**Regional data available for Brazil, China, England, India, Japan, Mexico, and the USA**
- Healthcare access and quality improved globally from 2000-2016 as many countries showed large gains.
- As non-communicable diseases and cancers become more common globally, some health systems are struggling to keep pace with the changing health needs of the population.
- Countries with the highest levels of healthcare access and quality were Iceland, Norway, and the Netherlands, while the lowest scoring countries were the Central African Republic, Somalia and Guinea-Bissau.
Healthcare access and quality improved globally from 2000-2016 due in part to large gains seen in many low and middle-income countries in sub-Saharan Africa and Southeast Asia, according to the latest data from the Global Burden of Disease study published in The Lancet.
Despite this, some countries saw progress slow or stall over this time. The authors say that their findings may be a warning sign that some countries' health systems are not evolving at the same rate as population health needs, especially as many non-communicable diseases and cancers become more common.
"These results emphasise the urgent need to improve both access to and quality of healthcare, otherwise health systems could face widening gaps between the health services they provide and the disease burden in their population," says senior author of the study Dr Rafael Lozano, Institute of Health Metrics and Evaluation at the University of Washington, USA. "Now is the time to invest to help deliver health systems for the next generation, and accelerate progress in the Sustainable Development Goal era." 1
The study used an index to measure the quality and accessibility of healthcare, based on 32 causes of death which should be preventable with effective medical care. Each of the 195 countries and territories assessed were given a score between 0-100. For the first time, the study also analysed healthcare access and quality between regions within seven countries: Brazil, China, England, India, Japan, Mexico, and the USA.
In 2016, the global average healthcare access and quality score was 54.4, increasing from 42.4 points in 2000. Disparities between countries remained similar in 2016 and 2000, with a 78.5 point gap between the best and worst performing countries in 2016 (18.6 in the Central African Republic and 97.1 in Iceland), compared with 79.3 points in 2000 (13.5 in Somalia and 92.8 in Iceland).
The five countries with the highest levels of healthcare access and quality in 2016 were Iceland (97.1 points), Norway (96.6), the Netherlands (96.1), Luxembourg (96.0), and Finland and Australia (each with 95.9). While the countries with the lowest scores were the Central African Republic (18.6), Somalia (19.0), Guinea-Bissau (23.4), Chad (25.4), and Afghanistan (25.9).
There were major gains in healthcare access and quality in many countries in sub-Saharan Africa and Southeast Asia between 2000-2016, with Ethiopia, Rwanda, Equatorial Guinea, Myanmar and Cambodia seeing among the biggest improvements. Meanwhile, progress in the USA and some Latin American countries (including Puerto Rico, Panama and Mexico) slowed or stalled over the same time.
The authors also analysed healthcare access and quality locally within Brazil, China, England, India, Japan, Mexico, and the USA. They found that China and India had the widest disparities in healthcare access and quality with 43.5 and 30.8 point differences, respectively. Japan had the narrowest differences with a 4.8 point difference.
Brazil - key findings
Overall in 2016, the score for Brazil's healthcare access and quality was 63.8, placing it 96th out of 195 countries (up from 46.5 in 1990).
In 2016, there was a 20.4 point difference between the best- and worst-performing states (from 75.4 in the Federal District to 55.0 in Maranhão). Northern states had the highest scores on healthcare access and quality (Federal District, Sao Paulo, Santa Catarina, Rio Grande do Sul, Parana, Rio de Janeiro, Minas Gerais, Espirito Santo).
Between 1990-2016, inequalities between states slightly increased by 3.2 points (from a 17.2 point difference in 1990, to a 20.4 point difference in 2016).
China - key findings
Overall in 2016, the score for China's healthcare access and quality was 77.9, placing it 48th out of 195 countries.
Between 1990 and 2016, China significantly increased its score for healthcare access and quality (an increase of 35.5 points), achieving some of the most pronounced gains worldwide. China achieved substantial gains during both time periods studied, but ultimately accelerated its progress from 2000 to 2016.
Of all seven countries studied in-depth, China had the widest disparities between its provinces - a 43.5-point difference (ranging from 91.5 in Beijing to 48.0 in Tibet). Provinces in the East generally had better scores on healthcare access and quality than the West of the country.
England/UK - key findings
Overall in 2016, