personal health care,4,68 can provide vital insights into used in the literature focused on assessing health-care quality and how they relate to GBD
access to and quality of health care worldwide. Assessments terminology:
of both mortality and disease burden attributable to risk
factors modifiable through public health programmes and Avertable burden refers to disease burden that could be avoided in the presence of
policy (eg, tobacco taxation), combined with access to high- high-quality personal health care in addition to disease burden that could be prevented
quality personal health care, can provide a more complete through effective public health (ie, non-personal) interventions.
picture of the potential avenues for health improvement. Amenable burden entails disease burden that could be avoided in the presence of
In the late 1970s, Rutstein and colleagues first introduced high-quality personal health care.2,3 To be considered a cause amenable to personal health
the idea of unnecessary, untimely deaths, proposing a care, effective interventions must exist for the disease.4 The most widely used and cited
list of causes from which death should not occur with list of causes amenable to health care is that of Nolte and McKee.
timely and effective medical care.6 Eventually termed Preventable burden involves disease burden that could be avoided through public health
amenable mortality, this approach has been modified programmes or policies focused on wider determinants of health, such as behavioural and
and extended since, with researchers refining the list of lifestyle influences, environmental factors, and socioeconomic status.2,3 For some causes,
included conditions by accounting for advances in medical both personal health care and public health programmes and policies can reduce burden.
care, the introduction of new interventions, and improved
knowledge of cause-specific epidemiology.7,8,2729 Numerous Within the GBD framework, we have two related terms: attributable and avoidable
studies have subsequently assessed amenable mortality burden.5
trends over time, by sex, and across ages in different Attributable burden refers to the difference in disease burden observed at present and
populations;2,10,11,3033 examples include analyses showing burden that would have been observed in a population if past exposure was at the lowest
variations in amenable mortality within the European level of risk.
Union and Organisation for Economic Co-operation and Avoidable burden concerns the reduction in future disease burden if observed levels of
Development (OECD),3,34 and how much the US health risk factor exposure today were decreased to a counterfactual level.
system has lagged behind other higher-income
countries.30,31 Some studies also extended the set of For this study, we use the definition of amenable burden and focus on amenable mortality
amenable conditions to include those targeted by public to provide a signal on approximate average levels of national personal health-care access
health programmes.31 The most widely cited and utilised and quality. Future analyses facilitated through the GBD study aim to provide more
list of causes amenable to personal health care is that of comprehensive assessments of health systems using amenable burden and preventable
Nolte and McKee,4 which has been extensively used in burden.
Europe, the USA, and other OECD countries.9,11,30,31,35 Garbage codes refer to causes certified by physicians on death certificates that cannot or
Previously, several technical challenges have emerged should not be considered the actual underlying causes of death. Examples include risk
concerning the quantification of mortality from con factors like hypertension, non-fatal conditions like yellow nails, and causes that are on
ditions amenable to personal health care and its use for the final steps of a disease pathway (eg, certifying cardiopulmonary arrest as the cause
understanding overall health-care access and quality. First, when ischaemic heart disease is the true underlying cause of death). A vital strength of
discrepancies in cause of death certification practices and the GBD Study is its careful identification of garbage codes by cause, over time, and
misclassification over time and across geographies affect across locations, and subsequent redistribution to underlying causes based on the GBD
comparisons of amenable mortality.4,36 Second, observed cause list.
geographic and temporal variations in deaths from Risk-standardisation involves removing the joint effects of environmental and
selected amenable causes (eg, stroke and heart disease) behavioural risk exposure on cause-specific mortality rates at the country or territory level
might be attributed partly differences in risk factor for each year of analysis, and then adding back the global average of environmental and
exposure (eg, diet, high BMI, and physical activity) rather behavioural risk exposure for every geography-year. The goal of risk-standardisation is to
than actual differences in access to quality personal health eliminate geographic or temporal differences in cause-specific mortality due to variations
care. Public health programmes and policies might modify in risk factors that are not immediately targeted by personal health careand thus
these risks in well-functioning health systems, but risk provide comparable measures of outcomes amenable to personal health-care access and
variation can still confound the measurement of personal quality over place and time.
health-care access and quality. Third, much of this work
has occurred in higher-income settings, with few studies Frontier analysis refers to the approach used for ascertaining the highest achieved values
applying the concept of amenable mortality as a on the Healthcare Access and Quality Index (HAQ Index) on the basis of development
mechanism for assessing access and quality to personal status, as measured by the Socio-demographic Index (SDI). The HAQ Index frontier
health care in lower-resource settings. Other critiques delineates the maximum HAQ Index reached by a location as it relates to SDI; if a country
involve weak correlations between observed trends and or territory falls well below the frontier value given its level SDI, this finding suggests that
variations in amenable mortality and indicators of health- greater gains in personal health-care access and quality should be possible based on the
care provision and spending, although this result could country or territorys place on the development spectrum.

Articles
effects of trauma care on various injuries,4,41,42 and the ages

Amenable age
range (years) at which personal health care can reduce mortality, namely
beyond the age of 75.43,44
Communicable, maternal, neonatal, and nutritional diseases
The goal of this analysis is to use estimates of mortality
Tuberculosis 074
amenable to personal health care from the Global Burden
Diarrhoea, lower respiratory, and other common infectious diseases
of Diseases, Injuries, and Risk Factors Study 2015
Diarrhoeal diseases 014
(GBD 2015) to approximate access to and quality of
Lower respiratory infections 074
personal health care in 195 countries and territories from
Upper respiratory infections 074
1990 to 2015. Quantifying access to and quality of personal
Diphtheria 074
health care has many policy uses, and no consistent
Whooping cough 014 measures of personal health-care access and quality
Tetanus 074 currently list across the development spectrum; for
Measles 114 instance, the World Bank coverage index only includes
Maternal disorders 074 three interventions,45 and the 201011 International Labour
Neonatal disorders 074 Organizations indicator of formal health coverage covered
Non-communicable diseases 93 countries, with substantial data missingness for sub-
Neoplasms Saharan Africa.46 The highly standardised cause of death
Colon and rectum cancer 074 estimates generated through GBD,47 along with risk factor
Non-melanoma skin cancer (squamous-cell 074 exposure,48 can address several limitations associated with
carcinoma)
previous studies of amenable mortality. GBD provides
Breast cancer 074 comprehensive, comparable estimates of cause-specific
Cervical cancer 074 death rates by geography, year, age, and sex through its
Uterine cancer 044 extensive data correction processes to account for
Testicular cancer 074 variations in cause of death certification.47 The
Hodgkins lymphoma 074 quantification of risk exposure and risk-attributable deaths
Leukaemia 044 due to 79 risk factors through GBD allows us to account for
Cardiovascular diseases variations in risk exposure across geographies and time,48
Rheumatic heart disease 074 and thus helps to isolate variations in death rates due to
Ischaemic heart disease 074 personal health-care access and quality. We also examine
Cerebrovascular disease 074 the relationship between our measure of health-care access
Hypertensive heart disease 074 and quality, as defined by risk-standardised mortality rates
Chronic respiratory diseases 114 amenable to health care, across development levels, as
Digestive diseases reflected by the Socio-demographic Index (SDI). Finally,
Peptic ulcer disease 074 we produce a frontier of maximum levels of personal
Appendicitis 074 health-care access and quality observed on the basis of
Inguinal, femoral, and abdominal hernia 074 SDI, which allows us to quantify the potential for further
Gallbladder and biliary diseases 074 improvement in relation to development status.
Neurological disorders
Epilepsy 074 Methods
Diabetes, urogenital, blood, and endocrine diseases Overview
Diabetes mellitus 049 We employed the most widely cited and used framework
Chronic kidney disease 074 for assessing mortality amenable to personal health
Other non-communicable diseases care.4,9,11,30,31,35 The Nolte and McKee cause list does not
Congenital heart anomalies 074 include all possible causes for which health care can
Injuries
improve survival; however, it does provide a set of
Unintentional injuries
conditions for which there is a reasonable consensus that
Adverse effects of medical treatment 074
personal health care has a major effect (table 1). Starting
with this list, our analysis followed four steps: mapping
The age groups for which mortality is regarded as amenable to health care are the Nolte and McKee cause list to GBD causes; risk-
listed. Causes are ordered on the basis of the GBD cause list and corresponding
cause group hierarchies. GBD=Global Burden of Disease.
standardising mortality rates to remove variations in death
rates not easily addressed through personal health care;
Table 1: Causes for which mortality is amenable to health care mapped computing a summary measure of personal health-care
to GBD 2015 causes access and quality using principal component analysis
(PCA); and assessing the highest recorded levels of health-
occur if health-care quality is heterogeneous within care access and quality across the development spectrum.
countries.3740 Additionally, existing lists might exclude This study draws from GBD 2015 results; further detail
causes for which health care can avert death, such as the on GBD 2015 data and methods are available

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Source and year Geographies HAQ Index construction

represented
PCA EFA Geometric Mean
weighted weighted mean
Health expenditure per capita GBD 2015 195 0884 0880 0854 0864
Hospital beds (per 1000) GBD 2015 195 0700 0683 0625 0650
UHC tracer index of 11 interventions GBD 2015 188 0826 0820 0812 0818
Physicians, nurses, and midwives per 1000 WHO 2010 73 0769 0755 0725 0732
Proportion of population with formal health coverage ILO 201011 93 0808 0798 0773 0781
Coverage index of three primary health-care interventions World Bank 2015 123 0601 0589 0557 0570
The universal health coverage tracer index of 11 interventions included coverage of four childhood vaccinations (BCG, measles, three doses of diphtheria-pertussis-tetanus,
and three doses of polio vaccines); skilled birth attendance; coverage of at least one and four antenatal care visits; met need for family planning with modern contraception;
tuberculosis case detection rates; insecticide-treated net coverage; and antiretroviral therapy coverage for populations living with HIV. The World Bank coverage index
included coverage of three interventions: three doses of diphtheria-pertussis-tetanus vaccine; at least four antenatal care visits; and children with diarrhoea receiving
appropriate treatment. HAQ Index=Healthcare Access and Quality Index. PCA=principal components analysis. EFA=exploratory factor analysis. GBD=Global Burden of
Disease. UHC=universal health coverage. ILO=International Labour Organization.
Table 2: Correlations between different constructions of the HAQ Index and existing indicators of health-care access or quality
elsewhere.4750 For the present analysis, a vital strength of stroke deaths due to high systolic blood pressure are
GBD is its careful evaluation and correction of cause of amenable to primary care management of hypertension.
death certification problems and misclassification at the To risk-standardise death rates, we removed the joint
national level. In the GBD, we systematically identified effects of national behavioural and environmental risk
causes of death that could not or should not be underlying levels calculated in GBD, and added back the global levels
causes of death (so-called garbage codes), and applied of risk exposure:
established statistical algorithms to correct for and
redistribute these deaths.51 1 JPAFjascy
Our study complies with the Guidelines for Accurate mrjascy = mjascy ( )
1 JPAFjasgy
and Transparent Health Estimates Reporting
(GATHER);52 additional information on the data and
modelling strategies used can be found in the appendix. where mjascy is the death rate from cause j in age a, sex s, See Online for appendix
location c, and year y; mrjascy is the risk-standardised death
Mapping the Nolte and McKee amenable cause list to the rate; JPAFjascy is the joint population attributable fraction
GBD cause list (PAF) for cause j, in age a, sex s, country c, and year y for
Drawing from Nolte and McKees list of 33 causes all behavioural and environmental risks included in
amenable to personal health care,4,9,11,30,31,35 we mapped GBD; and JPAFjasgy is the joint PAF for cause j, in age a,
these conditions to the GBD cause list based on sex s, and year y at the global level.
corresponding International Classification of Diseases GBD provides joint PAF estimation for multiple risks
(ICD) codes (appendix p 18). In GBD, thyroid diseases combined, which takes into account the mediation of
and benign prostatic hyperplasia are part of a larger different risks through each other. Further detail on
residual category and thus were excluded. Diphtheria and joint PAF computation is available in the appendix
tetanus are separate causes in GBD so we reported them (pp 58).
individually. Because of its extensive processes used to We used the GBD world population standard to
consistently map and properly classify ICD causes over calculate age-standardised risk-standardised death rates
time,47,53 GBD supported the assessment of 32 causes on from each cause regarded as amenable to health care.47
the Nolte and McKee cause list from 1990 to 2015. We did not risk-standardise death rates from diarrhoeal
diseases as mortality attributable to unsafe water and
Age-standardised risk-standardised death rates sanitation was not computed for high-SDI locations;
Some variation in death rates for amenable causes are such standardisation could lead to higher risk-
due to differences in behavioural and environmental risk standardised death rates in those countries compared
exposure rather than differences in personal health-care with countries where mortality was attributed to unsafe
access and quality.48,54,55 Using the wide range of risk water and sanitation.48 With all causes for which no PAFs
factors assessed by GBD,48 we risk-standardised death are estimated in GBD, such as neonatal disorders and
rates to the global level of risk exposure.48 We did not risk- testicular cancer, risk-standardised death rates equalled
standardise for variations in metabolic risk factors directly observed death rates.
targeted by personal health care: systolic blood pressure, The effects of risk-standardisation are highlighted by
total cholesterol, and fasting plasma glucose. For example, comparing the log of age-standardised mortality rates to

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HAQ Index
<429
429470
470513
513590
590634
634697
697744
744794
794863
>863
ATG VCT Barbados Comoros Marshall Isl Kiribati

West Africa Eastern
Mediterranean
Solomon Isl FSM
Dominica Grenada Maldives Mauritius Malta

Vanuatu Samoa
Caribbean LCA TTO TLS Seychelles Persian Gulf Singapore Balkan Peninsula Fiji Tonga
HAQ Index
<429
429470
470513
513590
590634
634697
697744
744794
794863
>863

West Africa Eastern
Mediterranean
Solomon Isl FSM

Vanuatu Samoa
Figure 1: Map of HAQ Index values, by decile, in 1990 (A) and 2015 (B)
Deciles were based on the distribution of HAQ Index values in 2015 and then were applied for 1990. HAQ Index = Healthcare Access and Quality Index. ATG=Antigua and Barbuda. VCT=Saint Vincent and the
Grenadines. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste. FSM=Federated States of Micronesia.

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the log of age-standardised risk-standardised mortality were associated with better access and quality of care;
rates for amenable causes (appendix p 14). For each SDI because this cannot be true we set these weights to zero
quintile, many countries had differing levels of age- in the final PCA-derived HAQ Index. The appendix
standardised mortality rates but their risk-standardised (p 15) compares each geographys HAQ Index in 2015
mortality rates were similar, demonstrating how with the log of its age-standardised risk-standardised
underlying local risk exposure can skew measures of mortality rates.
mortality amenable to personal health care.
Quantifying maximum levels of the HAQ Index across
Construction of the Healthcare Access and Quality Index the development spectrum
based on age-standardised risk standardised death rates To better understand maximum levels of personal health-
To construct the Healthcare Access and Quality (HAQ) care access and quality potentially achievable across the
Index, we first rescaled the log age-standardised risk- development spectrum, we produced a frontier based on
standardised death rate by cause to a scale of 0 to 100 the relationship between the HAQ Index and SDI. We
such that the highest observed value from 1990 to 2015 tested both stochastic frontier analysis models and data
was 0 and the lowest was 100. To avoid the effects of envelopment analysis; however, the relationship between
fluctuating death rates in small populations on rescaling, SDI and the HAQ Index did not fit standard stochastic
we excluded populations less than 1 million population frontier analysis models,58 and data envelopment analysis
from setting minimum and maximum values. Any cannot account for measurement error and is sensitive to
location with a cause-specific death rate below the outliers.59 To generate a frontier fit that closely follows the
minimum or above the maximum from 1990 to 2015 was observed HAQ Index and allowed for measurement error,
set to 100 or 0, respectively. we used free disposal hull analysis on 1000 bootstrapped
Because each included cause provided some signal on samples of the data.58 Every bootstrap included a subset
average levels of personal health-care access and quality, of locations produced by randomly sampling (with
we explored four approaches to construct the HAQ replacement) from all GBD geographies. The final HAQ
Index: PCA, exploratory factor analysis, arithmetic mean, Index value was drawn from the uncertainty distribution
and geometric mean. Details on these four approaches for each location-year, with outliers removed by excluding
are in the appendix (pp 7, 8, 21, 22). All four measures super-efficient units; additional methodological detail can
were highly correlated, with Spearmans rank order be found in the appendix (pp 912). Last, we used a Loess
correlations exceeding rs=098. We selected the PCA- regression to produce a smooth frontier for each five-year
derived HAQ Index because it provided the strongest interval from 1990 to 2015. For every geography, we report
correlations with six other currently available cross- the maximum possible HAQ Index value on the basis of
country measures of access to care or health-system SDI in 1990 and 2015, while values for all years can be
inputs (table 2). Three indicators came from the GBD Study found in the appendix (pp 2328).
2015: health expenditure per capita, hospital beds
per 1000, and the UHC tracer intervention index, a Uncertainty analysis
composite measure of 11 UHC tracer interventions (four GBD aims to propagate all sources of uncertainty
childhood vaccinations; skilled birth attendance; coverage through its estimation process,47,48 which results in
of at least one and four antenatal care visits; met need for uncertainty intervals (UIs) accompanying each point
family planning with modern contraception; tuberculosis estimate of death by cause, geography, year, age group,
case detection rates; insecticide-treated net coverage; and and sex. We computed the HAQ Index for each
antiretroviral therapy coverage for populations living geography-year based on 1000 draws from the posterior
with HIV).56 Three indicators came from WHO distribution for each included cause of death. We report
(physicians, nurses, and midwives per 1000),57 the 95% UIs based on the ordinal 25th and 975th draws for
International Labour Organization,46 and the World Bank each quantity of interest.
(coverage index based on diphtheria-pertussis-tetanus
vaccine coverage, coverage of at least four antenatal care Role of the funding source
visits, and proportion of children with diarrhoea receiving The funder of the study had no role in study design, data
appropriate treatment).45 All indicators had correlation collection, data analysis, data interpretation, or writing of
coefficients greater than 060, and three exceeded 080 the report. The corresponding author had full access to
(health expenditure per capita, the UHC tracer index, all the data in the study and had final responsibility for
and International Labour Organization formal health the decision to submit for publication.
coverage).
The appendix (pp 21, 22) provides final rescaled PCA Results
weights derived from the first five components that Distinct geographic patterns emerged for overall HAQ
collectively accounted for more than 80% of the variance Index levels and gains from 1990 to 2015 (figure 1).
in cause-specific measures. Colon and breast cancer had Andorra and Iceland had the highest HAQ Index in 1990,
negative PCA weights, which implied higher death rates whereas most of sub-Saharan Africa and south Asia and

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Inguinal, femoral, and abdominal hernia
Adverse effects of medical treatment

Healthcare Access and Quality Index
Gallbladder and biliary diseases

Lower respiratory infections
Upper respiratory infections
Congenital heart anomalies

Non-melanoma skin cancer
Chronic respiratory disease

Hypertensive heart disease
Rheumatic heart disease
Cerebrovascular disease
Ischaemic heart disease
Chronic kidney disease

Hodgkins lymphoma
Peptic ulcer disease

Diarrhoeal diseases
Neonatal disorders
Maternal disorders
Whooping cough
Diabetes mellitus
Testicular cancer
Cervical cancer
Uterine cancer
Tuberculosis
Appendicitis
Leukaemia
Diptheria
Epilepsy
Tetanus
Measles
100
Andorra 95 98 99 85 100 100 98 99 100 100 99 82 93 96 81 70 73 96 84 96 95 97 95 99 93 91 92 96 95 96 88
Iceland 94 95 97 72 99 100 100 100 100 100 99 90 87 91 67 63 75 94 75 95 93 98 93 99 99 84 92 100 100 98 87 75
Switzerland 92 99 91 87 99 100 100 100 100 97 80 76 90 94 75 72 72 96 86 100 85 97 92 96 92 86 89 94 93 85 92 50
Sweden 90 98 96 80 99 100 100 100 100 98 90 78 76 95 83 76 67 91 73 88 94 95 79 98 92 86 85 78 95 95 86
25
Norway 90 95 92 78 99 100 100 100 100 99 90 81 81 91 65 70 76 93 78 87 99 95 80 98 92 86 80 78 92 93 97
0
Australia 90 100 94 82 99 100 100 100 99 96 81 52 84 95 86 74 70 86 78 93 98 90 93 98 89 84 83 83 88 90 77
Finland 90 93 99 89 99 100 100 100 100 99 95 84 95 92 78 69 72 96 67 80 75 98 75 96 84 79 76 79 99 87 96
Spain 90 92 96 80 99 100 98 100 100 99 85 74 83 90 82 64 66 76 86 91 93 95 96 94 84 74 97 98 86 88 77
Netherlands 90 99 94 71 99 100 100 100 100 96 79 80 83 96 74 65 78 93 79 85 97 94 90 95 87 79 82 84 89 88 90
Luxembourg 89 99 87 85 99 100 98 100 100 92 93 74 84 96 82 73 65 81 83 88 91 97 91 93 85 78 79 90 86 100 74
Japan 89 89 94 61 99 100 100 100 99 98 100 87 77 78 85 89 71 92 94 75 89 91 87 99 99 81 99 90 65 84 84
Italy 89 95 96 90 99 100 99 99 100 100 81 74 85 89 76 60 60 78 84 88 72 98 95 98 88 78 93 89 83 85 83
Ireland 88 91 94 71 99 100 100 100 100 98 90 59 76 92 82 58 69 87 73 92 93 93 81 99 86 81 81 91 88 86 85
Austria 88 95 92 95 99 100 100 100 99 99 84 68 78 89 71 70 67 86 76 93 77 96 88 98 89 84 89 84 78 89 64
France 88 92 92 76 99 100 99 100 99 93 86 72 81 93 73 68 64 80 87 89 94 98 91 95 85 81 75 87 92 86 62
Belgium 88 94 92 68 99 100 99 100 100 95 83 68 79 91 84 65 67 90 78 86 97 94 84 97 86 79 76 90 87 93 70
Canada 88 98 93 73 99 100 99 100 100 96 71 64 79 93 81 71 71 82 72 90 95 92 89 96 86 82 91 78 82 86 82
Slovenia 87 92 99 80 98 100 100 100 99 97 91 71 77 92 60 65 74 77 83 78 71 100 76 97 79 76 89 100 98 90 56
Greece 87 90 100 84 98 100 100 99 100 95 85 62 78 85 67 31 62 94 61 72 83 98 85 100 92 85 100 98 76 71 68
Germany 86 98 95 73 99 100 100 100 100 96 82 75 78 94 66 68 68 81 71 85 78 95 80 95 91 80 75 84 81 87 70
Singapore 86 79 96 39 99 100 100 100 100 99 98 88 75 85 99 86 63 93 74 77 53 95 87 99 93 79 98 94 52 92 97
New Zealand 86 96 90 87 99 100 100 100 99 89 79 60 82 87 73 66 62 70 69 84 93 86 89 96 89 81 80 83 72 85 92
South Korea 86 67 97 79 98 100 99 99 98 94 85 89 79 86 99 87 55 98 100 67 84 95 92 93 98 72 81 63 62 95 83
Denmark 86 96 90 74 98 100 100 100 100 99 81 74 80 94 65 63 72 90 79 81 94 92 68 87 83 78 78 72 79 87 82
Panel A
Israel 86 95 91 69 99 100 99 100 100 92 85 64 79 92 92 57 62 71 81 85 98 91 97 96 87 75 80 81 59 85 65

Cyprus 85 96 84 84 99 100 97 98 99 100 72 67 84 94 75 65 56 64 68 86 82 94 99 96 92 73 94 71 70 89 75
Qatar 85 83 94 77 99 100 97 98 94 89 62 84 96 99 96 80 67 94 65 86 96 88 93 92 93 88 87 77 63 61 72
Malta 85 100 86 79 99 100 100 99 100 98 68 73 85 85 65 56 57 79 72 91 85 93 87 98 83 83 86 70 74 74 78
Czech Republic 85 96 96 70 98 100 100 100 99 97 88 66 66 81 53 58 72 80 61 75 78 98 68 93 84 69 85 85 81 100 72
UK 85 94 93 64 99 100 99 100 100 92 73 69 79 92 79 58 67 85 77 88 83 87 72 90 76 70 74 86 100 81 76
Portugal 85 81 92 60 98 100 99 100 99 97 91 65 74 87 76 63 59 80 87 70 92 91 86 91 82 72 87 84 75 85 70
Kuwait 82 77 91 60 99 100 100 100 95 96 69 87 93 93 92 82 71 93 55 74 54 91 89 87 95 83 85 92 63 52 63
Croatia 82 85 96 87 97 100 100 100 97 94 75 69 69 87 51 56 67 81 62 61 66 98 69 91 77 73 73 88 74 85 74
Estonia 81 75 98 72 97 100 99 100 100 98 91 71 65 90 75 62 63 72 58 71 43 99 67 95 89 81 66 74 77 90 71
USA 81 97 89 60 98 100 99 100 100 82 69 68 77 90 73 67 71 75 62 83 64 84 88 90 85 76 96 67 62 81 68
Montenegro 81 88 96 90 96 100 91 99 97 97 67 61 65 74 52 36 50 71 56 46 97 100 77 93 94 74 87 66 61 93 62
Lebanon 80 81 88 94 97 100 95 98 97 88 64 89 83 85 50 30 49 88 48 76 72 90 91 90 96 86 79 64 57 55 71
Hungary 80 91 93 89 96 100 100 100 100 95 71 62 60 86 36 64 61 79 56 67 58 94 58 85 74 61 85 81 81 72 79
Poland 80 80 97 68 97 100 100 100 100 99 76 61 59 86 50 51 66 70 61 66 75 99 63 91 78 78 72 78 72 71 64
Saudi Arabia 79 64 81 59 98 100 97 97 93 85 51 88 100 98 92 76 80 86 59 68 87 88 97 86 100 89 81 89 45 55 45
Bermuda 79 96 94 64 99 100 100 100 96 100 75 57 72 93 100 50 40 82 58 68 66 93 69 75 74 77 89 65 52 81 60
Bahrain 79 75 83 67 98 100 98 98 95 86 71 84 91 91 96 50 61 91 65 89 86 89 80 74 88 69 69 52 52 68 68
Slovakia 79 91 92 60 97 100 97 99 100 97 70 70 62 74 46 51 63 79 54 65 65 95 64 93 78 66 68 83 71 71 72
Latvia 78 72 97 65 96 100 100 100 100 93 80 61 66 84 53 54 60 65 45 53 61 99 62 97 87 74 66 66 81 74 63
Taiwan 78 78 95 64 98 100 94 98 80 95 73 83 68 75 93 84 49 85 82 63 60 92 73 91 91 57 79 58 50 62 78
Puerto Rico 77 90 87 49 98 100 99 99 95 89 60 62 70 86 74 60 61 84 68 81 56 85 88 83 82 68 76 55 45 76 59
Lithuania 77 61 97 62 96 100 100 100 100 94 88 65 59 81 59 51 60 61 47 60 65 100 55 86 79 66 65 72 82 76 65
Macedonia 76 74 80 89 95 100 89 98 99 94 54 65 65 60 39 45 46 72 58 44 63 93 80 95 84 89 81 70 61 65 80
Chile 76 72 92 66 97 100 92 99 100 85 69 65 58 93 19 67 54 72 80 70 65 90 82 81 69 56 76 83 53 63 71
Serbia 75 79 93 84 95 100 91 98 100 92 59 53 53 74 35 43 52 82 59 50 72 94 62 85 77 70 72 70 65 63 71
(Figure 2 continues on next page)

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Epilepsy
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Measles
100
Romania 74 62 82 54 95 100 99 99 100 88 71 53 48 79 51 54 57 72 52 46 50 98 72 86 76 78 77 83 71 66 75
Belarus 74 66 98 78 93 100 96 98 100 95 77 70 56 82 56 52 42 50 27 44 62 100 73 86 83 72 70 78 76 60 38 75
Cuba 74 94 85 57 96 100 100 100 100 78 70 47 57 61 77 42 56 67 57 59 55 88 69 68 65 65 85 77 51 68 77 50
Ukraine 73 56 91 70 91 98 99 99 100 85 62 82 59 88 57 48 50 57 27 47 62 98 66 82 79 80 73 70 82 53 50
25
United Arab Emirates 72 75 96 57 97 100 98 68 85 93 74 71 83 94 65 60 70 52 35 45 61 88 70 80 92 76 68 71 36 72 24
0
Northern Mariana Islands 72 69 94 57 95 100 91 99 78 76 76 43 69 82 85 82 55 54 62 54 64 85 74 77 93 43 88 50 28 80 55
Russia 72 58 88 56 94 99 99 100 100 87 65 57 59 62 57 45 57 63 36 41 63 97 53 82 68 63 92 78 77 62 59
Bulgaria 71 81 85 65 95 100 98 100 100 88 67 65 55 55 24 38 43 61 44 45 42 96 70 75 72 82 75 67 59 51 71
Greenland 71 68 88 56 97 99 96 98 78 79 41 59 54 87 82 64 74 67 58 54 70 98 47 70 73 55 57 84 73 69 72
Virgin Islands 70 85 90 53 97 100 98 98 95 89 58 57 59 97 99 73 45 75 42 60 43 85 70 57 72 48 73 54 41 70 47
Brunei 70 62 89 48 98 100 97 92 100 79 68 71 58 82 70 62 40 66 56 58 65 63 71 74 100 57 64 32 40 76 72
Panel A cont.
Argentina 68 76 80 38 96 100 88 99 100 69 53 57 49 82 31 56 50 52 59 66 62 79 75 76 74 59 91 67 48 52 41

Armenia 68 64 77 61 92 100 89 98 100 83 51 82 53 73 86 85 20 53 44 57 66 96 54 76 68 52 73 51 66 44 50
Barbados 67 82 81 41 96 100 100 96 100 77 42 70 52 86 96 61 39 69 62 52 58 82 60 66 68 70 69 49 45 43 42
Antigua and Barbuda 67 81 71 43 96 100 100 98 100 75 49 51 54 94 89 73 49 72 56 46 42 80 66 72 76 62 60 48 36 55 50
Malaysia 67 58 86 25 96 100 96 95 83 68 73 64 65 88 79 67 43 67 44 49 74 83 57 53 76 37 78 62 42 66 50
Seychelles 66 74 90 26 95 100 97 87 92 77 61 67 46 94 75 49 45 72 60 63 28 74 48 46 92 73 71 71 26 43 69
Azerbaijan 64 53 62 41 94 99 91 98 100 82 33 60 65 78 61 53 11 55 33 49 69 79 68 82 87 81 57 53 54 39 53
The Bahamas 64 68 81 40 96 100 95 97 100 73 39 59 50 88 98 62 40 69 48 46 27 77 64 65 69 57 75 52 37 60 46
Guam 63 67 90 40 95 99 91 99 75 72 45 51 69 67 71 71 35 52 29 52 41 67 73 61 83 51 84 52 32 51 49
Georgia 62 60 78 65 90 99 80 98 97 76 37 47 54 45 43 33 30 39 38 41 43 71 58 79 70 67 78 60 51 55 46
Trinidad and Tobago 62 77 70 50 95 99 100 100 100 74 37 83 51 81 88 67 47 72 42 49 45 72 48 68 54 61 57 31 34 40 44
Kazakhstan 61 51 77 50 93 99 98 100 99 77 43 68 51 68 64 59 40 41 33 39 49 86 53 69 53 49 62 65 51 37 43
Grenada 58 73 74 29 92 100 94 92 100 75 45 48 38 90 80 54 27 54 47 38 44 68 56 62 59 52 58 34 24 45 27
Turkmenistan 58 50 55 29 91 99 93 98 100 81 29 64 56 85 41 50 30 46 23 32 47 82 52 69 70 71 57 50 47 25 48
Bosnia and Herzegovina 78 72 91 99 96 100 90 99 90 93 71 69 67 66 53 51 53 86 73 65 81 97 79 90 79 72 70 63 66 70 45
Albania 78 92 91 68 95 100 91 98 98 91 70 57 73 64 58 55 37 72 53 49 85 77 93 95 84 93 65 90 57 42 73
Oman 77 75 92 44 98 100 98 97 94 88 61 85 83 97 84 65 68 80 50 64 72 90 79 74 80 87 86 60 50 66 73
Jordan 76 87 84 62 96 100 96 98 96 75 49 82 90 90 74 84 44 90 61 67 47 89 86 89 96 68 81 71 46 45 76
Turkey 76 76 80 72 97 100 93 97 85 86 43 72 87 87 49 65 28 100 68 72 68 77 89 97 82 75 64 73 57 45 84
Maldives 76 65 76 70 97 100 97 94 71 73 58 73 82 97 100 72 74 72 66 72 76 62 98 77 96 79 81 80 46 74 49
China 74 67 85 76 94 100 91 92 90 88 55 61 70 67 96 73 30 54 76 50 61 91 67 93 99 77 80 77 60 44 82
Moldova 73 59 84 56 89 100 100 100 100 91 63 59 62 78 73 47 59 61 40 46 58 98 55 85 69 73 72 81 89 58 72
Costa Rica 73 80 78 69 97 100 99 100 100 82 62 65 62 86 54 48 39 77 68 78 60 76 73 75 71 64 78 79 39 54 56
Sri Lanka 73 63 90 59 94 100 100 97 80 77 60 56 78 89 84 61 47 71 57 62 53 75 100 85 85 100 68 47 40 53 62
Uruguay 72 80 79 55 96 100 97 100 100 83 61 59 51 83 42 51 50 65 70 63 69 83 77 71 69 53 77 74 61 56 52
Iran 71 65 81 62 95 100 98 96 91 84 48 85 86 96 81 59 32 88 37 49 36 84 60 70 89 77 78 68 52 53 74
Panel B
Thailand 71 54 89 38 94 100 94 89 89 88 70 35 53 77 65 51 34 89 78 60 79 86 78 71 91 50 76 56 30 69 53
Tunisia 70 65 79 59 95 100 93 97 87 73 46 78 82 61 95 66 46 79 70 58 76 82 84 67 76 55 65 55 44 56 61
Libya 70 69 77 59 95 100 95 97 79 80 49 82 62 93 73 44 58 75 46 57 65 80 75 77 88 71 69 69 38 41 56
Peru 70 54 72 33 96 99 87 96 100 70 50 68 51 82 70 74 40 82 85 77 83 75 71 62 71 57 89 73 47 61 53
Colombia 68 71 70 54 96 100 93 96 100 71 51 57 56 89 62 60 33 91 60 63 57 66 69 63 64 48 77 68 46 42 77
Vietnam 66 45 87 61 91 99 85 81 85 86 56 84 68 82 56 59 49 70 73 38 50 83 62 70 91 63 56 56 39 45 57
Mauritius 66 80 75 56 95 99 99 100 66 77 48 79 64 82 85 67 52 69 51 56 47 67 67 86 92 76 62 28 9 52 37
Brazil 65 65 67 43 94 100 93 91 99 70 41 51 54 91 68 61 46 72 63 54 58 78 65 63 59 44 76 59 48 57 59
Venezuela 65 69 60 54 95 99 92 97 100 67 45 50 46 87 63 51 39 90 47 57 48 79 67 67 62 62 68 55 29 45 70
Panama 64 57 57 47 96 98 83 98 100 65 50 66 53 79 67 63 30 78 64 57 63 54 75 65 68 65 74 56 31 48 73
El Salvador 64 72 69 43 91 99 89 95 100 75 62 62 43 68 83 53 26 86 60 72 60 71 55 54 62 60 77 45 13 44 70
Jamaica 64 84 73 56 92 99 88 95 100 71 38 69 43 80 86 68 31 65 71 44 44 63 55 69 66 75 67 43 32 52 50
American Samoa 63 76 89 39 93 100 92 99 79 61 70 45 64 63 93 76 70 40 50 54 59 81 57 55 59 33 61 39 31 75 33

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Diptheria
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Measles
100
Mexico 63 67 69 53 95 100 95 99 100 70 48 56 53 88 34 54 31 75 63 67 65 74 60 56 51 42 69 40 13 41 63
Saint Lucia 63 64 72 44 94 100 96 96 100 70 42 69 47 85 64 55 41 58 63 47 47 62 66 66 72 68 57 43 37 53 44 75
Dominican Republic 62 56 60 50 94 99 84 81 100 67 31 47 53 77 96 75 54 71 47 46 48 62 58 73 82 87 77 53 39 47 35 50
Uzbekistan 62 50 75 36 89 99 91 98 100 76 39 72 63 83 71 59 30 39 30 41 24 95 48 80 85 67 47 53 54 61 59
25
Samoa 62 62 90 44 89 91 65 98 68 61 66 89 62 78 27 62 53 40 46 52 51 76 59 60 75 47 75 37 25 75 44
0
Tonga 62 69 80 34 86 100 94 98 87 51 45 50 86 99 78 72 48 48 48 55 62 67 38 35 55 24 83 36 99 54 41
Ecuador 61 54 65 35 94 99 90 94 100 68 49 57 48 75 59 52 33 68 67 62 50 76 62 53 63 43 66 58 28 48 56
Egypt 61 73 54 49 91 100 92 87 88 67 51 82 87 80 87 84 29 54 37 47 54 78 54 67 65 34 66 60 31 20 43
Paraguay 60 58 65 50 92 99 89 93 100 58 43 49 38 85 47 55 37 77 61 52 55 68 64 56 48 48 71 55 31 47 50
Kyrgyzstan 60 46 58 42 83 99 87 99 98 66 30 54 50 68 65 65 50 40 30 31 54 94 58 79 77 60 46 71 47 45 64
Bolivia 59 50 52 31 90 99 89 98 100 50 30 59 37 53 72 70 35 58 63 54 76 82 62 54 72 46 75 62 23 65 37
Mongolia 59 45 95 43 87 99 90 98 100 65 33 47 47 70 87 75 54 39 34 26 58 71 31 55 70 38 52 64 41 42 66
Panel B cont.
Belize 58 54 66 39 91 99 89 93 100 73 44 52 38 65 91 53 42 59 47 44 43 65 58 63 60 51 62 40 27 64 28
Dominica 58 59 59 38 93 99 94 89 100 75 31 54 51 83 97 47 25 65 57 49 34 58 59 72 66 68 45 38 25 47 33
Saint Vincent and the Grenadines 57 64 63 41 92 100 90 98 100 75 34 45 36 88 88 42 24 58 48 43 38 71 44 63 63 54 52 33 35 49 42
Suriname 57 72 57 46 93 98 82 91 100 70 27 70 45 92 69 51 37 65 52 39 48 58 50 61 44 51 58 49 30 42 24
Federated States of Micronesia 54 54 82 31 79 98 77 98 89 57 56 45 51 58 73 68 40 26 28 31 35 70 46 46 68 36 66 27 14 66 37
Namibia 54 21 36 26 89 99 90 93 78 53 25 93 56 92 78 82 89 47 57 47 35 61 54 62 58 43 27 40 40 77 52
South Africa 52 24 45 24 90 98 87 95 65 53 29 23 33 92 70 62 64 49 57 49 39 63 54 64 58 40 27 34 38 76 55
Philippines 52 32 56 34 88 99 97 73 72 61 38 63 59 54 79 78 24 47 45 37 32 44 32 61 68 56 82 42 18 38 63
Gabon 51 40 54 24 89 97 83 81 75 44 24 72 42 82 74 74 59 47 54 35 38 64 49 53 54 36 46 38 54 46 47
Botswana 51 21 46 24 88 99 96 93 86 53 33 24 29 88 65 62 65 46 54 42 36 68 49 57 51 36 25 32 37 78 46
Guyana 50 47 51 36 86 99 87 92 100 57 29 62 38 64 77 53 41 52 31 25 28 65 43 44 50 45 53 27 29 49 29
Indonesia 49 27 52 56 90 98 81 54 60 52 36 61 56 73 94 57 38 59 51 27 44 74 40 42 26 35 69 31 31 52 50
Fiji 47 56 54 23 83 98 85 98 63 59 35 66 41 61 45 57 20 21 24 40 29 56 48 42 64 41 55 7 9 33 41
Swaziland 42 16 29 15 78 98 88 91 79 46 25 14 19 86 63 55 59 30 40 31 28 53 39 46 44 27 15 19 27 70 37
Syria 75 86 85 57 92 99 79 95 77 64 54 85 91 81 95 77 63 83 36 48 75 54 93 76 93 78 89 81 74 34 67
Palestine 70 99 85 46 89 99 84 98 83 76 38 82 94 69 90 35 31 72 36 48 47 88 96 72 97 85 63 71 26 48 63
Nicaragua 64 60 63 55 91 100 88 98 100 65 51 60 44 92 64 67 35 84 68 65 54 70 66 61 59 62 72 51 12 57 69
Algeria 64 56 66 52 95 100 95 96 86 63 33 84 67 93 93 56 51 67 58 54 56 86 67 60 55 68 66 51 43 54 44
North Korea 62 53 81 64 79 99 81 87 79 68 45 62 63 49 84 64 19 36 61 28 43 88 53 81 92 61 66 63 41 40 71
Cape Verde 62 54 61 35 89 99 91 95 88 69 30 90 43 85 72 88 39 68 59 38 59 81 74 62 64 64 45 57 42 53 53
Morocco 61 46 71 43 92 100 89 91 88 64 34 62 58 52 94 57 46 57 56 53 57 80 70 70 76 61 59 47 38 49 44
Iraq 60 53 60 51 90 98 80 94 89 57 33 68 76 56 77 79 10 47 24 37 50 83 75 84 93 77 66 36 29 31 51
Tajikistan 59 48 44 34 84 99 80 98 100 72 33 74 80 72 79 60 42 41 35 38 47 79 48 72 72 71 39 53 48 44 57
Guatemala 56 62 45 27 90 98 81 95 100 59 45 51 41 76 61 59 30 89 59 60 58 65 34 45 42 51 57 30 16 55 53
Honduras 54 51 54 56 88 99 90 85 100 57 44 48 57 59 91 62 24 86 40 43 40 36 45 39 27 30 57 57 45 35 46
Panel C
Bhutan 53 35 50 46 90 99 86 55 68 52 16 93 70 89 74 64 48 37 50 55 46 44 49 54 45 64 71 43 34 45 78
Bangladesh 52 38 57 54 84 99 76 61 92 48 23 97 65 84 81 62 54 55 51 32 44 68 38 45 23 55 36 40 35 47 78
Timor-Leste 52 39 48 38 89 98 71 77 53 33 29 72 52 70 83 54 37 48 58 46 45 51 53 58 67 51 71 60 33 40 43
Nigeria 51 42 23 24 83 71 57 61 50 33 14 94 50 84 73 76 56 63 72 50 53 66 59 56 55 60 57 58 63 47 39
Nepal 51 26 48 44 80 99 72 46 85 41 25 92 58 83 80 58 55 32 52 54 44 53 40 49 37 57 71 49 34 64 76
Cambodia 51 35 56 40 81 99 77 75 89 52 30 55 48 68 77 51 38 46 45 36 39 55 42 51 67 47 66 47 21 41 45
Sudan 50 50 37 43 80 94 64 87 68 34 20 74 70 77 76 47 44 53 33 37 47 49 46 52 73 51 58 56 33 21 41
Marshall Islands 50 52 72 27 78 97 68 98 72 54 45 48 49 59 71 64 37 27 30 33 37 62 42 44 66 34 64 18 5 65 32
Ghana 50 35 50 21 77 99 86 61 84 37 19 74 45 72 84 74 40 57 47 30 39 73 43 51 56 57 62 43 39 53 28
So Tom and Prncipe 50 38 45 21 79 99 82 40 70 43 30 83 33 80 72 83 48 37 53 32 59 56 55 52 60 53 52 61 16 55 49
Zimbabwe 49 20 28 23 72 98 75 90 52 35 22 71 27 90 79 65 71 42 64 51 50 57 59 80 50 70 37 30 19 53 43
Kenya 49 33 35 27 75 98 76 27 61 32 28 82 26 93 86 97 68 58 79 42 31 78 39 50 48 39 48 47 64 49 50
Equatorial Guinea 48 39 48 30 89 83 79 75 62 32 18 73 45 80 74 75 64 49 62 45 35 49 48 51 54 37 46 27 47 42 41

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Leukaemia
Diptheria
Epilepsy
Tetanus
Measles
Myanmar 48 26 55 41 74 99 86 76 79 42 31 47 35 49 73 41 22 46 73 37 38 55 43 51 66 47 56 43 30 38 36 100
Laos 45 38 40 32 80 95 64 71 72 43 18 60 48 63 77 47 30 42 44 37 40 36 42 51 65 44 60 38 18 30 37 75
Kiribati 45 23 48 26 59 98 76 98 63 49 25 56 46 91 58 71 39 19 38 21 52 43 39 38 61 32 57 18 19 91 13 50
India 45 26 40 42 80 98 76 54 69 47 14 84 59 85 71 59 56 25 37 42 33 57 37 37 19 47 72 38 20 45 64
25
Djibouti 45 29 36 22 72 89 59 47 46 35 23 83 38 78 68 93 60 52 58 39 38 64 42 51 49 43 35 31 52 35 41
Cameroon 44 35 32 24 68 93 63 71 58 26 16 79 40 77 63 68 50 50 51 34 44 64 43 42 43 44 47 46 36 41 33 0
Panel C cont.
Congo (Brazzaville) 44 30 47 27 75 96 77 73 58 26 25 70 31 68 75 70 58 36 47 28 26 54 35 40 47 26 42 36 48 46 42
Vanuatu 43 43 60 23 70 98 77 97 70 46 36 38 43 40 69 59 35 21 21 21 26 52 34 33 56 23 59 19 11 53 26
Solomon Islands 43 39 64 27 65 98 76 96 75 42 44 36 41 44 67 57 36 16 24 23 29 57 30 29 53 22 60 18 6 59 26
Pakistan 43 29 34 48 82 96 67 55 77 36 7 92 74 50 36 55 43 19 31 40 39 45 31 35 29 42 67 41 43 44 54
Zambia 42 28 36 20 66 97 76 39 76 33 27 73 27 70 35 93 63 42 44 38 29 69 27 36 40 26 29 29 48 41 37
Angola 41 26 36 22 74 96 76 70 81 23 22 68 32 69 74 67 56 33 49 29 26 42 33 37 41 27 37 30 43 40 35
Papua New Guinea 39 48 50 19 69 90 61 93 37 34 35 47 40 31 73 56 44 18 30 23 27 35 29 29 50 20 63 15 5 52 24
Lesotho 36 9 24 16 62 97 79 82 71 31 11 11 15 84 56 50 57 28 38 29 21 47 30 41 36 25 13 17 22 65 35
Mauritania 52 34 37 33 81 95 63 70 75 30 19 92 43 82 69 73 48 61 68 52 55 72 56 51 52 56 54 58 49 44 40
Tanzania 50 32 43 28 70 98 73 50 82 30 25 88 34 78 91 96 62 57 66 51 45 68 44 56 58 45 28 41 65 33 44
The Gambia 50 30 38 34 72 99 77 61 52 26 24 79 47 64 69 56 74 56 62 46 47 73 52 51 48 57 51 57 41 52 40
Yemen 50 45 44 44 78 96 61 84 77 35 24 73 64 65 75 42 44 48 26 31 43 62 49 56 74 54 57 48 23 26 38
Rwanda 48 31 40 30 66 98 81 50 82 31 21 87 34 75 82 96 58 51 66 38 27 54 44 55 58 46 39 43 59 34 44
Comoros 48 26 43 26 69 97 65 46 62 41 25 88 33 74 78 95 65 51 66 37 28 75 43 54 52 45 36 44 55 43 47
Malawi 47 27 30 26 61 98 75 49 84 35 21 87 33 76 63 96 78 52 61 46 25 61 40 50 53 47 38 44 58 40 45
Mali 46 26 28 41 64 85 54 64 64 28 10 89 43 67 63 54 72 48 61 42 45 81 42 40 42 48 50 55 44 45 30
Liberia 45 19 31 23 59 94 56 58 57 22 20 84 38 79 70 71 56 56 59 42 50 70 43 45 47 51 50 53 43 48 38
Senegal 44 18 32 29 68 97 69 67 77 27 25 78 36 71 59 66 47 51 55 34 39 70 42 40 39 45 45 48 35 45 32
Togo 44 27 35 24 61 96 66 64 79 33 17 77 39 72 51 66 51 51 50 34 39 68 40 39 37 46 44 48 35 48 33
Ethiopia 44 20 38 32 66 89 47 50 55 29 21 91 34 72 58 92 66 49 52 41 29 69 38 53 47 45 39 38 56 42 39
Madagascar 44 33 31 26 67 97 66 56 61 32 24 90 34 73 78 96 75 34 52 20 13 42 37 49 48 41 40 45 60 47 46
Mozambique 43 22 39 31 57 96 63 50 77 30 20 81 29 74 91 93 53 43 58 31 28 66 33 45 47 41 18 35 52 40 39
Benin 43 26 35 22 63 94 64 64 68 29 19 76 38 73 57 65 49 49 46 35 46 66 37 36 35 43 44 42 38 45 31
Panel D
Uganda 43 30 38 30 64 96 66 50 61 30 21 86 32 50 60 95 65 42 61 30 23 59 35 47 49 38 37 37 51 37 41
Burkina Faso 43 24 27 23 60 97 75 52 87 29 21 81 33 66 59 65 47 37 48 49 32 59 38 38 40 45 48 38 51 42 28
Cte dIvoire 42 27 33 19 67 94 66 64 75 25 13 82 38 92 52 50 65 49 46 29 41 67 38 37 33 42 42 41 32 43 28
Sierra Leone 41 27 29 18 57 95 69 62 79 20 13 76 33 67 60 65 51 49 49 33 41 61 36 36 40 41 45 42 32 42 30
Niger 41 18 18 22 57 93 57 52 61 22 24 83 37 73 69 65 56 51 56 38 39 60 35 35 30 45 46 51 41 49 28
Burundi 40 20 30 25 50 98 77 38 76 24 21 81 29 67 78 93 63 42 60 31 19 53 28 42 44 35 33 35 50 36 38
DR Congo 40 18 35 24 49 91 54 52 82 22 20 69 35 73 78 68 64 36 57 29 17 46 31 41 42 37 38 43 51 48 41
South Sudan 39 22 21 22 68 48 51 25 55 25 21 87 30 69 80 91 72 44 62 37 27 54 29 40 40 32 39 37 51 42 30
Guinea 39 23 33 17 57 83 53 48 62 22 15 77 34 52 30 52 69 48 48 27 34 62 34 34 32 41 44 45 33 45 28
Haiti 38 45 31 32 68 93 57 61 100 32 23 51 31 59 83 37 34 37 36 24 24 38 28 35 34 38 49 32 20 21 24
Eritrea 38 19 28 21 54 98 77 39 66 23 25 84 25 59 73 92 63 36 52 22 17 58 25 37 39 28 31 34 47 39 35
Chad 38 23 15 16 64 51 46 44 55 21 14 82 36 74 59 59 50 44 54 37 43 56 35 33 32 40 45 44 40 42 21
GuineaBissau 36 24 20 17 50 90 54 56 36 27 12 78 34 61 58 60 44 48 48 32 39 50 34 31 35 40 40 36 30 36 23
Somalia 34 13 18 14 36 69 40 16 82 19 21 81 22 63 74 86 70 36 56 28 23 51 21 35 37 29 29 34 48 43 24
Afghanistan 32 33 37 25 47 79 49 44 57 18 19 52 49 38 66 20 43 31 6 13 31 48 23 29 55 27 42 33 7 18 19
Central African Republic 29 11 27 14 33 65 45 39 56 17 12 56 30 64 57 51 58 26 40 14 14 40 14 25 23 19 26 24 39 43 28
Figure 2: Figure 2: Performance of the HAQ Index and 25 individual causes by the fourth SDI quartile (A), third SDI quartile (B), second SDI quartile (C),
and first SDI quartile (D) in 2015
In addition to the HAQ Index, all causes presented in this figure are scaled 0 to 100, with 100 being the best value (ie, lowest observed age-standardised
risk-standardised mortality rate by cause) and 0 being the worst value (ie, highest observed age-standardised risk-standardised mortality rate by cause) between
1990 and 2015. Within each SDI quartile, countries and geographies are ordered by their HAQ Index in 2015. HAQ Index=Healthcare Access and Quality Index.
SDI=Socio-demographic Index.

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100
South Korea
China
Maldives Turkey
75
Peru
Healthcare Access and Quality Index 2015
50
25
SDI quintile
Low SDI
Low-middle SDI
Middle SDI
High-middle SDI
High SDI
0
0 25 50 75 100
Healthcare Access and Quality Index 1990
Figure 3: Comparison of 1990 and 2015 HAQ Index estimates, with uncertainty, by country or territory
Geographies with the largest improvement in the HAQ Index from 1990 to 2015 are labelled. All countries and territories are colour-coded by SDI quintile in 2015.
HAQ Index=Healthcare Access and Quality Index. SDI=Socio-demographic Index.
several countries in Latin America and the Caribbean countries remained in the first decile in 2015, including
were in the first decile. By 2015, nearly all countries and the Democratic Republic of the Congo, Niger, and
territories saw increases in their HAQ Index, yet the gap Zambia. In Asia and the Pacific, a number of countries
between the highest and lowest HAQ Index levels was also experienced relatively low HAQ Index levels:
wider in 2015 (660) than in 1990 (616). The tenth decile Afghanistan and Papua New Guinea (first decile);
included many countries in western Europe, Canada, Pakistan and India (second decile); and Indonesia,
Japan, and Australia, while the UK and the USA were Cambodia, and Myanmar (third decile).
in the ninth decile. Latin America and the Caribbean Comparing the overall HAQ Index with its component
had varied HAQ Index levels, spanning from Haiti parts showed substantial heterogeneity in 2015, even
(first decile) to Chile (seventh decile). By 2015, Vietnam within similar SDI quartiles (figure 2). Within the fourth
and Malaysia reached the sixth decile; China and SDI quartile, most geographies performed well on several
Thailand rose to the seventh decile; and Turkey and vaccine-preventable diseases, including measles, diph
several countries in the Middle East and Eastern Europe theria, tetanus, and whooping cough, yet some experienced
improved to the eighth decile. In sub-Saharan Africa, lower values for communicable conditions such as lower
Cape Verde (fifth decile), Namibia, South Africa, Gabon, respiratory infections. Geographies in the fourth SDI
and Mauritania (fourth decile) had the highest HAQ quartile generally performed worse for cancers, but many
Index levels in 2015, rising from their positions since recorded values exceeding 90 for cervical and uterine
1990. At the same time, many sub-Saharan African cancers. Nearly all geographies in the fourth SDI quartile

Articles
80
60
40
Year
1990
1995
2000
2005
2010
2015
20
025 050 075 100
Socio-demographic Index
Figure 4: Defining the HAQ Index frontier on the basis of SDI

Each circle represents the HAQ Index and level of SDI for a given geography-year, and circles are colour-coded by year from 1990 to 2015. The black line represents
the HAQ Index frontier, or the highest observed HAQ Index value, at a given level of SDI across years. HAQ Index=Healthcare Access and Quality Index.
SDI=Socio-demographic Index.
surpassed 90 for maternal disorders, while geographies in countries and territories saw values lower than 50 for
the third and second SDI quartiles showed far more causes associated with routine surgeries and more
diverse results. A similar pattern emerged in causes for complex case management (eg, epilepsy, diabetes, and
which routine surgeries can easily avert mortality (eg, chronic kidney disease).
appendicitis and hernias) among third and second SDI For nearly all countries and territories, the HAQ Index
quartile geographies, with some countries performing has markedly improved since 1990, with 167 recording
fairly well for such causes (eg, China, Turkey, Sri Lanka) statistically significant increases by 2015 (figure 3).
while others lagged behind (eg, Mexico, Indonesia, South Because of incomplete data systems, uncertainty bounds
Africa). Many geographies in the third and second SDI were relatively large for lower-SDI countries, whereas
quartiles not only had fairly low values for NCDs such as uncertainty for higher-SDI countriesplaces where data
diabetes, chronic kidney disease, and hypertensive heart systems are more complete and of high qualitywas
disease, but also fared poorly on a subset of infectious much smaller. Five countries with the largest significant
diseases (ie, tuberculosis, lower respiratory infections, and increases for the HAQ Index were South Korea (high
diarrhoeal diseases) and neonatal disorders. In the first SDI), Turkey and Peru (high-middle SDI), and China
SDI quartile, neonatal and maternal disorders, and the Maldives (middle SDI). Among low-middle-SDI
tuberculosis, lower respiratory infections, and diarrhoeal and low-SDI countries, Laos and Ethiopia saw among
diseases often led to the lowest scaled values, while most the greatest improvements in the HAQ Index; however,
geographies experienced relatively better performances for these gains were less pronounced due to wide
a subset of cancers. Notably, several countries in the uncertainty bounds.
first SDI quartile recorded fairly high values for vaccine- Based on a frontier analysis, we found that, as SDI
preventable diseases. By contrast, nearly all of these increases, the highest observed HAQ Index values also

Articles
HAQ Index (95% UI) HAQ Index frontier Difference between

observed and frontier
HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
Global 407 427 448 478 510 537 619 738 212 201
390428 410445 432467 463496 495527 522554
Southeast Asia, east 448 481 511 554 600 635 576 750 128 115
Asia, and Oceania 428471 461503 493530 537573 583617 617654
East Asia 495 538 578 636 697 738 571 754 76 16
475519 518559 560597 618654 680713 722754
China 495 537 578 637 699 742 562 754* 67 12
474518 517559 559597 619656 682715 725758
North Korea 531 558 560 575 604 623 706 691 175 69
462598 495616 502616 528623 560646 572671
Taiwan 642 668 701 736 771 776 768 886 126 110
625664 651688 685719 721754 756786 747804
Southeast Asia 386 409 430 460 494 521 590 740 204 219
358414 384434 407454 437485 471518 495547
Cambodia 300 313 341 407 455 507 454 623 153 116
265336 281349 308374 376440 422485 472546
Indonesia 372 397 413 438 468 492 606 744 234 252
334414 363437 383445 409467 437499 453529
Laos 238 257 287 336 396 449 463 639 225 190
191293 215304 250327 304369 364428 407489
Malaysia 542 572 603 632 639 666 693 815 151 149
522565 553592 585621 615649 623657 641692
Maldives 459 516 593 671 729 755 501 732* 43
433492 494543 573613 654690 711746 730780
Mauritius 536 573 598 618 633 657 686 790 150 133
516561 556591 582618 601635 616651 640675
Myanmar 297 316 347 395 444 484 458 649 161 165
224375 239395 269431 316481 362526 403563
Philippines 450 461 475 476 496 520 638 741 188 221
432471 443482 457495 458496 478515 499542
Sri Lanka 569 595 604 638 689 728 663 768 94 41
552585 575613 583622 620654 675703 695760
Seychelles 507 551 585 611 639 661 722 809 215 148
486532 529574 564606 591631 617657 636685
Thailand 524 559 593 648 684 708 665 768 141 59
501549 537581 573616 626670 661705 680738
Timor-Leste 322 354 382 426 484 516 466 591 143 75
272396 309413 337452 387481 444532 469570
Vietnam 495 524 558 596 630 663 522* 735 27 72
458540 488569 527592 554642 585677 621706
Oceania 338 348 354 361 377 403 513 629 175 227
284398 291407 298417 300426 314439 335464
American 546 556 602 617 631 633 740 774 194 141
Samoa 518575 524586 577628 590642 605657 598667
Federated 411 436 468 498 515 538 625 733 215 195
States of 334502 359519 383549 409576 420592 445615
Micronesia
Fiji 439 441 447 450 454 466 692 761 253 296
401478 406477 417477 419481 420489 425506
Guam 615 636 670 664 637 634 817 898 202 263
591640 613660 649692 641685 614659 605665
Kiribati 354 365 397 411 436 449 533 617 179 168
318393 330400 363434 370446 390477 400497
Marshall Islands 412 432 432 443 468 498 568 714 157 217
374452 393471 390481 402486 423514 457542
Northern 605 655 689 714 727 718 822 870 217 153
Mariana Islands 567640 627686 666712 694733 706750 686747
(Table 3 continues on next page)

Articles

HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
(Continued from previous page)
Papua New 320 330 334 340 358 386 487 588 167 202
Guinea 249397 257407 262416 265427 277437 299466
Samoa 509 536 565 586 607 621 634 738 124 117
454554 483586 518621 545635 569651 576668
Solomon 334 357 383 380 401 431 485 602 151 171
Islands 255416 276443 303466 300466 317488 345518
Tonga 550 563 573 584 601 621 638 732 88 111
509586 530594 543602 552612 567634 580656
Vanuatu 364 374 383 384 411 431 528 664 163 232
283443 285463 300474 304461 327490 349502
Central Europe, 575 559 584 608 654 685 767 853 192 167
eastern Europe, and 562590 545575 571600 594624 641668 673699
central Asia
Central Asia 507 492 507 524 566 599 723 782 216 183
492525 476510 489526 508543 550584 584616
Armenia 568 556 590 600 637 675 717 806 149 131
548591 535580 569615 579626 617662 655700
Azerbaijan 529 518 536 554 599 645 740 833 211 188
508551 497540 514556 535575 579621 626665
Georgia 584 602 609 607 608 621 761 811 177 191
564606 580622 584630 587626 588629 600642
Kazakhstan 551 499 513 519 579 611 755 847 204 236
535569 482519 496533 501540 563598 592633
Kyrgyzstan 525 517 524 546 577 604 715 736 190 132
506545 498539 506545 526566 559596 584622
Mongolia 423 421 447 509 549 585 644 768 221 183
398450 397449 423474 476535 511574 548612
Tajikistan 487 481 486 517 554 586 638 700 151 114
468512 458503 464512 497541 534578 567607
Turkmenistan 471 477 488 511 545 581 717 826 246 246
448495 454501 465511 488537 524570 560604
Uzbekistan 519 517 540 561 592 623 671 765 153 142
499541 495539 519562 539584 571616 602645
Central Europe 606 634 675 705 738 771 762 864 156 93
593622 621648 662688 693718 726749 760782
Albania 624 651 685 716 753 782 697 791* 73 09
606642 633670 667704 697734 731772 760802
Bosnia and 609 621 688 721 753 782 625* 793* 16 10
Herzegovina 592629 604640 671705 702736 730769 759799
Bulgaria 630 632 648 667 679 714 766 848 136 135
617645 619647 635663 653682 664693 696731
Croatia 688 704 734 768 789 816 750 829 62 12
675700 692718 722746 756779 779800 805827
Czech Republic 683 732 771 792 818 848 830 902 147 53
671697 721743 758781 780803 809828 839857
Hungary 646 672 710 737 761 796 784 876 138 80
634660 660685 699722 726748 751772 782810
Macedonia 619 634 670 699 742 760 741 811 122 51
603639 619653 657685 684713 727755 738780
Montenegro 702 702 699 744 782 807 758 840 56 33
680722 687719 683714 730758 769796 790823
Poland 621 654 708 738 763 796 768 888 147 92
608636 642668 695720 724750 751775 782810
Romania 583 600 642 672 711 744 761 840 178 96
568600 586616 628657 656686 697725 727760

Articles

HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
Serbia 642 644 666 694 731 754 744 819 102 65
621664 628663 651683 679710 718743 742767
Slovakia 666 694 708 722 749 786 773 885 107 99
650682 678709 692722 707736 736762 773799
Slovenia 712 728 764 798 843 874 804 880* 92 06
701724 716742 753775 788808 834853 865884
Eastern Europe 617 582 604 634 689 719 794 872 177 153
604631 567598 590620 619650 677702 706732
Belarus 639 632 656 680 717 744 758 874 119 130
621657 614651 634674 660697 702733 728761
Estonia 658 625 674 714 775 814 773 883 115 69
645672 610641 660689 701728 764786 801826
Latvia 657 624 687 707 744 777 790 884 132 106
645671 610640 675701 694720 732757 763793
Lithuania 670 642 696 702 736 766 776 870 106 104
658683 628656 685710 690716 725749 755779
Moldova 596 560 608 648 668 731 728 767 132 36
581614 543579 590625 629667 651684 712749
Russia 614 576 597 629 685 717 811 881 198 164
600629 561594 583613 614646 671699 703731
Ukraine 628 594 620 644 705 727 767 850 139 124
613645 578612 606638 629661 692720 708745
High-income 711 746 772 796 816 831 833 900 122 70
702722 736756 763782 788805 808824 823838
High-income Asia 726 772 798 833 860 874 826 900 100 26
Pacific 713738 762783 788808 824842 852868 867882
Brunei 620 643 667 686 695 700 830 913 210 213
601640 624662 651686 670703 680712 683718
Japan 783 807 829 856 878 890 845 904 62 13
774792 798816 821837 849863 872886 883898
South Korea 617 705 746 804 839 858 773 890 156 32
596639 690722 734760 793816 829849 847870
Singapore 674 728 773 808 842 863 773 896 99 33
662688 716741 762785 798819 833851 853873
Australasia 772 801 829 853 874 891 845 908 73 17
762782 792811 821838 846861 867881 884898
Australia 780 808 837 862 882 898 847 910 67 11
770791 798818 829846 854869 875889 891906
New Zealand 742 776 800 825 842 862 834 899 92 36
732752 766786 792809 817834 834850 854872
Western Europe 732 768 799 829 849 868 809 888 77 21
723742 760778 790808 821837 842856 860875
Andorra 847 880 911 926 940 946 858* 912* 11
827879 860922 894935 911944 925955 933960
Austria 744 782 816 842 861 882 832 900 88 18
732755 771792 807825 834850 853869 873890
Belgium 754 788 816 846 863 879 826 896 72 18
743766 779798 806826 836854 854871 868888
Cyprus 720 734 764 792 826 853 782 895 61 42
706735 722747 750775 781803 816837 842864
Denmark 766 772 795 819 836 857 856 909 90 52
755777 761782 784805 810828 827846 847867
Finland 754 788 820 845 872 896 830 902* 76 06
743766 778799 810829 835853 864881 886905
France 743 775 803 842 857 879 790 867* 48
732754 765785 794813 834851 849865 869889

Articles

HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
Germany 731 771 806 832 849 864 835 906 104 43
720743 761782 794816 820841 839857 854873
Greece 765 795 822 844 852 870 770* 859* 05
756776 787805 814830 836852 844860 861879
Iceland 819 842 871 898 921 936 831 903* 12
810830 833852 861880 889906 912928 929944
Ireland 756 784 796 835 860 884 790 900 33 16
745767 773795 785807 826844 852869 875893
Israel 713 743 775 803 837 855 803 871 90 16
702725 732753 762786 790814 825846 842865
Italy 762 791 825 855 875 887 818 881* 55
753772 782800 817834 847863 868882 878896
Luxembourg 745 788 822 849 875 893 836 909 91 16
734757 779799 813831 841858 866883 884902
Malta 747 768 789 814 829 851 749* 845* 01
735760 756780 778801 803826 818839 840861
Netherlands 792 808 821 851 882 895 832 903* 40 08
782802 797818 810831 841860 874889 886904
Norway 775 810 828 859 880 905 859 916 84 11
765786 801820 818837 851868 872889 896914
Portugal 672 715 747 797 819 845 714 805* 41
661686 704727 737758 787807 811829 836855
Spain 739 781 814 841 872 896 747* 857* 08
730750 773790 806823 834849 865878 888903
Sweden 804 839 857 870 887 905 829 902* 24
795814 830848 849866 862879 879897 896914
Switzerland 814 834 854 882 901 918 864 914* 50
805823 826843 847862 875889 895908 909926
UK 743 766 784 806 827 846 834 903 92 57
732753 757776 775793 798814 820835 838854
Southern Latin 576 611 647 667 681 700 734 826 157 125
America 563593 598626 633661 654681 669694 688713
Argentina 574 603 635 653 666 684 733 819 159 135
560591 590619 621650 640668 653679 671697
Chile 588 642 692 720 739 760 738 845 150 85
574604 627656 677705 705733 726751 745774
Uruguay 608 631 671 687 706 720 725 797 117 77
594622 619646 657684 674700 692719 705735
High-income 740 763 781 792 809 818 885 915 144 97
North America 730751 753773 773790 783801 801817 810827
Canada 789 807 832 847 863 876 881 916 92 40
780799 798816 822840 839855 855871 868885
Greenland 590 623 643 658 681 710 725 810 136 100
565620 598652 620675 635689 660713 687741
USA 737 760 778 788 805 813 885 915 148 102
727748 750770 769787 779797 796813 805822
Latin America and 465 508 546 574 596 619 654 753 189 134
Caribbean 449485 492526 530564 558591 580613 604635
Caribbean 424 459 488 508 523 545 685 749 261 204
402449 439481 466510 486533 499547 519572
Antigua and 566 578 603 625 649 667 792 870 226 203
Barbuda 546587 559599 584625 605646 630669 646689
The Bahamas 509 541 570 599 621 639 779 866 270 227
482536 517566 546594 575622 597645 610667
Barbados 559 595 626 643 655 668 756 828 197 160
537584 575619 605648 624661 636675 644693

Articles

HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
Belize 497 505 506 537 563 583 614 748 117 165
473522 482531 481532 513564 539587 556613
Bermuda 608 648 716 741 770 790 869 911 260 121
589628 629666 697735 724758 752786 770810
Cuba 641 652 677 705 721 735 748 815 107 79
627657 639668 664690 693718 710734 723749
Dominica 530 546 577 590 585 581 720 804 190 223
507554 523570 555599 568613 561608 552610
Dominican 479 522 566 586 608 625 641 756 162 131
Republic 458502 501544 544587 564605 585626 602645
Grenada 494 528 540 551 570 583 673 805 179 222
463525 503554 515565 525575 545596 552612
Guyana 393 413 425 447 470 498 627 744 234 246
369420 389441 399451 422478 442500 467532
Haiti 249 292 327 348 359 385 482 546 233 161
212289 257331 290368 304390 315403 337435
Jamaica 550 580 595 622 629 637 712 777 162 141
526574 555605 568619 591648 597655 601665
Puerto Rico 645 661 698 726 740 766 817 896 172 130
629662 647676 686713 713739 729753 751781
Saint Lucia 497 530 560 585 611 625 699 794 202 169
471525 508554 539582 562607 587635 593654
Saint Vincent 504 514 530 552 567 575 710 800 205 225
and the 479531 490537 508553 532576 545590 547602
Grenadines
Suriname 467 486 495 510 535 567 675 767 208 200
444490 462510 472521 484535 510560 539595
Trinidad and 516 535 558 586 605 621 755 864 239 244
Tobago 496537 515556 538578 567607 584626 594646
Virgin Islands, 604 631 658 688 698 702 812 899 208 197
USA 585626 613651 639677 669706 677717 679724
Andean Latin 432 470 535 581 609 641 649 756 217 115
America 412456 451493 515555 561601 591629 621659
Bolivia 405 438 485 533 564 592 566 726 161 134
376436 412468 462512 507558 535592 559627
Ecuador 454 487 535 561 586 612 662 757 208 145
435477 468509 513556 539583 563607 588636
Peru 459 498 571 627 659 696 667 768 208 72
436484 475522 548593 605647 637679 670718
Central Latin 476 522 558 583 602 624 666 761 190 137
America 459496 505541 541575 565599 585619 608641
Colombia 511 549 584 616 644 678 671 765 160 86
495532 533566 568601 599632 625662 658697
Costa Rica 621 628 654 686 708 729 686 780 65 51
604636 611644 638671 670701 691723 709746
El Salvador 443 490 553 596 622 644 572 730 129 86
419468 468513 531576 568618 588646 612669
Guatemala 401 444 487 513 532 557 507 669 106 112
379425 423468 466510 489535 508555 527588
Honduras 423 457 476 495 518 539 515 695 91 156
400448 429486 438512 453534 477560 499578
Mexico 492 541 574 591 605 626 689 776 197 151
476512 524559 556591 574607 589621 610642
Nicaragua 497 517 555 588 618 643 531 689 34 47
475521 497538 534576 565609 593639 618667

Articles

HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
Panama 529 567 598 613 622 644 716 799 187 155
507552 546587 576618 589635 597643 614670
Venezuela 531 556 593 623 642 647 714 785 183 138
514549 538575 575610 607640 625658 622669
Tropical Latin 501 537 569 598 625 647 637 747 137 100
America 483520 520556 553587 583614 610641 632665
Brazil 501 538 570 599 626 649 638 747 138 98
483520 520556 554587 584616 612643 634667
Paraguay 530 551 566 574 586 604 617 740 87 136
507554 529575 540589 548599 561610 574632
North Africa and 438 465 499 528 557 584 557 723 119 138
Middle East 419460 445486 480519 510548 539577 565605
Afghanistan 247 245 248 271 294 325 380 476 133 151
186320 185316 187317 212335 235357 266386
Algeria 482 526 562 596 622 637 583 714 101 76
455511 499552 537587 573621 599643 613663
Bahrain 597 632 673 713 772 790 718 823 121 33
574622 606656 649697 690734 751791 762817
Egypt 450 493 544 569 582 610 580 730 129 120
425475 471517 524564 548587 562601 587631
Iran 546 596 635 657 689 711 600 775 54 64
515576 565623 609656 626686 654723 679742
Iraq 511 507 518 544 572 601 532* 701 21 100
475544 474540 484550 504580 532613 558643
Jordan 591 620 650 684 743 765 631 763* 40
562619 592648 626673 664703 728758 744784
Kuwait 717 714 749 757 777 820 760 885 43 64
701733 700728 736761 745770 764789 799840
Lebanon 587 634 685 731 770 800 695 805* 109 06
553622 601665 652717 697764 734809 760843
Libya 600 637 654 671 697 699 615* 740 14 41
573628 612664 631678 649693 674720 672726
Morocco 440 478 526 556 587 613 494 630* 54 17
407473 447511 492560 514591 541628 566660
Palestine 618 656 683 687 690 705 558* 694*
578655 623686 662704 666705 663715 672741
Oman 661 714 744 762 729 771 543* 786* 15
620704 676749 713770 742780 710751 746801
Qatar 708 713 731 775 831 852 729* 845* 21
681733 688738 709756 750797 807853 820883
Saudi Arabia 634 668 712 742 770 794 654* 810* 20 16
611658 648688 696727 728756 756784 777811
Sudan 366 388 420 449 474 501 466 564 100 64
324410 341432 372467 401496 426525 450551
Syria 582 631 682 714 738 746 521* 704*
549612 595662 653707 690734 719755 721770
Tunisia 530 569 614 645 674 701 591 743 61 43
503557 542594 590640 616674 643707 666738
Turkey 513 554 624 686 743 762 652 759* 139
488539 530578 603644 667706 724759 743781
United Arab 569 608 647 690 714 722 737 892 168 171
Emirates 527610 573643 619678 667713 681746 680763
Yemen 352 380 413 445 478 496 370* 541* 18 45
277435 303466 328500 361533 388560 404576

Articles

HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
South Asia 307 329 351 381 411 444 485 663 177 219
285333 308352 329376 360405 390434 423467
Bangladesh 326 358 396 443 487 517 470 611 144 94
295357 328388 368424 417472 461514 484549
Bhutan 346 376 423 462 501 527 473 659 127 132
304388 339417 386458 424498 464539 485567
India 307 331 353 382 412 448 488 684 180 236
284335 308356 329379 360407 389436 426472
Nepal 340 371 416 457 482 508 444 557 104 49
302381 338405 386446 423491 442521 467550
Pakistan 365 356 363 381 412 431 472 607 106 177
333403 322393 329401 349419 375451 392471
Sub-Saharan Africa 323 335 346 374 405 422 466 523 143 101
297352 312361 324369 353397 384429 396449
Central 311 321 330 357 372 386 457 481 146 95
sub-Saharan Africa 259368 270374 278378 300410 309427 318456
Angola 258 281 312 356 377 407 461 553 203 146
122434 129452 153478 183511 187521 203549
Central African 255 258 267 280 288 286 440 473 186 187
Republic 203306 191339 182377 183398 186409 174413
Congo 322 314 333 393 412 435 536 655 214 220
(Brazzaville) 269380 268364 287384 344445 349471 342527
DR Congo 356 361 362 381 393 404 447 452* 91 48
292426 307415 311410 330430 338448 331490
Equatorial 261 275 354 429 456 484 464 725 204 241
Guinea 120452 125467 175506 230553 256571 279594
Gabon 391 401 418 441 484 514 611 740 220 226
349434 361444 371463 391489 423542 427590
Eastern 296 312 338 375 405 424 431 499 135 75
Burundi 235 234 270 355 405 404 399 453* 164 49
170319 183291 223317 305403 342473 316489
Comoros 327 343 384 441 472 477 460 505* 133 28
237416 279401 338429 392488 416525 396552
Djibouti 389 388 394 409 432 447 489 602 100 154
308471 290480 286504 297514 313541 331548
Eritrea 289 353 380 388 378 381 415 489* 127 109
244339 298412 292471 276495 264485 256499
Ethiopia 231 268 306 349 404 442 368 481* 137 39
191282 228315 263358 309396 343470 352526
Kenya 426 423 440 464 475 487 495 611 68 124
393456 391457 407474 431496 443506 452522
Madagascar 348 365 387 416 425 437 464 508* 116 71
310387 326433 341473 365494 355503 349531
Malawi 347 354 365 406 443 470 424 484* 77 14
299396 288424 291431 341468 378505 384551
Mozambique 332 351 364 396 409 430 315* 471* 41
290375 309393 314418 334462 339489 337532
Rwanda 299 233 304 426 470 478 433 510* 134 32
254344 185277 254350 374479 404536 390558
Somalia 291 293 301 318 333 342 355* 386* 64 44
139458 148463 149473 159496 160500 172508
South Sudan 334 347 375 390 388 388 380* 464* 46 76
172476 180496 198523 205535 179536 188532

Articles

HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
Tanzania 399 410 431 467 488 499 470 546* 72 46
360441 367456 380483 402523 399565 390590
Uganda 340 339 352 382 414 429 432 513* 92 83
288409 281414 302412 336433 349486 336537
Zambia 374 346 343 355 374 416 490 607 116 192
326422 296399 294390 311402 322426 339501
Southern 448 467 434 431 463 492 653 748 205 256
Botswana 449 454 437 439 486 511 554* 739 105 229
276581 243593 205594 218603 260625 280636
Lesotho 408 418 394 332 344 357 491 651 84 293
353469 364484 330452 279384 274416 261459
Namibia 418 419 399 435 504 537 580 729 162 192
381456 379457 346452 373492 438573 447615
South Africa 456 479 448 452 494 520 697 771 241 251
427484 454504 418481 416487 460528 492549
Swaziland 415 457 407 351 378 419 550 733 135 314
357476 387542 333475 278421 289478 307545
Zimbabwe 481 495 454 418 421 487 560 666 79 179
438529 411570 368522 344486 358482 401573
Western 353 362 370 397 433 448 462 533 109 85
Benin 369 370 373 404 415 430 428 497* 59 67
329412 328413 327422 345465 330499 328529
Burkina Faso 329 341 360 403 427 429 331* 452* 02 23
289374 298387 316407 354452 362494 338515
Cameroon 383 377 372 410 425 444 489 604 106 160
346422 335418 323426 361464 356491 350533
Cape Verde 501 493 508 537 579 617 483* 676 58
474526 453532 455562 492584 556603 581649
Chad 356 352 321 341 363 377 381* 475* 25 98
308406 308403 271374 269411 268461 271482
Cte dIvoire 355 332 344 376 407 424 463 515 108 92
314394 285383 292397 324425 342472 337508
The Gambia 413 424 433 456 477 497 452* 490* 40
321504 352497 386482 416501 432525 431563
Ghana 348 385 403 442 473 497 498 642 150 146
283409 339433 354455 385504 388557 400588
Guinea 326 336 340 370 376 386 404 471 78 85
286369 296379 301383 326415 326430 307466
Guinea-Bissau 327 331 336 333 351 363 408* 478* 81 115
153467 147473 157482 149483 162491 150502
Liberia 347 371 395 417 432 454 439 473* 92 19
289405 323419 347447 370467 382485 378529
Mali 327 338 377 435 444 456 351* 448* 24
288370 299379 337420 392478 392499 381532
Mauritania 373 389 429 469 496 520 466 534* 92 14
333414 348435 385478 421527 435554 438603
Niger 318 331 346 377 403 410 326* 382* 08
269369 286379 303389 332423 347455 323489
Nigeria 383 397 406 431 488 513 482 614 99 101
312454 344450 362454 384479 432544 432570
So Tom and 413 419 428 440 473 496 481 588 68 92
Prncipe 378452 380457 393468 393484 409537 407586

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HAQ Index values
1990 1995 2000 2005 2010 2015 1990 2015 1990 2015
Senegal 376 381 389 415 429 444 435 494* 60 49
333418 340422 348430 357471 344512 340543
Sierra Leone 376 372 354 361 382 413 413* 489* 36 76
308451 321428 307404 318408 331437 333491
Togo 374 369 369 401 418 443 455 503* 82 60
330418 328413 321426 348456 361479 366525
Geographies that exceed the HAQ Index frontier associated with their level of SDI have double dots in place of values in the columns representing the difference between observed and frontier HAQ Index levels.
GBD=Global Burden of Disease. HAQ Index=Healthcare Access and Quality Index. SDI=Socio-demographic Index. UI=Uncertainty interval. *Geographies for which the HAQ Index frontier in 1990 or 2015 is within
the 95% UIs of their observed HAQ Index values for those years.
Table 3: Global, regional, and national or territory-level estimates of the HAQ Index for each 5-year interval from 1990 to 2015, frontier values in 1990 and 2015 on the basis of SDI, and
the difference between observed HAQ Index and frontier values in 1990 and 2015
rose (figure 4). Further, maximum HAQ Index levels Discussion

achieved generally improved since 1990 across levels of Drawing from GBD 2015, we constructed a novel measure
SDI. Table 3 details each geographys HAQ Index values of personal health-care access and qualitythe HAQ
for 5-year intervals from 1990 to 2015, as well as their Indexby using highly standardised estimates of
frontier HAQ Index levels on the basis of a locations 32 different causes that are amenable to personal health
SDI. Measuring the distance between a geographys care. Compared with previous efforts, the HAQ Index
observed HAQ Index in 1990 and 2015 and its frontier for provides a clearer signal on personal health-care access
these years provides a benchmark for potential gains in and quality over time and place because GBD provides
health-care access and qualitya metric that also enhanced comparability of cause of death data, helps to
considers the geographys relative resources on the basis account for variation due to behavioural and environmental
of SDI. Additionally, comparing how differences between risk factors, and includes 195 countries and territories
a given places observed HAQ Index and frontier change over time. Our analysis showed large differences in
over time can show where personal health-care access personal health-care access and quality, spanning from a
and quality have improved in parallel with changes in low of 231 in Ethiopia in 1990 to higher than 90 in
development. Andorra, Iceland, Switzerland, Norway, and Sweden in
Worldwide, the average HAQ Index values 2015. The global HAQ Index improved from 407 in 1990
significantly increased, but the average global frontier to 537 in 2015, and 167 of 195 countries and territories
improved in tandem; subsequently, gaps between the significantly increased their HAQ Index during this time.
global HAQ Index and frontier changed minimally Although the HAQ Index and SDI were highly correlated,
between 1990 and 2015. While most regions recorded we noted substantial heterogeneity for geographies at
narrowing gaps between average HAQ Index values and similar SDI. If every location reached the highest observed
maximum levels achieved, a subset saw negligible HAQ Index experienced by level of SDI, our global
progress or widening differences (eg, southern sub- measure of health-care access and quality could have
Saharan Africa, south Asia, and the Middle East). In reached 738 in 2015a clear indicator of untapped
2015, 52 countries and territories had HAQ Index potential for health-care improvement worldwide.
estimates that included the frontier within their While most countries saw progress on the HAQ Index
uncertainty bounds, indicating these geographies met since 1990, the marked improvements recorded for
the maximum levels of personal health-care access and countries including South Korea, Turkey, and China
quality attained by locations of similar SDI. Conversely, highlight that much more rapid advances are possible. A
62 geographies fell further behind the HAQ Index subset of countries narrowed the gap between observed
frontier associated with their level of SDI; this trend was personal health-care access and quality and what could be
especially pronounced in much of southern sub- expected given their level of developmentand then
Saharan Africa, Iraq, Pakistan, and Honduras (figure 5). achieved gains beyond what might be anticipated on
This result was in stark contrast with several countries the basis of SDI. Peru, the Maldives, and Ethiopia are
in eastern and western sub-Saharan Africa (eg, Burundi, examples of such stand-out geographies for reaching
Comoros, Rwanda), Turkey, Peru, and South Korea, higher-than-expected levels of personal health care and
many of which more than halved the differences access since 1990. Case studies conducted by the World
between their HAQ Index and frontiers given their SDI Bank highlight potential drivers of these countries
by 2015. successes,60 and additional research on how certain

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Difference between observed

and frontier HAQ Index values
<1 1013
13 1317
35 1721
57 2125
710 >25

West Africa Eastern
Mediterranean
Solomon Isl FSM

Vanuatu Samoa
Difference between observed

and frontier HAQ Index values
<1 1013
13 1317
35 1721
57 2125
710 >25

West Africa Eastern
Mediterranean
Solomon Isl FSM

Vanuatu Samoa
Figure 5: Map of the gap between observed HAQ Index and frontier values in 1990 (A) and 2015 (B)
Difference in observed HAQ Index and frontier values were the highest levels achieved by geographies of similar SDI in a given year. HAQ Index=Healthcare Access and Quality Index.
SDI=Socio-demographic Index. ATG=Antigua and Barbuda. VCT=Saint Vincent and the Grenadines. LCA=Saint Lucia. TTO=Trinidad and Tobago. TLS=Timor-Leste. FSM=Federated States of Micronesia.

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health-system attributes, including financing of care. Subnational work that identifies variation in
arrangements, provider ownership, and stewardship personal health-care access and quality within a particular
functions, are related to personal health-care access and health-system structure, and that uses multi-method
quality is warranted. Separating out measures of access approaches to view the health system from the
from quality of care received would be ideal, especially perspective of patients and frontline providers,62,63 may
because programmatic and policy options to address help elucidate whether some health-system components
barriers in access and quality can differ across and within function distinctly from its average. For example, access
countries. Nonetheless, such information measured in a to and quality of oncology care might be relatively distinct
consistent manner is rarely available.34,46,57,60 from other health-system dimensions and, where
Several geographies had minimal gains in reducing the appropriate treatment is contingent on specialists or
difference between their observed HAQ Index and the particular equipment, such as radiotherapy for cancer,
highest levels achieved at a similar SDIa warning sign even a temporary loss of these resources may substantially
that heightened health-care access and quality is not an affect outcomes.64 Conversely, access to high-quality
inevitable product of increased development. Further, primary care services, which enable early detection of
a subset of countries in southern sub-Saharan Africa, conditions that are fatal if diagnosed at later stages, can
south Asia, and the Middle East saw widening gaps be shaped by different factors, such as flexibility of clinic
between HAQ Index values in 2015 and the frontier hours or types of insurance providers accepted.65
reached by countries of comparable SDI. These findings
could reflect several challenges faced by these countries, Mortality amenable to personal health care and mortality
including subnational inequalities in both wealth and attributable to modifiable behavioural and environmental
health-care options; and recent or rapid epidemiological risk factors
transitions wherein the health-care sector and cause- For the present study, we based the HAQ Index on the list
specific services offered trail behind the diseases of causes established by Nolte and McKee,4,9,11,30,31,35 and did
afflicting populations. Along with examining the drivers not systematically re-examine scientific literature to update
of greater-than-expected gains, future studies should causes for which personal health care can significantly
strive to understand why other countries are lagging improve outcomes. Conducting this kind of systematic
behindand how they can pursue advancing health-care review is crucial to identifying additional causes for
access and quality for all individuals. inclusion in the HAQ Index. Numerous causes should be
Improving personal health-care access and quality is an considered, and would likely result in adding antiretroviral
important priority in the SDG era, emphasising the therapy for HIV, artemisinin-based combination therapies
potential utility of the HAQ Index for SDG monitoring. At for malaria, treatment of hepatitis C, and improvements in
present, the UHC targetSDG 3.8focuses mainly on emergency and trauma care, among others.41,42,6669
so-called tracer interventions in the areas of maternal and Expanding the amenable cause list should be determined
child health, reproductive health, and a subset of infectious by clear criteria that define when health care sufficiently
diseases,61 and thus fails to adequately capture the vital reduces cause-specific mortality and thus provides a strong
role of personal health care for NCDs and injuries. The enough signal about access and quality. Such additions
HAQ Index provides a more comprehensive measure that will probably improve the HAQ Index, though the nature
reflects health-system capacity for effectively detecting of PCA estimation and its measurement of common
risk for, managing, and preventing early death from a variance across 32 causes may not substantially change
range of conditions. Combining the HAQ Index, coverage future results. This analysis stemmed from existing
of health interventions, and prevalence of risk factors that scientific literature on mortality amenable to health care,
are modifiable through public health initiatives could but personal health care also can have profound effects on
provide a more robust mechanism for tracking UHC non-fatal health outcomes (eg, hip replacement for
progress across multiple dimensions of health-system oesteoarthritis or surgery for cataracts). Future updates of
action. the HAQ Index should consider incorporating measures
Health systems can provide differential access and of non-fatal conditions amenable to personal health care,
quality across therapeutic areas and levels of care. The which would then capture health-system capacity to deliver
HAQ Index reflects the average experience as captured health gains through improved functional health status.
by included conditions, and does not currently Understanding how much mortality or disease burden
distinguish between diseases more strongly related to is avertable based on providing access to high-quality
primary or secondary care. Our PCA weights suggest personal health care and modifying behavioural and
some conditions are less highly correlated with other environmental risks through public health initiatives is
causes, including colon cancer, breast cancer, testicular of high policy interest. GBD currently assesses mortality
cancer, non-melanoma skin cancer, or diphtheria. The and burden attributable to a large set of risk factors,
comparatively low weights on these outcomes could which supplies useful insights on the potential of risk
reflect measurement error, residual challenges in risk modification to improve health. Quantification of the
standardisation, or health-system heterogeneity by level full potential of personal health care to reduce burden

Articles
by cause would provide an important additional piece In particular, this might shed light on the association
of policy-relevant information. Controlling for other between investment in health-care resources and
factors through statistical modelling, such as income and outcomes, a relationship that is unlikely to be linear. For
educational attainment, we could examine how much instance, audits have identified three main factors
cause-specific variation relates to the HAQ Index. Such underlying maternal deaths: substandard care, delays in
work would help to pinpoint opportunities for national care, and problems with blood transfusions.73 Addressing
and subnational progress through health-system the latter requires a different type of intervention, namely
improvements, which would likely include public health investments in infrastructure, than the former two factors.
programmes and policies as well as the organisation and Such knowledge is of particular importance in the SDG
delivery of personal health services across levels of care. era, as some studies point to advances in medical
technology and innovation as the primary pathway for
Moving to performance measurement elevating health alongside increasing development.74
In estimating the HAQ Index frontier by SDI,58 we
quantified the gap between observed personal health- HAQ Index compared to other measures of access and
care access and quality and levels potentially achievable quality of care
at a given level of SDI. With these analyses, we lay the Detailed results on HAQ Index components seem
foundation for a refined assessment of health-system consistent with previous, albeit limited, studies on health-
performance. The World Health Report 2000, which care performance. Within Europe, Nordic countries
sought to evaluate health-system performance by performed especially well, corresponding with past work
country,70 estimated the contribution of health systems on a composite measure of public health policies.75 Country
for improving healthy life expectancy while statistically performance on diabetes aligned with earlier work on
controlling for other factors. As suggested by Nolte and diabetes mortality and incidence,25 wherein country-level
McKee,9,71 using a measure more directly related to differences were largely explained by known health-system
health-system actions, such as mortality amenable to changes, such as substantial improvements in several
personal health care, could reduce the need to control for Baltic states during the late 1990s. In Latin America,
other factors in health-system performance assessment. Costa Ricas relatively high HAQ Index (729), as compared
The World Health Report 2000 framework used five broad with nearby countries (eg, Nicaragua [643],
dimensionsaverage levels of health, inequalities in Guatemala [557]), is consistent with its designation as an
health, average levels of health-system performance, original good health at low cost country.76
inequalities in responsiveness, and fair financingand In view of the paucity of standard health-care access and
then compared overall health system attainment based quality measures, assessing HAQ Index validity compared
on a frontier for health expenditure per capita.71 Our to other indicators was challenging. In this analysis, we
current analysis only focused on the contribution of identified three measures of health-system resources and
personal health care to mortality and the potential for three measures of intervention coverage that included
improvement in this domain relative to development. In at least 70 countries. These correlations, which all
the future, GBD could support examining subnational exceeded 060, offer some evidence of convergent validity
health inequalities and expanding into health finance but do not provide criterion validity.77,78 Nonetheless, these
quantification of financial risk protection. A stronger results are encouraging and stand in contrast to previous
empirical basis for assessing these three domains of studies done in limited settings.3740 In comparison with
health-system performance would also facilitate testing a past work,9,11,31 the moderately high correlation with other
range of efficiency and performance models. health-care indicators might be due to our efforts to risk-
Our frontier analysis showed that the highest observed standardise mortality amenable to health care; PCA
HAQ Index levels, as achieved by geographies with an weighting of different amenable conditions; and the
SDI of 08 or higher, steadily shifted higher over time. inclusion of a substantively larger, more diverse set of
This expansion of health-care access and quality may health systems across the development spectrum.
reflect a rising share of GDP allocated to health among Additional validation analyses are needed to compare
high-SDI countries. However, the frontier estimate for HAQ Index performance with other measures of health-
GDP per capita spent on health points to a similar shift care access and quality; such validation exercises might be
upward at high expenditure. One explanation of this trend more feasible at the subnational level with greater data
is new medical technologies and programmes, which density, such as states in the USA.79
could be driving an overall upward shift in health-care
access and quality achievable in well financed systems. Limitations
Another potential explanation is innovation in health-care This analysis has a number of limitations beyond those
organisation, such as the creation of centralised stroke already described. First, many limitations experienced in
care units in major cities.72 A more detailed examination GBD cause of death estimation are applicable to this
of these changes may further elucidate how investing in study.47 Second, our risk-standardisation procedure might
medical innovations can affect health-system performance. not represent all possible risk-outcome pairs as they

Articles
pertain to included causes of amenable mortality quality, which might emerge on the basis of geographic
(eg, determinants of testicular cancer or neonatal location or socioeconomic status, among other factors.
disorders).48 With its annual updates, GBD aims to improve Future efforts to quantify these measures with greater
upon its comparative risk assessment, and thus HAQ geospatial resolution should be prioritised.
Index assessment is likely to be improved alongside
advances in risk quantification. Third, two causes received Conclusions
negative weights in the PCA analysis and were Our analysis demonstrates that a policy-relevant summary
subsequently excluded. One potential explanation for this measure of personal health-care access and quality can be
is that joint PAFs for these causes may underestimate risk- derived from GBD. This novel measure supports the first-
attributable mortality in high-SDI countries (eg, the effects ever comparable assessment of personal health-care
of diet, obesity, and physical inactivity for breast cancer). access and quality across 195 countries and territories,
However, given the high Spearmans rank order correlation over time, and along the development spectrum. The
between the average of all 32 causes and the HAQ Index, HAQ Index considerably advances previous efforts to
excluding these causes from the PCA likely had minimal approximate personal health-care access and quality by
effect on our results. Fourth, we used PCA to construct the systematically adjusting for cause of death certification
HAQ Index based on age-standardised risk-standardised biases and misclassification, risk-standardising death
death rates from the 32 causes. Alternative methods for rates across geographies, and applying PCA to identify
index construction led to highly correlated results, but common dimensions of health-care access and quality
exact rankings somewhat varied. We subsequently view associated with multiple conditions. Globally, most
exact rank orders as less useful than comparing a given countries and territories recorded gains in personal
geographys HAQ Index values over time, to countries of health-care access and quality from 1990 to 2015, yet many
similar SDI, and relative to the HAQ Index frontier. Fifth, still experienced levels that fell well below what has been
while the HAQ Index offers a more robust indicator of achieved by geographies at a similar development status.
overall health-care access and quality than currently Amid calls to improve monitoring of UHC and overall
available measures, it does not directly capture effects of health-system performance, the HAQ Index provides a
personal health care on causes without substantial strong basis for benchmarking progress toward greater
mortality (eg, depression, hip oesteoarthritis, and access and higher-quality personal health care alongside
cataracts). The effects of health care on both fatal and non- country-level gains in resources to achieve these aims.
fatal conditions may be highly correlated, but incorporating GBD 2015 Healthcare Access and Quality Collaborators
how access and quality of care explicitly affect non-fatal Ryan M Barber, Nancy Fullman, Reed J D Sorensen, Thomas Bollyky,
outcomes would improve measurement. Sixth, GBD Martin McKee, Ellen Nolte, Amanuel Alemu Abajobir,
Kalkidan Hassen Abate, Cristiana Abbafati, Kaja M Abbas,
corrections for cause of death misclassifications (so-called Foad Abd-Allah, Abdishakur M Abdulle, Ahmed Abdulahi Abdurahman,
garbage codes) varies substantially by geography and thus Semaw Ferede Abera, Biju Abraham, Girmatsion Fisseha Abreha,
can affect results. Even among high-SDI countries, GBD Kelemework Adane, Ademola Lukman Adelekan,
showed substantial variation for the proportion of Ifedayo Morayo O Adetifa, Ashkan Afshin, Arnav Agarwal,
Sanjay Kumar Agarwal, Sunilkumar Agarwal, Anurag Agrawal,
amenable deaths assigned to garbage codes, ranging from Aliasghar Ahmad Kiadaliri, Alireza Ahmadi, Kedir Yimam Ahmed,
79% in Finland to 398% in Portugal (appendix p 19). Muktar Beshir Ahmed, Rufus Olusola Akinyemi, Tomi F Akinyemiju,
Seventh, for countries with complete or nearly complete Nadia Akseer, Ziyad Al-Aly, Khurshid Alam, Noore Alam,
vital registration (VR) data and few deaths misclassified Sayed Saidul Alam, Zewdie Aderaw Alemu, Kefyalew Addis Alene,
Lily Alexander, Raghib Ali, Syed Danish Ali, Reza Alizadeh-Navaei,
based on ICD codes, the HAQ Index may be more robust Alaa Alkerwi, Franois Alla, Peter Allebeck, Christine Allen,
and less prone to high levels of uncertainty than for Rajaa Al-Raddadi, Ubai Alsharif, Khalid A Altirkawi,
countries with lower-quality or non-existent VR data. Elena Alvarez Martin, Nelson Alvis-Guzman, Azmeraw T Amare,
Mortality estimates that heavily draw from verbal autopsy Erfan Amini, Walid Ammar, Joshu Amo-Adjei, Yaw Ampem Amoako,
Benjamin O Anderson, Sofia Androudi, Hossein Ansari,
data or other modelling approaches have larger UIs. Our Mustafa Geleto Ansha, Carl Abelardo T Antonio, Johan rnlv,
results for most of sub-Saharan Africa, for example, Al Artaman, Hamid Asayesh, Reza Assadi, Ayalew Astatkie,
include wide UIs and thus few countries recorded HAQ Tesfay Mehari Atey, Suleman Atique, Niguse Tadele Atnafu,
Index values that statistically differed from the regional Sachin R Atre, Leticia Avila-Burgos, Euripide Frinel G Arthur Avokpaho,
Beatriz Paulina Ayala Quintanilla, Ashish Awasthi,
mean. Eighth, we rescale the log age-standardised risk- Nebiyu Negussu Ayele, Peter Azzopardi, Huda Omer Ba Saleem,
standardised death rate for each cause from 0 to 100 using Till Brnighausen, Umar Bacha, Alaa Badawi, Amitava Banerjee,
the observed range across countries from 1990 to 2015, but Aleksandra Barac, Miguel A Barboza, Suzanne L Barker-Collo,
Lope H Barrero, Sanjay Basu, Bernhard T Baune, Kaleab Baye,
achieving 100 does not mean that additional improvement
Yibeltal Tebekaw Bayou, Shahrzad Bazargan-Hejazi, Neeraj Bedi,
is not possible. Subsequently, the HAQ Index range Ettore Beghi, Yannick Bjot, Aminu K Bello, Derrick A Bennett,
reported here is relative to national achievements to date, Isabela M Bensenor, Adugnaw Berhane, Eduardo Bernab,
and these thresholds may rise if or when improved Oscar Alberto Bernal, Addisu Shunu Beyene, Tariku Jibat Beyene,
Zulfiqar A Bhutta, Sibhatu Biadgilign, Boris Bikbov, Sait Mentes Birlik,
personal health-care access and quality occurs for given
Charles Birungi, Stan Biryukov, Donal Bisanzio,
causes. Ninth, the HAQ Index does not currently capture Habtamu Mellie Bizuayehu, Dipan Bose, Michael Brainin,
subnational inequalities in personal health-care access and

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Michael Brauer, Alexandra Brazinova, Nicholas J K Breitborde, Dharmesh Kumar Lal, Ratilal Lalloo, Tea Lallukka, Qing Lan,
Hermann Brenner, Zahid A Butt, Rosario Crdenas, Sinead M Langan, Van C Lansingh, Heidi J Larson, Anders Larsson,
Lucero Cahuana-Hurtado, Ismael Ricardo Campos-Nonato, Josip Car, Dennis Odai Laryea, Asma Abdul Latif,
Juan Jesus Carrero, Daniel Casey, Valeria Caso, Alicia Elena Beatriz Lawrynowicz, Janet L Leasher, James Leigh,
Carlos A Castaeda-Orjuela, Jacqueline Castillo Rivas, Mall Leinsalu, Cheru Tesema Leshargie, Janni Leung, Ricky Leung,
Ferrn Catal-Lpez, Pedro Cecilio, Kelly Cercy, Fiona J Charlson, Miriam Levi, Xiaofeng Liang, Stephen S Lim, Margaret Lind, Shai Linn,
Alan Z Chen, Adrienne Chew, Mirriam Chibalabala, Steven E Lipshultz, Patrick Liu, Yang Liu, Loon-Tzian Lo,
Chioma Ezinne Chibueze, Vesper Hichilombwe Chisumpa, Giancarlo Logroscino, Alan D Lopez, Scott A Lorch, Paulo A Lotufo,
Abdulaal A Chitheer, Rajiv Chowdhury, Hanne Christensen, Rafael Lozano, Raimundas Lunevicius, Ronan A Lyons,
Devasahayam Jesudas Christopher, Liliana G Ciobanu, Erlyn Rachelle King Macarayan, Mark T Mackay,
Massimo Cirillo, Megan S Coggeshall, Leslie Trumbull Cooper, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek,
Monica Cortinovis, John A Crump, Koustuv Dalal, Hadi Danawi, Mahdi Mahdavi, Azeem Majeed, Reza Malekzadeh,
Lalit Dandona, Rakhi Dandona, Paul I Dargan, Jose das Neves, Deborah Carvalho Malta, Lorenzo G Mantovani, Tsegahun Manyazewal,
Gail Davey, Dragos V Davitoiu, Kairat Davletov, Diego De Leo, Chabila C Mapoma, Wagner Marcenes, Guy B Marks, Neal Marquez,
Liana C Del Gobbo, Borja del Pozo-Cruz, Robert P Dellavalle, Jose Martinez-Raga, Melvin Barrientos Marzan, Joo Massano,
Kebede Deribe, Amare Deribew, Don C Des Jarlais, Subhojit Dey, Manu Raj Mathur, Pallab K Maulik, Mohsen Mazidi, Colm McAlinden,
Samath D Dharmaratne, Daniel Dicker, Eric L Ding, Klara Dokova, John J McGrath, Claire McNellan, Peter A Meaney, Alem Mehari,
E Ray Dorsey, Kerrie E Doyle, Manisha Dubey, Rebecca Ehrenkranz, Man Mohan Mehndiratta, Toni Meier, Alemayehu B Mekonnen,
Christian Lycke Ellingsen, Iqbal Elyazar, Ahmadali Enayati, Kidanu Gebremariam Meles, Ziad A Memish, Melkamu Merid
Sergey Petrovich Ermakov, Babak Eshrati, Alireza Esteghamati, Mengesha, Desalegn Tadese Mengiste, Mubarek Abera Mengistie,
Kara Estep, Thomas Frst, Imad D A Faghmous, Bereket Gebremichael Menota, George A Mensah, Seid Tiku Mereta,
Fanuel Belayneh Bekele Fanuel, Emerito Jose Aquino Faraon, Atte Meretoja, Tuomo J Meretoja, Haftay Berhane Mezgebe,
Talha A Farid, Carla Sofia e Sa Farinha, Andre Faro, Maryam S Farvid, Renata Micha, Anoushka Millear, Edward J Mills, Shawn Minnig,
Farshad Farzadfar, Valery L Feigin, Andrea B Feigl, Mojde Mirarefin, Erkin M Mirrakhimov, Charles N Mock,
Seyed-Mohammad Fereshtehnejad, Jefferson G Fernandes, Karzan Abdulmuhsin Mohammad, Shafiu Mohammed,
Joo C Fernandes, Tesfaye Regassa Feyissa, Florian Fischer, Sanjay K Mohanty, Ali H Mokdad, Glen Liddell D Mola,
Christina Fitzmaurice, Thomas D Fleming, Nataliya Foigt, Mariam Molokhia, Lorenzo Monasta, Marcella Montico,
Kyle J Foreman, Mohammad H Forouzanfar, Richard C Franklin, Maziar Moradi-Lakeh, Paula Moraga, Lidia Morawska, Rintaro Mori,
Joseph Frostad, Tsegaye Tewelde G/hiwot, Emmanuela Gakidou, Mark Moses, Ulrich O Mueller, Srinivas Murthy, Kamarul Imran Musa,
Ketevan Gambashidze, Amiran Gamkrelidze, Wayne Gao, Jean B Nachega, Chie Nagata, Gabriele Nagel, Mohsen Naghavi,
Alberto L Garcia-Basteiro, Teshome Gebre, Aliya Naheed, Luigi Naldi, Vinay Nangia, Bruno Ramos Nascimento,
Amanuel Tesfay Gebremedhin, Mengistu Welday Gebremichael, Ionut Negoi, Sudan Prasad Neupane, Charles R Newton, Marie Ng,
Alemseged Aregay Gebru, Amha Admasie Gelaye, Johanna M Geleijnse, Frida Namnyak Ngalesoni, Josephine Wanjiku Ngunjiri, Grant Nguyen,
Ricard Genova-Maleras, Katherine B Gibney, Ababi Zergaw Giref, Dina Nur Anggraini Ningrum, Sandra Nolte, Marika Nomura,
Melkamu Dedefo Gishu, Giorgia Giussani, William W Godwin, Ole F Norheim, Bo Norrving, Jean Jacques N Noubiap,
Audra Gold, Ellen M Goldberg, Philimon N Gona, Amador Goodridge, Carla Makhlouf Obermeyer, Felix Akpojene Ogbo, In-Hwan Oh,
Sameer Vali Gopalani, Atsushi Goto, Nicholas Graetz, Felix Greaves, Anselm Okoro, Olanrewaju Oladimeji, Andrew Toyin Olagunju,
Max Griswold, Peter Imre Guban, Harish Chander Gugnani, Pedro R Olivares, Helen E Olsen, Bolajoko Olubukunola Olusanya,
Prakash C Gupta, Rahul Gupta, Rajeev Gupta, Tanush Gupta, Jacob Olusegun Olusanya, John Nelson Opio, Eyal Oren, Alberto Ortiz,
Vipin Gupta, Tesfa Dejenie Habtewold, Nima Hafezi-Nejad, Richard H Osborne, Majdi Osman, Mayowa O Owolabi, Mahesh PA,
Demewoz Haile, Alemayehu Desalegne Hailu, Gessessew Bugssa Hailu, Amanda W Pain, Smita Pakhale, Elizabeth Palomares Castillo,
Alex Hakuzimana, Randah Ribhi Hamadeh, Mitiku Teshome Hambisa, Adrian Pana, Christina Papachristou, Mahboubeh Parsaeian, Tejas Patel,
Samer Hamidi, Mouhanad Hammami, Graeme J Hankey, Yuantao Hao, George C Patton, Deepak Paudel, Vinod K Paul, Neil Pearce,
Hilda L Harb, Habtamu Abera Hareri, Josep Maria Haro, David M Pereira, Rogelio Perez-Padilla, Fernando Perez-Ruiz,
Mohammad Sadegh Hassanvand, Rasmus Havmoeller, Roderick J Hay, Norberto Perico, Konrad Pesudovs, Max Petzold,
Simon I Hay, Delia Hendrie, Ileana Beatriz Heredia-Pi, Hans W Hoek, Michael Robert Phillips, David M Pigott, Julian David Pillay,
Masako Horino, Nobuyuki Horita, H Dean Hosgood, Aung Soe Htet, Christine Pinho, Suzanne Polinder, Constance D Pond, V Prakash,
Guoqing Hu, Hsiang Huang, John J Huang, Bethany M Huntley, Manorama Purwar, Mostafa Qorbani, D Alex Quistberg, Amir Radfar,
Chantal Huynh, Kim Moesgaard Iburg, Bogdan Vasile Ileanu, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar,
Kaire Innos, Asnake Ararsa Irenso, Nader Jahanmehr, Mahfuzar Rahman, Mohammad Hifz Ur Rahman, Rajesh Kumar Rai,
Mihajlo B Jakovljevic, Peter James, Spencer Lewis James, Usha Ram, Saleem M Rana, Zane Rankin, Paturi Vishnupriya Rao,
Mehdi Javanbakht, Sudha P Jayaraman, Achala Upendra Jayatilleke, Puja C Rao, Salman Rawaf, Maria Albertina Santiago Rego,
Panniyammakal Jeemon, Vivekanand Jha, Denny John, Marissa Reitsma, Giuseppe Remuzzi, Andre M N N Renzaho,
Catherine Johnson, Sarah C Johnson, Jost B Jonas, Knud Juel, Serge Resnikoff, Satar Rezaei, Mohammad Sadegh Rezai,
Zubair Kabir, Yogeshwar Kalkonde, Ritul Kamal, Haidong Kan, Antonio L Ribeiro, Hirbo Shore Roba, Mohammad Bagher Rokni,
Andre Karch, Corine Kakizi Karema, Seyed M Karimi, Amir Kasaeian, Luca Ronfani, Gholamreza Roshandel, Gregory A Roth,
Nicholas J Kassebaum, Anshul Kastor, Srinivasa Vittal Katikireddi, Dietrich Rothenbacher, Nawal K Roy, Perminder S Sachdev,
Konstantin Kazanjan, Peter Njenga Keiyoro, Laura Kemmer, Ben Benasco Sackey, Mohammad Yahya Saeedi, Saeid Safiri,
Andrew Haddon Kemp, Andre Pascal Kengne, Amene Abebe Kerbo, Rajesh Sagar, Mohammad Ali Sahraian, Muhammad Muhammad Saleh,
Maia Kereselidze, Chandrasekharan Nair Kesavachandran, Joshua A Salomon, Abdallah M Samy, Juan Ramon Sanabria,
Yousef Saleh Khader, Ibrahim Khalil, Abdur Rahman Khan, Maria Dolores Sanchez-Nio, Logan Sandar, Itamar S Santos,
Ejaz Ahmad Khan, Gulfaraz Khan, Young-Ho Khang, Joo Vasco Santos, Milena M Santric Milicevic,
Abdullah Tawfih Abdullah Khoja, Irma Khonelidze, Rodrigo Sarmiento-Suarez, Benn Sartorius, Maheswar Satpathy,
Jagdish Khubchandani, Getiye Dejenu Kibret, Daniel Kim, Pauline Kim, Miloje Savic, Monika Sawhney, Mete I Saylan, Ben Schttker,
Yun Jin Kim, Ruth W Kimokoti, Yohannes Kinfu, Niranjan Kissoon, Aletta E Schutte, David C Schwebel, Soraya Seedat,
Miia Kivipelto, Yoshihiro Kokubo, Anneli Kolk, Dhaval Kolte, Abdulbasit Musa Seid, Canaan Negash Seifu, Sadaf G Sepanlou,
Jacek A Kopec, Soewarta Kosen, Parvaiz A Koul, Ai Koyanagi, Berrin Serdar, Edson E Servan-Mori, Tesfaye Setegn,
Michael Kravchenko, Sanjay Krishnaswami, Kristopher J Krohn, Katya Anne Shackelford, Amira Shaheen, Saeid Shahraz,
Barthelemy Kuate Defo, Burcu Kucuk Bicer, Ernst J Kuipers, Masood Ali Shaikh, Marina Shakh-Nazarova, Mansour Shamsipour,
Veena S Kulkarni, G Anil Kumar, Fekede Asefa Kumsa, Michael Kutz, Sheikh Mohammed Shariful Islam, Jayendra Sharma, Rajesh Sharma,
Hmwe H Kyu, Anton Carl Jonas Lager, Aparna Lal, Jun She, Sara Sheikhbahaei, Jiabin Shen, Peilin Shi, Mika Shigematsu,

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Min-Jeong Shin, Rahman Shiri, Haitham Shoman, Mark G Shrime, (H J Larson PhD), London School of Hygiene & Tropical Medicine,
Ephrem Lejore Sibamo Sibamo, Inga Dora Sigfusdottir, London, UK (Prof M McKee DSc, I M O Adetifa PhD,
Diego Augusto Santos Silva, Dayane Gabriele Alves Silveira, I D A Faghmous MPH, S M Langan PhD, Prof N Pearce PhD); School of
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Prashant Kumar Singh, Virendra Singh, Abiy Hiruye Sinke, Prof H A Whiteford PhD), School of Dentistry (Prof R Lalloo PhD),
Aklilu Endalamaw Sinshaw, Vegard Skirbekk, Karen Sliwa, University of Queensland, Brisbane, QLD, Australia
Alison Smith, Eugene Sobngwi, Samir Soneji, Joan B Soriano, (Prof J J McGrath MD); College of Health Sciences, Department of
Tatiane Cristina Moraes Sousa, Luciano A Sposato, Epidemiology, ICT and e-Learning Coordinator (M B Ahmed MPH),
Chandrashekhar T Sreeramareddy, Vasiliki Stathopoulou, Nicholas Steel, Jimma University, Jimma, Ethiopia (K H Abate MS, T T Ghiwot MPH,
Caitlyn Steiner, Sabine Steinke, Mark Andrew Stokes, Saverio Stranges, A T Gebremedhin MPH, M A Mengistie MS, S T Mereta PhD,
Mark Strong, Konstantinos Stroumpoulis, Lela Sturua, T Wakayo MS, A Workicho MPH); La Sapienza, University of Rome,
Muawiyyah Babale Sufiyan, Rizwan Abdulkader Suliankatchi, Rome, Italy (C Abbafati PhD); Virginia Tech, Blacksburg, VA, USA
Jiandong Sun, Patrick Sur, Soumya Swaminathan, Bryan L Sykes, (Prof K M Abbas PhD); Department of Neurology, Cairo University,
Rafael Tabars-Seisdedos, Karen M Tabb, Getachew Redae Taffere, Cairo, Egypt (Prof F Abd-Allah MD); New York University Abu Dhabi,
Roberto Tchio Talongwa, Musharaf Tarajia, Mohammad Tavakkoli, Abu Dhabi, United Arab Emirates (A M Abdulle PhD); Uro-Oncology
Nuno Taveira, Stephanie Teeple, Teketo Kassaw Tegegne, Research Center (E Amini MD), Endocrinology and Metabolism
Arash Tehrani-Banihashemi, Tesfalidet Tekelab, Dejen Yemane Tekle, Population Sciences Institute Research Institute (E Amini MD,
Girma Temam Shifa, Abdullah Sulieman Terkawi, Prof A Esteghamati MD, S Sheikhbahaei MD, N Hafezi-Nejad MD,
Azeb Gebresilassie Tesema, JS Thakur, Alan J Thomson, Taavi Tillmann, A Kasaeian PhD), Non-Communicable Diseases Research Center
Tenaw Yimer Tiruye, Ruoyan Tobe-Gai, Marcello Tonelli, (F Farzadfar MD, M Parsaeian PhD), Department of Epidemiology and
Roman Topor-Madry, Miguel Tortajada, Christopher Troeger, Biostatistics, School of Public Health (M Parsaeian PhD), Center for Air
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Narayanaswamy Venketasubramanian, Francesco S Violante, S G Sepanlou PhD), Sina Trauma and Surgery Research Center
Sergey K Vladimirov, Vasiliy Victorovich Vlassov, Stein Emil Vollset, (Prof V Rahimi-Movaghar MD), MS Research Center, Neuroscience
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Judd L Walson, Haidong Wang, Yuan-Pang Wang, David A Watkins, Tehran, Iran (A A Abdurahman PhD, Prof M B Rokni PhD); School of
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Andrea Werdecker, Joshua Wesana, Ronny Westerman, G R Taffere PhD), College of Health Sciences (D T Mengiste MS),
Harvey A Whiteford, James D Wilkinson, Charles Shey Wiysonge, Department of Medical Microbiology and Immunology (K Adane MS),
Belete Getahun Woldeyes, Charles D A Wolfe, Sungho Won, Mekelle University, Mekelle, Ethiopia (T M Atey MS, M W Gebremichael
Abdulhalik Workicho, Shimelash Bitew Workie, Mamo Wubshet, MS, A A Gebru MPH, G B Hailu MSc, H B Mezgebe MS, D Y Tekle MS,
Denis Xavier, Gelin Xu, Ajit Kumar Yadav, Mohsen Yaghoubi, A G Tesema MPH, Z M Zenebe MS); Food Security and Institute for
Bereket Yakob, Lijing L Yan, Yuichiro Yano, Mehdi Yaseri, Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart,
Hassen Hamid Yimam, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Germany (S F Abera MSc); NMSM Governement College Kalpetta,
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Christopher J L Murray. KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
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of Epidemiology and Biostatistics, Institute of Public Health R G Weintraub MBBS, Prof G C Patton MD), Department of Paediatrics
(K A Alene MPH), University of Gondar, Gondar, Ethiopia (P Azzopardi MEpi), Melbourne School of Population and Global Health
(A B Mekonnen MS); Nuffield Department of Medicine (Prof A D Lopez PhD), Department of Medicine (A Meretoja PhD),
(D Bisanzio PhD, A Deribew PhD), Oxford Big Data Institute, Li Ka University of Melbourne, Melbourne, VIC, Australia (K Alam PhD);
Shing Centre for Health Information and Discovery (Prof S I Hay DSc), Wardliparingga Aboriginal Research Unit, South Australian Health and
University of Oxford, Oxford, UK (R Ali FRCP, D A Bennett PhD, Medical Research Institute, Adelaide, SA, Australia (P Azzopardi MEpi);
Prof V Jha DM, K Rahimi DM); University of London, London, UK Centre for International Health, Burnet Institute, Melbourne, VIC,
(S D Ali BA); SIR management consultants, Oxford, UK (S D Ali BA); Australia (P Azzopardi MEpi); Faculty of Medicine and Health Sciences,
Institute and Faculty of Actuaries, Oxford, UK (S D Ali BA); Aden University, Aden, Yemen (Prof H O Ba Saleem PhD); Department
Gastrointestinal Cancer Research Center (R Alizadeh-Navaei PhD), of Global Health and Population (Prof T Brnighausen MD,
Mazandaran University of Medical Sciences, Sari, Iran (M S Rezai MD); A B Feigl ScD, J A Salomon PhD), Department of Epidemiology
Luxembourg Institute of Health (LIH), Strassen, Luxembourg (P James ScD), Department of Nutrition (M S Farvid PhD), Harvard T.H.
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(Prof J rnlv PhD), Department of Clinical Science, Intervention and Health, Heidelberg University, Heidelberg, Germany
Technology (Prof J J Carrero PhD), Department of Neurobiology, Care (Prof T Brnighausen MD, S Mohammed PhD); School of Health
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Center (Prof M Kivipelto PhD), Department of Medical Epidemiology (U Bacha PhD); Public Health Agency of Canada, Toronto, ON, Canada
and Biostatistics (E Weiderpass PhD), Karolinska Institutet, Stockholm, (A Badawi PhD); Farr Institute of Health Informatics Research
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Iran (R Assadi PhD); Hawassa University, Hawassa, Ethiopia Research (Prof C D Wolfe MD), Kings College London, London, UK
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Taipei Medical University, Taipei, Taiwan (D N A Ningrum MPH); Mizan Sciences (A S Beyene MPH, M T Hambisa MPH,
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MPH); PMA 2020, Mizan Teferi, Ethiopia (N T Atnafu MS); Clinical University, Dire Dawa, Ethiopia (M D Gishu MS, A A Irenso MPH,
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(S R Atre PhD); National Institute of Public Health, Cuernavaca, Mexico (J M Geleijnse PhD), Wageningen University, Wageningen, Netherlands
(L Avila-Burgos PhD); Institut de Recherche Clinique du Bnin (IRCB), (T J Beyene MS); Centre of Excellence in Women and Child Health, Aga
Cotonou, Benin (E F G A Avokpaho MPH); Laboratoire dEtudes et de Khan University, Karachi, Pakistan (Z A Bhutta PhD); Independent
Recherche-Action en Sant (LERAS Afrique), Parakou, Benin Public Health Consultants, Addis Ababa, Ethiopia (S Biadgilign MPH);
(E F G A Avokpaho MPH); The Judith Lumley Centre for Mother, Infant IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo,
and Family Health Research, La Trobe University, Melbourne, VIC, Italy (B Bikbov MD, M Cortinovis Biotech D, Prof G Remuzzi MD);
Australia (B P Ayala Quintanilla PhD); Peruvian National Institute of GBS-CIDP International Foundation, Menemen, Turkey (S M Birlik BS);
Health, Lima, Peru (B P Ayala Quintanilla PhD); Sanjay Gandhi Debre Markos University, Debre Markos town, Ethiopia
Postgraduate Institute of Medical Sciences, Lucknow, India (H M Bizuayehu MPH); World Bank, Washington DC, DC, USA
(A Awasthi PhD); Ministry of Health, Addis Ababa, Ethiopia (D Bose PhD); Danube-University Krems, Krems, Austria
(N N Ayele MPH); Department of Paediatrics (P Azzopardi MEpi), (Prof M Brainin PhD); University of British Columbia, Vancouver, BC,
Murdoch Childrens Research Institute (K Alam PhD, P Azzopardi MEpi, Canada (Prof M Brauer ScD, Prof N Kissoon MD, J A Kopec PhD,

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S Murthy MD); Faculty of Health Sciences and Social Work, Department Canberra, ACT, Australia (Prof K E Doyle PhD); International Institute
of Public Health, Trnava University, Trnava, Slovakia (A Brazinova PhD); for Population Sciences, Mumbai, India (M Dubey MPhil,
International Neurotrauma Research Organization, Vienna, Austria A Kastor MPhil, S K Mohanty MD, M H U Rahman MPhil, Prof U Ram
(A Brazinova PhD); College of Medicine (J Shen PhD), Ohio State PhD, A Singh PhD, A K Yadav MPhil); Center for Disease Burden
University, Columbus, OH, USA (Prof N J K Breitborde PhD); Division (Prof S E Vollset), Norwegian Institute of Public Health, Oslo, Norway
of Clinical Epidemiology and Ageing Research (B Schttker MPH), (C L Ellingsen MD, M Savic PhD, Prof V Skirbekk PhD); Eijkman-
German Cancer Research Center, Heidelberg, Germany Oxford Clinical Research Unit, Jakarta, Indonesia (I Elyazar PhD);
(Prof H Brenner MD); Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan School of Public Health and Health Sciences Research Center, Sari, Iran
(Z A Butt PhD); Metropolitan Autonomous University, Mexico City, (Prof A Enayati PhD); The Institute of Social and Economic Studies of
Mexico (R Crdenas ScD); National Institute of Public Health, Population, Russian Academy of Sciences, Moscow, Russia
Cuernavaca, Mexico (L Cahuana-Hurtado PhD, I R Campos-Nonato PhD, (Prof S P Ermakov DSc); Federal Research Institute for Health
I B Heredia-Pi PhD, R Lozano MD, Prof E E Servan-Mori MSc); Nanyang Organization and Informatics, Ministry of Health of the Russian
Technological University, Singapore, Singapore (J Car PhD); Stroke Unit, Federation, Moscow, Russia (Prof S P Ermakov DSc); Ministry of Health
University of Perugia, Perugia, Italy (V Caso MD); Colombian National and Medical Education, Tehran, Iran (B Eshrati PhD); Arak University of
Health Observatory, Instituto Nacional de Salud, Bogota, Colombia Medical Sciences, Arak, Iran (B Eshrati PhD); Department of Infectious
(C A Castaeda-Orjuela MSc); Epidemiology and Public Health Disease Epidemiology (T Frst PhD), Imperial College London, London,
Evaluation Group, Public Health Department, Universidad Nacional de UK (K J Foreman PhD, F Greaves PhD, Prof A Majeed MD,
Colombia, Bogota, Colombia (C A Castaeda-Orjuela MSc); Caja Prof S Rawaf MD); Department of Epidemiology and Public Health
Costarricense de Seguro Social, San Jose, Costa Rica (T Frst PhD), Swiss Tropical and Public Health Institute, Basel,
(Prof J Castillo Rivas MPH); Universidad de Costa Rica, San Pedro, Switzerland (C K Karema MSc); University of Basel, Basel, Switzerland
Montes de Oca, Costa Rica (Prof J Castillo Rivas MPH); Department of (T Frst PhD); Wolaita Sodo University, Wolaita Sodo, Ethiopia
Medicine, University of Valencia/INCLIVA Health Research Institute (F B B Fanuel MPH, A A Kerbo MPH, C N Seifu MS,
and CIBERSAM, Valencia, Spain (F Catal-Lpez PhD); Clinical E L S Sibamo MPH); Department of Health, Manila, Philippines
Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, (E J A Faraon MD); University of Louisville, Louisville, KY, USA
ON, Canada (F Catal-Lpez PhD); Independent Collaborator, Porto, (T A Farid MD, A R Khan MD); DGS Directorate General of Health,
Portugal (P Cecilio MS); Queensland Centre for Mental Health Research, Lisboa, Portugal (C S E S Farinha MSc); Universidade Aberta, Lisboa,
Brisbane, QLD, Australia (F J Charlson PhD, Prof H A Whiteford PhD); Portugal (C S E S Farinha MSc); Federal University of Sergipe, Aracaju,
Crowd Watch Africa, Lusaka, Zambia (M Chibalabala BS); National Brazil (Prof A Faro PhD); Harvard/MGH Center on Genomics,
Center for Child Health and Development, Setagaya ku, Japan Vulnerable Populations, and Health Disparities, Mongan Institute for
(C E Chibueze PhD); University of Zambia, Lusaka, Zambia Health Policy, Massachusetts General Hospital, Boston, MA, USA
(V H Chisumpa MPhil, C C Mapoma PhD); University of (M S Farvid PhD); National Institute for Stroke and Applied
Witwatersrand, Johannesburg, South Africa (V H Chisumpa MPhil); Neurosciences, Auckland University of Technology, Auckland, New
Ministry of Health, Baghdad, Iraq (A A Chitheer FETP); Department of Zealand (V L Feigin PhD); Institute of Education and Sciences, German
Public Health and Primary Care, University of Cambridge, Cambridge, Hospital Oswaldo Cruz, Sao Paulo, Brazil (Prof J G Fernandes PhD);
UK (R Chowdhury PhD); Bispebjerg University Hospital, Copenhagen, CBQF - Center for Biotechnology and Fine Chemistry - Associate
Denmark (Prof H Christensen DMSCi); Christian Medical College, Laboratory, Faculty of Biotechnology, Catholic University of Portugal,
Vellore, India (Prof D J Christopher MD, Prof S Varughese DM); School Porto, Portugal (J C Fernandes PhD); Wollega University, Nekemte,
of Medicine (A T Amare MPH, Prof B T Baune PhD); University of Ethiopia (T R Feyissa MPH, T Tekelab MS); School of Public Health,
Salerno, Baronissi, Italy (Prof M Cirillo MD); Mayo Clinic, Jacksonville, Bielefeld University, Bielefeld, Germany (F Fischer PhD);
FL, USA (L T Cooper MD); Centre for International Health, Dunedin Fred Hutchinson Cancer Research Center, Seattle, WA, USA
School of Medicine, University of Otago, Dunedin, New Zealand (C Fitzmaurice MD); Institute of Gerontology, Academy of Medical
(Prof J A Crump MD); Centre for Injury Prevention and Safety Science, Kyiv, Ukraine (N Foigt PhD); Seattle Genetics, Seattle, WA, USA
Promotion, School of Health and Medical Sciences, Orebro University, (M H Forouzanfar PhD); James Cook University, Townsville, QLD,
Orebro, Sweden (Prof K Dalal PhD); Walden University, Minneapolis, Australia (R C Franklin PhD); National Center for Disease Control and
MN, USA (H Danawi PhD); Centre for Control of Chronic Conditions Public Health, Tbilisi, Georgia (K Gambashidze MS, K Kazanjan MS,
(P Jeemon PhD), Public Health Foundation of India, New Delhi, India M Kereselidze PhD, I Khonelidze MPA, M Shakh-Nazarova MS,
(Prof L Dandona MD, R Dandona PhD); Guys and St. Thomas NHS L Sturua PhD); National Center for Disease Control & Public Health,
Foundation Trust, London, UK (P I Dargan FRCP); i3S - Instituto de Tbilisi, Georgia (A Gamkrelidze PhD); Health Policy (Prof C Wen PhD),
Investigao e Inovao em Sade (J das Neves PhD), INEB - Instituto National Health Research Institute, Taipei, Taiwan (W Gao PhD);
de Engenharia Biomdica (J das Neves PhD), Faculty of Medicine, Manhia Health Research Center, Manhia, Mozambique
University of Porto, Porto, Portugal (J Massano MD, J V Santos BHlthSc); (A L Garcia-Basteiro MSc); Barcelona Institute for Global Health,
Wellcome Trust Brighton & Sussex Centre for Global Health Research, Barcelona, Spain (A L Garcia-Basteiro MSc); The Task Force for Global
Brighton, UK (Prof G Davey MD); University of Medicine and Pharmacy Health, Decatur, GA, USA (T Gebre PhD); Ludwig Maximilians
Bucharest, Bucharest, Romania (D V Davitoiu PhD); Republican University, Munich, Germany (A T Gebremedhin MPH); Kilte Awlaelo
Institute of Cardiology and Internal Diseases, Almaty, Kazakhstan Health and Demographic Surveillance System, Mekelle, Ethiopia
(K Davletov PhD); School of Public Health, Kazakh National Medical (A A Gebru MPH, G B Hailu MSc); Wolaita Sodo University, Sodo,
University, Almaty, Kazakhstan (K Davletov PhD); Griffith University, Ethiopia (A A Gelaye MPH); Directorate General for Public Health,
Brisbane, QLD, Australia (Prof D De Leo DSc); University of Colorado Regional Health Council, Madrid, Spain (R Genova-Maleras MS);
School of Medicine and the Colorado School of Public Health, Aurora, National School of Public Health, Madrid, Spain (R Genova-Maleras MS);
CO, USA (R P Dellavalle MD); Brighton and Sussex Medical School, The Peter Doherty Institute for Infection and Immunity, University of
Brighton, UK (K Deribe MPH); Mount Sinai Beth Israel, New York, NY, Melbourne & The Royal Melbourne Hospital, Melbourne, VIC, Australia
USA (Prof D C Des Jarlais PhD); Icahn School of Medicine at Mount (K B Gibney FRACP); Kersa Health and Demographic Surveillance
Sinai, New York City, NY, USA (Prof D C Des Jarlais PhD); Indian System, Harar, Ethiopia (M D Gishu MS); University of Massachusetts
Institute of Public Health-Delhi, Public Health Foundation of India, Boston, Boston, MA, USA (Prof P N Gona PhD); Instituto de
Gurgaon, India (S Dey PhD, Prof S Zodpey PhD); Department of Investigaciones Cientificas y Servicios de Alta Tecnologia - INDICASAT-
Community Medicine, Faculty of Medicine, University of Peradeniya, AIP, Cuidad del Saber, Panama (A Goodridge PhD); Department of
Peradeniya, Sri Lanka (S D Dharmaratne MD); Department of Social Health and Social Affairs, Government of the Federated States of
Medicine, Faculty of Public Health, Medical University - Varna, Varna, Micronesia, Palikir, Federated States of Micronesia (S V Gopalani MPH);
Bulgaria (K Dokova PhD); University of Rochester Medical Center, Division of Epidemiology, Center for Public Health Sciences, National
Rochester, NY, USA (E R Dorsey MD); RMIT University, Bundoora, VIC, Cancer Center, Tokyo, Japan (A Goto PhD); Public Health England,
Australia (Prof K E Doyle PhD); Australian National University, London, UK (F Greaves PhD, Prof N Steel PhD); Stockholm County

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Community Medicine, Solna, Sweden (P I Guban MSc); Departments of Lucknow, India (R Kamal MSc, C N Kesavachandran PhD); Department
Microbiology and Epidemiology & Biostatistics, Saint James School of of Pulmonary Medicine, Zhongshan Hospital (J She MD), Fudan
Medicine, The Quarter, Anguilla (Prof H C Gugnani PhD); Healis - University, Shanghai, China (H Kan MD); Epidemiological and
Sekhsaria Institute for Public Health, Navi Mumbai, India (P C Gupta DSc); Statistical Methods Research Group, Helmholtz Centre for Infection
West Virginia Bureau for Public Health, Charleston, WV, USA Research, Braunschweig, Germany (A Karch MD); Hannover-
(R Gupta MD); Eternal Heart Care Centre and Research Institute, Jaipur, Braunschweig Site, German Center for Infection Research,
India (R Gupta PhD); Montefiore Medical Center, Bronx, NY, USA Braunschweig, Germany (A Karch MD); Quality and Equity Health Care,
(T Gupta MD); Department of Anthropology, University of Delhi, Delhi, Kigali, Rwanda (C K Karema MSc); University of Washington Tacoma,
India (V Gupta PhD); Department of Psychiatry, University Medical Tacoma, WA, USA (S M Karimi PhD); Department of Anesthesiology &
Center Groningen (Prof H W Hoek MD), University of Groningen, Pain Medicine, Seattle Childrens Hospital, Seattle, WA, USA
Groningen, Netherlands (T D Habtewold MS, A K Tura MPH, (N J Kassebaum MD); University of Glasgow, Glasgow, UK
J F M van Boven PhD); Department of Global Public Health and Primary (S V Katikireddi PhD); Institute of Tropical and Infectious Diseases,
Care (Prof S E Vollset), University of Bergen, Bergen, Norway (A D Nairobi, Kenya (P N Keiyoro PhD); School of Continuing and Distance
Hailu MPH, Prof O F Norheim PhD); Faculty of Health Sciences, Hatter Education, Nairobi, Kenya (P N Keiyoro PhD); Farr Institute
Institute for Cardiovascular Research in Africa (Prof K Sliwa PhD), (Prof R A Lyons MD), Swansea University, Swansea, UK
University of Cape Town, Cape Town, South Africa (A Hakuzimana (Prof A H Kemp PhD); Woolcock Institute of Medical Research
MPH, A P Kengne PhD, J J N Noubiap MD, D A Watkins MD); Euclid (G B Marks PhD), University of Sydney, Camperdown, NSW, Australia
University, Banjul, The Gambia (A Hakuzimana MPH); Arabian Gulf (Prof A H Kemp PhD); South African Medical Research Council, Cape
University, Manama, Bahrain (Prof R R Hamadeh DPhil); Hamdan Bin Town, South Africa (A P Kengne PhD); Jordan University of Science and
Mohammed Smart University, Dubai, United Arab Emirates Technology, Irbid, Jordan (Prof Y S Khader ScD); Health Services
(S Hamidi DrPH); Wayne County Department of Health and Human Academy, Islamabad, Pakistan (E A Khan MD); Department of
Services, Detroit, MI, USA (M Hammami MD); School of Medicine and Microbiology and Immunology, College of Medicine & Health Sciences,
Pharmacology, University of Western Australia, Perth, WA, Australia United Arab Emirates University, Al Ain, United Arab Emirates
(Prof G J Hankey MD); Harry Perkins Institute of Medical Research, (G Khan PhD); College of Medicine (Prof Y Khang MD), Graduate
Nedlands, WA, Australia (Prof G J Hankey MD); Western Australian School of Public Health (Prof S Won PhD), Seoul National University,
Neuroscience Research Institute, Nedlands, WA, Australia Seoul, South Korea; Mohammed Ibn Saudi University, Riyadh, Saudi
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Guangzhou, China (Prof Y Hao PhD); College of Health and Medical (J Khubchandani PhD); Department of Health Sciences, Northeastern
Science (A S Beyene MPH), Haramaya University, Harar, Ethiopia University, Boston, MA, USA (Prof D Kim DrPH); Southern University
(T A Hassen MS, F A Kumsa MPH, A A Irenso MPH); International College, Skudai, Malaysia (Y J Kim PhD); Simmons College, Boston,
Foundation for Dermatology, London, UK (Prof R J Hay DM); Centre for MA, USA (R W Kimokoti MD); Centre for Research & Action in Public
Population Health Research, Curtin University, Bentley, WA, Australia Health, Faculty of Health, University of Canberra, Canberra, ACT,
(D Hendrie MA); Department of Epidemiology, Mailman School of Australia (Y Kinfu PhD); Department of Preventive Cardiology, National
Public Health (Prof H W Hoek MD), Columbia University, New York, Cerebral and Cardiovascular Center, Suita, Japan (Y Kokubo PhD);
NY, USA (Prof V Skirbekk PhD); Department of Health and Human Department of Pediatrics, Faculty of Medicine, University of Tartu, Tartu,
Services, Nevada Division of Public and Behavioral Health, Carson City, Estonia (A Kolk PhD); Division of Cardiology, Brown University,
NV, USA (M Horino MPH); Department of Pulmonology, Yokohama Providence, RI, USA (D Kolte MD); Center for Community
City University Graduate School of Medicine, Yokohama, Japan Empowerment, Health Policy and Humanities, NIHRD, Jakarta,
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Health, Nay Pyi Taw, Myanmar (A S Htet MPhil); University of Oslo, Parc Sanitari Sant Joan de Deu (CIBERSAM), Barcelona, Spain
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Epidemiology and Health Statistics, School of Public Health, Central Moscow, Russia (M Kravchenko PhD); Oregon Health and Science
South University, Changsha, China (G Hu PhD); Cambridge Health University, Portland, OR, USA (S Krishnaswami MD); Department of
Alliance, Cambridge, MA, USA (H Huang MD); Yale University, Demography and Public Health Research Institute
New Haven, CT, USA (J J Huang MD, E R K Macarayan PhD); Aarhus (Prof B Kuate Defo PhD), Department of Social and Preventive
University, Aarhus, Denmark (K M Iburg PhD); Bucharest University of Medicine, School of Public Health (Prof B Kuate Defo PhD), University
Economic Studies, Bucharest, Romania (B V Ileanu PhD, A Pana MPH); of Montreal, Montreal, QC, Canada; Institute of Public Health,
National Institute for Health Development, Tallinn, Estonia Hacettepe University, Ankara, Turkey (B Kucuk Bicer PhD); Department
(K Innos PhD, M Leinsalu PhD); School of Public Health of Public Health (S Polinder PhD), Erasmus MC, University Medical
(N Jahanmehr PhD), Ophthalmic Research Center (M Yaseri PhD), Center Rotterdam, Rotterdam, Netherlands (Prof E J Kuipers PhD);
Shahid Beheshti University of Medical Sciences, Tehran, Iran; Faculty of Arkansas State University, State University, AR, USA
Medical Sciences, University of Kragujevac, Kragujevac, Serbia (V S Kulkarni PhD); Centre for Epidemiology and Community Medicine,
(Prof M B Jakovljevic PhD); Denver Health/University of Colorado, Stockholm County Council, Solna, Sweden (A C J Lager PhD); National
Denver, CO, USA (S L James MD); University of Aberdeen, Aberdeen, Centre for Epidemiology and Population Health, The Australian National
UK (M Javanbakht PhD); Department of Surgery, Virginia University, Canberra, ACT, Australia (A Lal PhD); Centre for Control of
Commonwealth University, Richmond, VA, USA (S P Jayaraman MD); Chronic Conditions (P Jeemon PhD), Public Health Foundation of India,
Postgraduate Institute of Medicine, Colombo 07, Sri Lanka Gurgaon, India ( D K Lal MD, M R Mathur PhD); Finnish Institute of
(A U Jayatilleke PhD); Institute of Violence and Injury Prevention, Occupational Health, Work Organizations, Work Disability Program,
Colombo 08, Sri Lanka (A U Jayatilleke PhD); Centre for Chronic Department of Public Health, Faculty of Medicine (T Lallukka PhD,
Disease Control, New Delhi, India (P Jeemon PhD); Centre for Control R Shiri PhD), University of Helsinki, Helsinki, Finland (T J Meretoja PhD);
of Chronic Conditions (P Jeemon PhD), Public Health Foundation of National Cancer Institute, Rockville, MD, USA (Q Lan PhD); Help Me
India, Guragon, India (G A Kumar PhD); George Institute for Global See, Inc, New York, NY, USA (V C Lansingh PhD); Instituo Mexicano de
Health, New Delhi, India (Prof V Jha DM); International Center for Oftalmologia, Queretaro, Mexico (V C Lansingh PhD); Department of
Research on Women, New Delhi, India (D John MPH); Department of Medical Sciences, Uppsala University, Uppsala, Sweden
Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University (Prof A Larsson PhD); Department of Zoology, Lahore College for
Heidelberg, Mannheim, Germany (Prof J B Jonas MD); The National Women University, Lahore, Pakistan (A A Latif PhD); Instituto Nacional
Institute of Public Health, Copenhagen, Denmark (Prof K Juel PhD); de Epidemiologa Dr. Juan H. Jara, Mar del Plata, Argentina
University College Cork, Cork, Ireland (Z Kabir PhD); Society for (A E B Lawrynowicz MPH); College of Optometry, Nova Southeastern
Education, Action and Research in Community Health, Gadchiroli, India University, Fort Lauderdale, FL, USA (J L Leasher OD); Woolcock

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Institute of Medical Research (G B Marks PhD), University of Sydney, Community Medicine, Gastrointestinal and Liver Disease Research
Sydney, NSW, Australia (J Leigh PhD, A B Mekonnen MS); Stockholm Center (GILDRC), Preventative Medicine and Public Health Research
Centre for Health and Social Change, Sdertrn University, Stockholm, Center (M Moradi-Lakeh MD), Preventive Medicine and Public Health
Sweden (M Leinsalu PhD); State University of New York, Albany, Research Center (A Tehrani-Banihashemi PhD), Iran University of
Rensselaer, NY, USA (R Leung PhD); Tuscany Regional Centre for Medical Sciences, Tehran, Iran; International Laboratory for Air Quality
Occupational Injuries and Diseases, Florence, Italy (M Levi PhD); and Health (L Morawska PhD), School of Public Health and Social Work
Chinese Center for Disease Control and Prevention, Beijing, China (J Sun PhD), Queensland University of Technology, Brisbane, QLD,
(Prof X Liang MD); University of Haifa, Haifa, Israel (Prof S Linn MD); Australia (P Moraga PhD); National Center for Child Health and
School of Medicine, Wayne State University, Detroit, MI, USA Development, Setagaya, Japan (R Mori PhD); Competence Center
(Prof S E Lipshultz MD, Prof J D Wilkinson MD); Childrens Hospital of Mortality-Follow-Up of the German National Cohort (A Werdecker PhD),
Michigan, Detroit, MI, USA (Prof S E Lipshultz MD, Federal Institute for Population Research, Wiesbaden, Germany
Prof J D Wilkinson MD); Emory University, Atlanta, GA, USA (Prof U O Mueller PhD, R Westerman PhD); School of Medical Sciences,
(Prof Y Liu PhD, Prof M R Phillips MD); UnionHealth Associates, LLC, University of Science Malaysia, Kubang Kerian, Malaysia (K I Musa MD);
St. Louis, MO, USA (L Lo MD); Alton Mental Health Center, Alton, IL, Graduate School of Public Health, University of Pittsburgh, Pittsburgh,
USA (L Lo MD); University of Bari, Bari, Italy (Prof G Logroscino PhD); PA, USA (Prof J B Nachega PhD); Stellenbosch University, Cape Town,
Childrens Hospital of Philadelphia, University of Pennsylvania School South Africa (Prof J B Nachega PhD, Prof S Seedat PhD,
of Medicine, Philadelphia, PA, USA (S A Lorch MD); Aintree University Prof C S Wiysonge PhD); Johns Hopkins Bloomberg School of Public
Hospital National Health Service Foundation Trust, Liverpool, UK Health, Baltimore, MD, USA (Prof J B Nachega PhD); National Center
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Liverpool, UK (Prof R Lunevicius PhD); Royal Childrens Hospital, Institute of Epidemiology and Medical Biometry
Melbourne, VIC, Australia (M T Mackay MBBS, R G Weintraub MBBS); (Prof D Rothenbacher MD), Ulm University, Ulm, Germany
Mansoura Faculty of Medicine, Mansoura, Egypt (Prof G Nagel PhD); Azienda Ospedaliera Papa Giovanni XXIII,
(H Magdy Abd El Razek MBBCH); Aswan University Hospital, Aswan Bergamo, Italy (Prof L Naldi MD); Suraj Eye Institute, Nagpur, India
Faculty of Medicine, Aswan, Egypt (M Magdy Abd El Razek MBBCh); (V Nangia MD); Hospital das Clinicas da Universidade Federal de Minas
Institute of Health Policy and Management, Erasmus University Gerais, Belo Horizonte, Brazil (Prof B R Nascimento PhD,
Rotterdam, Rotterdam, Netherlands (M Mahdavi PhD); Social Security Prof A L Ribeiro MD); Hospital Universitrio Cincias Mdicas, Belo
Organization Research Institute, Tehran, Iran (M Mahdavi PhD); Horizonte, Brazil (Prof B R Nascimento PhD); Carol Davila University of
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Minas Gerais, Belo Horizonte, Brazil (Prof D C Malta PhD); University KEMRI Wellcome Trust, Kilifi, Kenya (Prof C R Newton MD); Ministry
of Milano Bicocca, Monza, Italy (Prof L G Mantovani DSc); Ethiopian of Health and Social Welfare, Dar es Salaam, Tanzania
Public Health Association, Addis Ababa, Ethiopia (T Manyazewal PhD); (F N Ngalesoni MSc); University of Nairobi, Nairobi, Kenya
Division of Population and Patient Health, Kings College London (J W Ngunjiri PhD); Department of Public Health, Semarang State
Dental Institute, London, UK (Prof W Marcenes PhD); Hospital University, Semarang City, Indonesia (D N A Ningrum MPH);
Universitario Doctor Peset, Valencia, Spain (J Martinez-Raga PhD); CEU Population Health Strategic Research Centre, School of Health and
Cardinal Herrera University, Moncada, Spain (J Martinez-Raga PhD); Social Development (S Nolte PhD), Deakin University, Burwood, VIC,
University of the East Ramon Magsaysay Memorial Medical Center, Australia (Prof M A Stokes PhD); National Institute of Public Health,
Quezon City, Philippines (M B Marzan MSc); Hospital Pedro Hispano/ Saitama, Japan (M Nomura PhD); Medical Diagnostic Centre, Yaounde,
ULS Matosinhos, Matosinhos, Portugal (J Massano MD); George Cameroon (J J N Noubiap MD); Center for Research on Population and
Institute for Global Health India, New Delhi, India (P K Maulik PhD); Health, Faculty of Health Sciences, American University of Beirut,
Key State Laboratory of Molecular Developmental Biology, Institute of Beirut, Lebanon (Prof C M Obermeyer DSc); Centre for Health Research
Genetics and Developmental Biology, Chinese Academy of Sciences, (F A Ogbo MPH), Western Sydney University, Penrith, NSW, Australia
Beijing, China (M Mazidi PhD); University Hospitals Bristol NHS (Prof A M N Renzaho PhD); Department of Preventive Medicine, School
Foundation Trust, Bristol, UK (C McAlinden PhD); Public Health Wales, of Medicine, Kyung Hee University, Seoul, South Korea (Prof I Oh PhD);
Swansea, UK (C McAlinden PhD); Perelman School of Medicine, Society for Family Health, Abuja, Nigeria (A Okoro MPH); Human
University of Pennsylvania, Philadelphia, PA, USA (P A Meaney MD); Sciences Research Council (HSRC), South Africa and University of
Childrens Hospital of Philadelphia, Philadelphia, PA, USA KwaZulu-Natal, Durban, South Africa (O Oladimeji MS); Universidad
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Hospital, New Delhi, India (Prof M M Mehndiratta DM); Martin Luther J O Olusanya MBA); Lira District Local Government, Lira Municipal
University Halle-Wittenberg, Halle (Saale), Germany (T Meier PhD); Council, Uganda (J N Opio MPH); University of Arizona, Tucson, AZ,
Saudi Ministry of Health, Riyadh, Saudi Arabia (Prof Z A Memish MD); USA (Prof E Oren PhD); IIS-Fundacion Jimenez Diaz-UAM, Madrid,
College of Medicine, Alfaisal University, Riyadh, Saudi Arabia Spain (Prof A Ortiz PhD); Population Health Strategic Research Centre,
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Implementation Science, National Heart, Lung, and Blood Institute, University, Geelong, VIC, Australia (Prof R H Osborne PhD); YBank,
National Institutes of Health, Bethesda, MD, USA (G A Mensah MD); Cambridge, MA, USA (M Osman MD); Department of Medicine,
Department of Neurology (A Meretoja PhD), Comprehensive Cancer Ibadan, Nigeria (M O Owolabi Dr Med); Blossom Specialist Medical
Center, Breast Surgery Unit (T J Meretoja PhD), Helsinki University Center, Ibadan, Nigeria (M O Owolabi Dr Med); JSS Medical College,
Hospital, Helsinki, Finland; Friedman School of Nutrition Science and JSS University, Mysore, India (Prof M PA DNB); The Ottawa Hospital
Policy (R Micha PhD), Tufts University, Boston, MA, USA (P Shi PhD); Research Institute, Ottawa, ON, Canada (S Pakhale MD); Ministry of
University of Ottawa, Ottawa, ON, Canada (E J Mills PhD); Hunger Health, Mexico City, Mexico (E Palomares Castillo PhD); Universidad
Action Los Angeles, Los Angeles, CA, USA (M Mirarefin MPH); Kyrgyz Nacional Autnoma de Mxico (UNAM), Mexico City, Mexico
State Medical Academy, Bishkek, Kyrgyzstan (E Palomares Castillo PhD); Mount Sinai Health System, New York, NY,
(Prof E M Mirrakhimov PhD); National Center of Cardiology and USA (T Patel MD); UK Department for International Development,
Internal Disease, Bishkek, Kyrgyzstan (Prof E M Mirrakhimov PhD); Lalitpur, Nepal (D Paudel PhD); REQUIMTE/LAQV, Laboratrio de
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Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Universidade do Porto, Porto, Portugal (Prof D M Pereira PhD); National
Nigeria (S Mohammed PhD); Reproductive Health and ObGyn School of Institute of Respiratory Diseases, Mexico City, Mexico
Medicine and Health Sciences, University of Papua New Guinea, (Prof R Perez-Padilla MD); Hopsital Universitario Cruces,
Boroko, Papua New Guinea (Prof G L D Mola DPH); Institute for OSI EE-Cruces, Baracaldo, Spain (F Perez-Ruiz PhD); Biocruces Health
Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy Research Institute, Baracaldo, Spain (F Perez-Ruiz PhD); Flinders
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(Prof M Petzold PhD); University of the Witwatersrand, Johannesburg, Varanasi, India (O P Singh PhD); Institute for Human Development,
South Africa (Prof M Petzold PhD); Shanghai Jiao Tong University New Delhi, India (P K Singh PhD); Asthma Bhawan, Jaipur, India
School of Medicine, Shanghai, China (Prof M R Phillips MD); Durban (V Singh MD); Ethiopian Medical Association, Addis Ababa, Ethiopia
University of Technology, Durban, South Africa (J D Pillay PhD); (A H Sinke MD); University of Gondar, Ethiopia, Gondar, Ethiopia
University of Newcastle, Callaghan, NSW, Australia (A E Sinshaw MS); University of Yaound, Yaound, Cameroon
(Prof C D Pond PhD); Charotar University of Science and Technology, (Prof E Sobngwi PhD); Yaound Central Hospital, Yaound, Cameroon
Anand, India (Prof V Prakash MPT); Intergrowth 21st Study Research (Prof E Sobngwi PhD); Dartmouth College, Hanover, NH, USA
Centre, Nagpur, India (Prof M Purwar MD); Non-communicable (S Soneji PhD); Instituto de Investigacin Hospital Universitario de la
Diseases Research Center, Alborz University of Medical Sciences, Karaj, Princesa, Universidad Autnoma de Madrid, Madrid, Spain
Iran (M Qorbani PhD); A T Still University, Kirksville, MO, USA (Prof J B Soriano PhD); National School of Public Health/Oswaldo Cruz
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Pakistan (A Rafay MS, Prof S M Rana PhD); Contech School of Public Department of Clinical Neurological Sciences, Western University,
Health, Lahore, Pakistan (A Rafay MS, Prof S M Rana PhD); Research London, ON, Canada (L A Sposato MD); Department of Community
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Society for Health and Demographic Surveillance, Suri, India (C T Sreeramareddy MD); Attikon University Hospital, Athens, Greece
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(Prof P V Rao MD); Diabetes Research Center, Hyderabad, India (Prof N Steel PhD); Department of Dermatology, University Hospital
(Prof P V Rao MD); Azienda Socio-Sanitaria Territoriale, Papa Giovanni Muenster, Muenster, Germany (S Steinke DrMed); School of Health and
XXIII, Bergamo, Italy (Prof G Remuzzi MD); Department of Biomedical Related Research, University of Sheffield, Sheffield, UK (M Strong PhD);
and Clinical Sciences L. Sacco, University of Milan, Milan, Italy Alexandra General Hospital of Athens, Athens, Greece (K Stroumpoulis
(Prof G Remuzzi MD); Brien Holden Vision Institute PhD); Centre Hospitalier Public du Cotentin, Cherbourg, France
(Prof S Resnikoff MD), School of Optometry and Vision Science (K Stroumpoulis PhD); Ahmadu Bello University, Zaria, Zaria, Nigeria
(Prof S Resnikoff MD), University of New South Wales, Randwick, NSW, (M B Sufiyan MBA); Ministry of Health, Kingdom of Saudi Arabia,
Australia (Prof P S Sachdev MD); Golestan Research Center of Riyadh, Saudi Arabia (R A Suliankatchi MD); University of Southern
Gastroenterology and Hepatology, Golestan University of Medical Queensland, Institute for Resilient Regions, Springfield, QLD, Australia
Sciences, Gorgan, Iran (G Roshandel PhD); Holmusk, Singapore, (J Sun PhD); Indian Council of Medical Research, Chennai, India
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Singapore (N K Roy MS); Prince of Wales Hospital, Randwick, NSW, Sociology, and Public Health, University of California, Irvine, Irvine, CA,
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Development Research and Projects Center, Abuja, Nigeria Ministry of Health, MINSANTE, Yaounde, Cameroon (R T Talongwa
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(A M Samy PhD); J Edwards School of Medicine, Marshall Univeristy, City, Panama (M Tarajia MD); New York Medical Center, Valhalla, NY,
Huntington, WV, USA (J R Sanabria MD); Case Western Reserve USA (M Tavakkoli MD); Instituto Superior de Cincias da Sade Egas
University, Cleveland, OH, USA (J R Sanabria MD); IIS-Fundacion Moniz, Almada, Portugal (Prof N Taveira PhD); Faulty of Pharmacy,
Jimenez Diaz, Madrid, Spain (M D Sanchez-Nio PhD); Universidad Universidade de Lisboa, Lisboa, Portugal (Prof N Taveira PhD);
Ciencias Aplicadas y Ambientales, Bogot, Colombia University of Newcastle, Newcastle, New South Wales, Australia
(R Sarmiento-Suarez MPH); Public Health Medicine, School of Nursing (T Tekelab MS); Arba Minch University, Arba Minch, Ethiopia
and Public Health (Prof B Sartorius PhD), Discipline of Public Health (G Temam Shifa MPH); Department of Anesthesiology, University of
Medicine, School of Nursing and Public Health (B Yakob PhD), Virginia, Charlottesville, VA, USA (A S Terkawi MD); Department of
University of KwaZulu-Natal, Durban, South Africa; UKZN Anesthesiology, King Fahad Medical City, Riyadh, Saudi Arabia
Gastrointestinal Cancer Research Centre, South African Medical (A S Terkawi MD); Outcomes Research Consortium, Cleveland Clinic,
Research Council (SAMRC), Cape Town, South Africa Cleveland, OH, USA (A S Terkawi MD); School of Public Health, Post
(Prof B Sartorius PhD); Marshall University, Huntington, WV, USA Graduate Institute of Medical Education and Research, Chandigarh,
(M Sawhney PhD); Bayer Turkey, Istanbul, Turkey (M I Saylan PhD); India (Prof J Thakur MD); Adaptive Knowledge Management, Victoria,
Institute of Health Care and Social Sciences, FOM University, Essen, BC, Canada (A J Thomson PhD); National Center for Child Health and
Germany (B Schttker MPH); Hypertension in Africa Research Team Development, Tokyo, Japan (R Tobe-Gai PhD); University of Calgary,
(HART), North-West University, Potchefstroom, South Africa Calgary, AB, Canada (Prof M Tonelli MD); Institute of Public Health,
(Prof A E Schutte PhD); South African Medical Research Council, Faculty of Health Sciences, Jagiellonian University Medical College,
Potchefstroom, South Africa (Prof A E Schutte PhD); University of Krakw, Poland (R Topor-Madry PhD); Faculty of Health Sciences,
Colorado, Aurora, CO, USA (B Serdar PhD); Department of Public Wroclaw Medical University, Wroclaw, Poland (R Topor-Madry PhD);
Health, An-Najah University, Nablus, Palestine (A Shaheen PhD); Tufts Hospital Universitario Dr. Peset, Valencia, Spain (M Tortajada PhD);
Medical Center, Boston, MA, USA (Prof S Shahraz PhD); Independent Department of Neurology, Rigshospitalet, University of Copenhagen,
Consultant, Karachi, Pakistan (M A Shaikh MD); Ministry of Health, Copenhagen, Denmark (T Truelsen DMSc); Department of Veterans
Thimphu, Bhutan (J Sharma MPH); Indian Institute of Technology Affairs, Washington DC, DC, USA (U S Uchendu MD); Department of
Ropar, Rupnagar, India (R Sharma MA); Research Institute at Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria
Nationwide Childrens Hospital, Columbus, OH, USA (J Shen PhD); (K N Ukwaja MD); Brandeis University, Waltham, MA, USA
National Institute of Infectious Diseases, Tokyo, Japan (E A Undurraga PhD); Ebonyi State University, Abakaliki, Nigeria
(M Shigematsu PhD); Sandia National Laboratories, Albuquerque, NM, (C J Uneke PhD); Warwick Medical School, University of Warwick,
USA (M Shigematsu PhD); Department of Public Health Science, Coventry, UK (O A Uthman PhD); Joint Research Centre, European
Graduate School (Prof M Shin PhD), Department of Preventive Commission, Ispra, Italy (R Van Dingenen PhD); UKK Institute for
Medicine, College of Medicine (S Yoon PhD), Korea University, Seoul, Health Promotion Research, Tampere, Finland (Prof T Vasankari PhD);
South Korea; Imperial College London, UK (H Shoman MPH); Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore
Reykjavik University, Reykjavik, Iceland (I D Sigfusdottir PhD); Federal (N Venketasubramanian FRCP); University of Bologna, Bologna, Italy
University of Santa Catarina, Florianopolis, Brazil (D A S Silva PhD); (Prof F S Violante MD); Federal Research Institute for Health
Braslia University, Braslia, Brazil (D G A Silveira MD); University of Organization and Informatics, Moscow, Russia (S K Vladimirov PhD);
Alabama at Birmingham and Birmingham Veterans Affairs Medical National Research University Higher School of Economics, Moscow,
Center, Birmingham, AL, USA (J A Singh MD); Department of Russia (Prof V V Vlassov MD); Uniformed Services University of Health

Articles
Sciences, Bethesda, MD, USA (Prof S G Waller MD); Natural History MOO is supported by the National Institute of Health (grant number
Museum, London, UK (J L Walson MD); University of Sao Paulo Medical U54 HG007479). JdN was supported in his contribution to this work by a
School, Sao Paulo, Brazil (Y Wang PhD); Department of Research, Fellowship from Fundao para a Cincia e a Tecnologia, Portugal
Cancer Registry of Norway, Institute of Population-Based Cancer (SFRH/BPD/92934/2013). Imperial College London is grateful for
Research, Oslo, Norway (E Weiderpass PhD); Department of support from the NW London National Institute for Health Research
Community Medicine, Faculty of Health Sciences, University of Troms, (NIHR) Collaboration for Leadership in Applied Health Research and
The Arctic University of Norway, Troms, Norway (E Weiderpass PhD); Care. JMcG is supported by the National Health and Medical Research
Genetic Epidemiology Group, Folkhlsan Research Center, Helsinki, Council John Cade Fellowship in Mental Health Research (APP1056929)
Finland (E Weiderpass PhD); Ghent University, Gent, Belgium and the Danish National Research Foundation Niels Bohr Professorship.
(J Wesana MPH); Mountains of the Moon University, Fort Portal, LLY is partly supported by the National Natural Sciences Foundation of
Uganda (J Wesana MPH); German National Cohort Consortium, China (grant numbers 71233001 and 71490732). AB received institutional
Heidelberg, Germany (R Westerman PhD); South African Medical support from the Ministry of Education, Science and Technological
Research Council, Cochrane South Africa, Cape Town, South Africa Development (project number III45005). AES is funded by the Medical
(Prof C S Wiysonge PhD); National Institute for Health Research Research Council of South Africa, and the South African Research Chair
Comprehensive Biomedical Research Centre, Guys & St. Thomas NHS Initiative by the Department of Science and Technology. KD is funded by
Foundation Trust and Kings College London, London, UK the Wellcome Trust Intermediate Fellowship in Public Health and
(Prof C D Wolfe MD); Ghent University, Ghent, Belgium Tropical Medicine (grant number 201900). This research was supported
(A Workicho MPH); Wolaita Sodo University, Wolaita Sodo, Ethiopia by the NIHR Biomedical Research Centre at Guys and St Thomas NHS
(S B Workie MPH); St Pauls Hospital Millenium Medical College, Addis Foundation Trust and Kings College London. The views expressed are
Ababa, Ethiopia (M Wubshet Terefe PhD); Addis Continental Institute of those of the author(s) and not necessarily those of the NHS, the NIHR,
Public Health, Addis Ababa, Ethiopia (M Wubshet Terefe PhD); or the Department of Health. SI is supported by a Postdoctoral Research
St. Johns Medical College and Research Institute, Bangalore, India Fellowship funded by The George Institute for Global Health. CWs
(Prof D Xavier MD); Department of Neurology, Jinling Hospital, Nanjing research was funded by the NIHR Collaboration for Leadership in
University School of Medicine, Nanjing, China (Prof G Xu PhD); Applied Health Research and Care South London at Kings College
University of Saskatchewan, Saskatoon, SK, Canada (M Yaghoubi MA); Hospital NHS Foundation Trust. The views expressed are those of the
Global Health Research Center, Duke Kunshan University, Kunshan, author(s) and not necessarily those of the NHS, the NIHR, or the
China (Prof L L Yan PhD); Department of Preventive Medicine, Department of Health. The research was funded by the NIHR
Northwestern University, Chicago, IL, USA (Y Yano MD); Uro-Oncology Biomedical Research Centre based at Guys and St Thomas NHS
Research Center (E Amini MD), Endocrinology and Metabolism Foundation Trust and Kings College London. The views expressed are
Population Sciences Institute (Prof A Esteghamati MD, those of the author(s) and not necessarily those of the NHS, the NIHR or
S Sheikhbahaei MD), Non-Communicable Diseases Research Center the Department of Health. DB is supported by Bill & Melinda Gates
(F Farzadfar MD, M Parsaeian PhD), Endocrinology and Metabolism Foundation (grant numbers OPP1068048 and OPP1106023). TL is
Research Center (N Hafezi-Nejad MD), Center for Air Pollution supported by the Academy of Finland (grant numbers 287488 and
Research, Institute for Environmental Research (M S Hassanvand PhD), 294096). UM was funded by the German National Cohort BMBF (grant
Hematology-Oncology and Stem Cell Transplantation Research Center number 0IER1301/22). RB acknowledged funding from the Brien Holden
(A Kasaeian PhD), Digestive Diseases Research Institute Vision Institute. All other authors declare no competing interests.
(Prof R Malekzadeh MD, G Roshandel PhD, S G Sepanlou PhD), Sina
Acknowledgments
Trauma and Surgery Research Center (Prof V Rahimi-Movaghar MD),
We thank the countless individuals who have contributed to the Global
MS Research Center, Neuroscience Institute (M A Sahraian MD),
Burden of Disease Study 2015 in various capacities.
Institute for Environmental Research (M Shamsipour PhD), Tehran
University of Medical Sciences, Terhan, Iran (M Yaseri PhD); Social References
Work and Social Administration Department (Prof P Yip PhD), The 1 United Nations. Transforming our World: the 2030 Agenda for
Hong Kong Jockey Club Centre for Suicide Research and Prevention Sustainable Development. New York, NY, USA: UN, 2015.
(Prof P Yip PhD), University of Hong Kong, Hong Kong, China; 2 Tobias M, Yeh L-C. How much does health care contribute to health
Department of Biostatistics, School of Public Health, Kyoto University, gain and to health inequality? Trends in amenable mortality in
Kyoto, Japan (N Yonemoto MPH); Jackson State University, Jackson, MS, New Zealand 19812004. Aust N Z J Public Health 2009; 33: 7078.
USA (Prof M Z Younis DrPH); Department of Epidemiology and 3 Gay JG, Paris V, Devaux M, de Looper M. Mortality Amenable to
Biostatistics, School of Public Health (Prof C Yu PhD), Global Health Health Care in 31 OECD Countries. Paris: Organisation for Economic
Institute (Prof C Yu PhD), Wuhan University, Wuhan, China; University Co-operation and Development, 2011. http://www.oecd-ilibrary.org/
content/workingpaper/5kgj35f9f8s2-en (accessed Dec 23, 2016).
Hospital, Setif, Algeria (Prof Z Zaidi PhD); Faculty of Medicine,
Mansoura University, Mansoura, Egypt (Prof M E Zaki PhD); EcoHealth 4 Nolte E, McKee M. Does healthcare save lives? Avoidable mortality
revisited. London, UK: Nuffield Trust, 2004.
Alliance, New York, NY, USA (C Zambrana-Torrelio MSc); Instituto de
5 Murray CJ, Lopez AD. On the comparable quantification of health
Ecologia-Bolivia, La Paz, Bolivia (C Zambrana-Torrelio MSc); World
risks: lessons from the Global Burden of Disease Study.
Health Organization, Windhoek, Namibia (T Zapata MD); and Red Cross
Epidemiol Camb Mass 1999; 10: 594605.
War Memorial Childrens Hospital, Cape Town, South Africa
6 Rutstein DD, Berenberg W, Chalmers TC, et al. Measuring the
(L J Zuhlke PhD).
Quality of Medical Care. N Engl J Med 1976; 294: 58288.
Contributors 7 Charlton JR, Velez R. Some international comparisons of mortality
CJLM and NF prepared the first draft of the report. RMB conducted risk- amenable to medical intervention. Br Med J Clin Res Ed 1986;
standardisation analyses, computed indices, and led sensitivity analyses. 292: 295301.
RJDS developed methods for the frontier analysis. CJLM conceived of 8 Holland W. Avoidable death as a measure of quality.
this study and provided overall guidance, with key inputs from TB, MM, Int J Qual Health Care 1990; 2: 22733.
and EN. CJLM and NF finalised the manuscript based on reviewer 9 Nolte E, McKee M. Measuring the health of nations: analysis of
feedback. All other authors provided data or developed models, reviewed mortality amenable to health care. BMJ 2003; 327: 1129.
results, initiated modelling infrastructure, or reviewed and contributed 10 Treurniet HF, Boshuizen HC, Harteloh PPM. Avoidable mortality
to this manuscript. in Europe (19801997): a comparison of trends.
J Epidemiol Community Health 2004; 58: 29095.
Declaration of interests 11 Nolte E, McKee M. Variations in amenable mortalitytrends in
HEO was supported by the National Science Foundation Graduate 16 high-income nations. Health Policy Amst Neth 2011; 103: 4752.
Research Fellowship Program. MDS-N was supported by Miguel Servet 12 Petrie D, Tang KK. Relative health performance in BRICS over the
contract MS14/00133 (ISCIII, Spanish Government). ALR receives an past 20 years: the winners and losers. Bull World Health Organ 2014;
unrestricted scholarship from CNPq, the Brazilian Research Agency. 92: 396404.

Articles
13 McKeown T. The role of medicine: dream, mirage or nemesis? 39 Pampalon R. Avoidable mortality in Qubec and its regions.
Oxford, UK: Blackwell, 1979. Soc Sci Med 1982 1993; 37: 82331.
14 Illich I. Medical Nemesis: the Appropriation of Health. London, 40 Mackenbach JP, Kunst AE, Looman CW, Habbema JD,
UK: Calder and Boyars, 1975. van der Maas PJ. Regional differences in mortality from conditions
15 McKinlay JB, McKinlay SM. The questionable contribution of medical amenable to medical intervention in The Netherlands: a comparison
measures to the decline of mortality in the United States in the of four time periods. J Epidemiol Community Health 1988; 42: 32532.
twentieth century. Milbank Mem Fund Q Health Soc 1977; 55: 40528. 41 Harris AR, Thomas SH, Fisher GA, Hirsch DJ. Murder and
16 Mackenbach JP. The contribution of medical care to mortality medicine: the lethality of criminal assault 1960-1999. Homicide Stud
decline: McKeown revisited. J Clin Epidemiol 1996; 49: 120713. 2002; 6: 12866.
17 Dye C, Fengzeng Z, Scheele S, Williams B. Evaluating the impact of 42 Lecky F, Woodford M, Yates D. Trends in trauma care in England
tuberculosis control: number of deaths prevented by short-course and Wales 198997. Lancet 2000; 355: 177175.
chemotherapy in China. Int J Epidemiol 2000; 29: 55864. 43 Modig K, Andersson T, Drefahl S, Ahlbom A. Age-specific trends in
18 Borgdorff MW, Floyd K, Broekmans JF. Interventions to reduce morbidity, mortality and case-fatality from cardiovascular disease,
tuberculosis mortality and transmission in low- and middle-income myocardial infarction and stroke in advanced age: evaluation in the
countries. Bull World Health Organ 2002; 80: 21727. Swedish population. PLoS One 2013; 8: e64928.
19 Koenig MA, Khan MA, Wojtyniak B, et al. Impact of measles 44 Endreseth BH, Romundstad P, Myrvold HE, Bjerkeset T, Wibe A,
vaccination on childhood mortality in rural Bangladesh. The Norwegian Rectal Cancer Group. Rectal cancer treatment of the
Bull World Health Organ 1990; 68: 44147. elderly. Colorectal Dis 2006; 8: 47179.
20 Campbell OM, Graham WJ. Strategies for reducing maternal 45 The Primary Health Care Performance Initiative (PHCPI). Coverage
mortality: getting on with what works. Lancet 2006; 368: 128499. Index. Sept 17, 2015. http://phcperformanceinitiative.org/indicator/
21 Adam T, Lim SS, Mehta S, et al. Cost effectiveness analysis of coverage-index (accessed Dec 23, 2016).
strategies for maternal and neonatal health in developing countries. 46 International Labour Organization. World Social Security Report
BMJ 2005; 331: 1107. 2010/2011: Providing coverage times of crisis and beyond. Geneva,
22 Richards MA, Stockton D, Babb P, Coleman MP. How many deaths Switzerland: International Labour Organization, 2010.
have been avoided through improvements in cancer survival? 47 Wang H, Naghavi M, Allen C, et al. Global, regional, and national
BMJ 2000; 320: 89598. life expectancy, all-cause mortality, and cause-specific mortality for
23 Stockton D, Davies T, Day N, McCann J. Retrospective study of reasons 249 causes of death, 19802015: a systematic analysis for the Global
for improved survival in patients with breast cancer in east Anglia: Burden of Disease Study 2015. Lancet 2016; 388: 1459544.
earlier diagnosis or better treatment. BMJ 1997; 314: 47275. 48 Forouzanfar MH, Afshin A, Alexander LT, et al. Global, regional,
24 Ebrahim S, Harwood R. Stroke: Epidemiology, Evidence and Clinical and national comparative risk assessment of 79 behavioural,
Practice, 2nd edn. Oxford; New York: Oxford University Press, 1999. environmental and occupational, and metabolic risks or clusters of
risks, 19902015: a systematic analysis for the Global Burden of
25 Nolte E, Bain C, McKee M. Diabetes as a tracer condition in
Disease Study 2015. Lancet 2016; 388: 1659724.
international benchmarking of health systems. Diabetes Care 2006;
29: 100711. 49 Vos T, Allen C, Arora M, et al. Global, regional, and national
incidence, prevalence, and years lived with disability for
26 Tonelli M, Wiebe N, Culleton B, et al. Chronic kidney disease and
310 diseases and injuries, 19902015: a systematic analysis for the
mortality risk: a systematic review. J Am Soc Nephrol 2006;
Global Burden of Disease Study 2015. Lancet 2016; 388: 1545602.
17: 203447.
50 Kassebaum NJ, Arora M, Barber RM, et al. Global, regional,
27 Rutstein DD, Berenberg W, Chalmers TC, Fishman AP, Perrin EB,
and national disability-adjusted life-years (DALYs) for 315 diseases
Zuidema GD. Measuring the quality of medical care: second
and injuries and healthy life expectancy (HALE), 19902015:
revision of tables of indexes. N Engl J Med 1980; 302: 1146.
a systematic analysis for the Global Burden of Disease Study 2015.
28 Holland WW. The avoidable death guide to Europe. Health Policy Lancet 2016; 388: 160358.
1986; 6: 11517.
51 Naghavi M, Makela S, Foreman K, OBrien J, Pourmalek F,
29 Mackenbach JP, Looman CW, Kunst AE, Habbema JD, Lozano R. Algorithms for enhancing public health utility of national
van der Maas PJ. Post-1950 mortality trends and medical care: causes-of-death data. Popul Health Metr 2010; 8: 9.
gains in life expectancy due to declines in mortality from conditions
52 Stevens GA, Alkema L, Black RE, et al. Guidelines for Accurate and
amenable to medical intervention in The Netherlands.
Transparent Health Estimates Reporting: the GATHER statement.
Soc Sci Med 1988; 27: 88994.
Lancet 2016; 388: e19e23.
30 Nolte E, McKee CM. Measuring the health of nations: updating an
53 Lozano R, Naghavi M, Foreman K, et al. Global and regional
earlier analysis. Health Aff (Millwood) 2008; 27: 5871.
mortality from 235 causes of death for 20 age groups in 1990 and
31 Nolte E, McKee CM. In amenable mortalitydeaths avoidable 2010: a systematic analysis for the Global Burden of Disease Study
through health careprogress in the US lags that of 2010. Lancet 2012; 380: 2095128.
three European countries. Health Aff (Millwood) 2012; 31: 211422.
54 Forouzanfar MH, Alexander L, Anderson HR, et al. Global,
32 Manuel DG, Mao Y. Avoidable Mortality in the United States and regional, and national comparative risk assessment of
Canada, 19801996. Am J Public Health 2002; 92: 148184. 79 behavioural, environmental and occupational, and metabolic
33 Niti M, Ng TP. Temporal trends and ethnic variations in amenable risks or clusters of risks in 188 countries, 19902013: a systematic
mortality in Singapore 1965-1994: the impact of health care in analysis for the Global Burden of Disease Study 2013. Lancet 2015;
transition. Int J Epidemiol 2001; 30: 96673. 386: 2287323.
34 OECD. Health at a Glance: Europe 2016. State of the Health in 55 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment
the EU Cycle. Paris, France: Organisation for Economic of burden of disease and injury attributable to 67 risk factors and
Cooperation and Development, 2016. risk factor clusters in 21 regions, 19902010: a systematic analysis
35 Nolte E, Scholz R, Shkolnikov V, McKee M. The contribution of for the Global Burden of Disease Study 2010. Lancet 2012;
medical care to changing life expectancy in Germany and Poland. 380: 222460.
Soc Sci Med 2002; 55: 190521. 56 Lim SS, Allen K, Bhutta ZA, et al. Measuring the health-related
36 Kelson M, Farebrother M. The effect of inaccuracies in death Sustainable Development Goals in 188 countries: a baseline analysis
certification and coding practices in the European Economic from the Global Burden of Disease Study 2015. Lancet 2016;
Community (EEC) on international cancer mortality statistics. 388: 181350.
Int J Epidemiol 1987; 16: 41114. 57 WHO. Global Health Observatory. World Health Organization.
37 Mackenbach JP. Health care expenditure and mortality from http://www.who.int/gho/database/en/ (accessed Sept 10, 2015).
amenable conditions in the European Community. 58 Bogetoft P, Otto L. Benchmarking with data envelopment analysis,
Health Policy Amst Neth 1991; 19: 24555. stochastic frontier analysis, and R, 2011 edition. New York, NY,
38 Poikolainen K, Eskola J. Health services resources and their relation USA: Springer, 2013.
to mortality from causes amenable to health care intervention: 59 Hwang S-N, Lee H-S, Zhu J. Handbook of operations analytics
a cross-national study. Int J Epidemiol 1988; 17: 8689. using data envelopment analysis. Berlin: Springer, 2016.

Articles
60 Smith OK, Cortez RA, Tandon A, Nagpal S, Cotlear D. Going 69 Strader DB, Wright T, Thomas DL, Seeff LB. Diagnosis, management,
universal: how 24 developing countries are implementing universal and treatment of hepatitis C. Hepatology 2004; 39: 114771.
health coverage reforms from the bottom up. The World Bank, 70 WHO. The World Health Report 2000. Health systems: improving
2015. http://documents.worldbank.org/curated/ performance. Geneva, Switzerland: World Health Organization,
en/936881467992465464/Going-universal-how-24-developing- 2000.
countries-are-implementing-universal-health-coverage-reforms- 71 McKee M. The World Health Report 2000: 10 years on.
from-the-bottom-up (accessed Dec 3, 2016). Health Policy Plan 2010; 25: 3468.
61 IAEG-SDGs. Report of the Inter-Agency and Expert Group on the 72 Morris S, Hunter RM, Ramsay AIG, et al. Impact of centralising
Sustainable Development Goal Indicators. Economic and Social acute stroke services in English metropolitan areas on mortality and
Council, 2016 http://unstats.un.org/unsd/statcom/47th-session/ length of hospital stay: difference-in-differences analysis. BMJ 2014;
documents/2016-2-SDGs-Rev1-E.pdf (accessed Nov 18, 2016). 349: g4757.
62 McKee M, Nolte E. Measuring and evaluating performance. 73 Merali HS, Lipsitz S, Hevelone N, et al. Audit-identified avoidable
In: Health systems in low- and middle-income countries. Oxford, factors in maternal and perinatal deaths in low resource settings:
UK: Oxford University Press, 2011. a systematic review. BMC Pregnancy Childbirth 2014; 14: 280.
63 Risso-Gill I, Balabanova D, Majid F, et al. Understanding the 74 Jamison DT, Summers LH, Alleyne G, et al. Global health 2035:
modifiable health systems barriers to hypertension management in a world converging within a generation. Lancet 2013; 382: 1898955.
Malaysia: a multi-method health systems appraisal approach.
75 Mackenbach JP, McKee M. A comparative analysis of health policy
BMC Health Serv Res 2015; 15: 254.
performance in 43 European countries. Eur J Public Health 2013;
64 Burki TK. Radiotherapy challenges in Uganda. Lancet Oncol 2016; 23: 195201.
17: e185.
76 Halstead S, Walsh J, Warren K. Good health at low cost. Bellagio:
65 Schoen C, Osborn R, Huynh PT, et al. Primary Care And Health- Rockefeller Foundation, 1985.
system performance: Adults Experiences In Five Countries.
77 Campbell DT, Fiske DW. Convergent and discriminant validation by
Health Aff (Millwood) 2004; published online Oct 28. DOI:10.1377/
the multitrait-multimethod matrix. Psychol Bull 1959; 56: 81105.
hlthaff.w4.487.
78 Carmines EG, Zeller RA. Reliability and Validity Assessment.
66 Bartlett JA, DeMasi R, Quinn J, Moxham C, Rousseau F.
Beverly Hills, CA, USA and London, UK: SAGE Publications, 1979.
Overview of the effectiveness of triple combination therapy in
antiretroviral-naive HIV-1 infected adults. AIDS 2001; 15: 136977. 79 McCarthy D, Radley D, Hayes S. Aiming higher: results from a
scorecard on state health-system performance, 2015 Edition.
67 Baird JK. Effectiveness of antimalarial drugs. N Engl J Med 2005;
Washington DC: The Commonwealth Fund, 2015.
352: 156577.
68 Group IAS. Artesunate combinations for treatment of malaria:
meta-analysis. Lancet 2004; 363: 917.

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Articles

Healthcare Access and Quality Index based on mortality from

www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 1

Funding Bill & Melinda Gates Foundation.

Introduction dimensions of health-system performance and to identify

2 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

several cancers (eg, testicular, skin, and cervical cancers);22,23

www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 3

effects of trauma care on various injuries,4,41,42 and the ages

4 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

Source and year Geographies HAQ Index construction

www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 5

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

ATG VCT Barbados Comoros Marshall Isl Kiribati

Dominica Grenada Maldives Mauritius Malta

6 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 7

Inguinal, femoral, and abdominal hernia

Adverse effects of medical treatment

Gallbladder and biliary diseases

Congenital heart anomalies

Chronic respiratory disease

Chronic kidney disease

Peptic ulcer disease

Israel 86 95 91 69 99 100 99 100 100 92 85 64 79 92 92 57 62 71 81 85 98 91 97 96 87 75 80 81 59 85 65

(Figure 2 continues on next page)

8 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

Inguinal, femoral, and abdominal hernia

Adverse effects of medical treatment

Gallbladder and biliary diseases

Congenital heart anomalies

Chronic respiratory disease

Chronic kidney disease

Peptic ulcer disease

Argentina 68 76 80 38 96 100 88 99 100 69 53 57 49 82 31 56 50 52 59 66 62 79 75 76 74 59 91 67 48 52 41

(Figure 2 continues on next page)

www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 9

Inguinal, femoral, and abdominal hernia

Adverse effects of medical treatment

Gallbladder and biliary diseases

Congenital heart anomalies

Chronic respiratory disease

Chronic kidney disease

Peptic ulcer disease

(Figure 2 continues on next page)

10 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

Inguinal, femoral, and abdominal hernia

Adverse effects of medical treatment

Gallbladder and biliary diseases

Congenital heart anomalies

Chronic respiratory disease

Chronic kidney disease

Peptic ulcer disease

www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 11

12 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

Figure 4: Defining the HAQ Index frontier on the basis of SDI

www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8 13

HAQ Index (95% UI) HAQ Index frontier Difference between

14 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8

HAQ Index (95% UI) HAQ Index frontier Difference between

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HAQ Index (95% UI) HAQ Index frontier Difference between

16 www.thelancet.com Published online May 18, 2017 http://dx.doi.org/10.1016/S0140-6736(17)30818-8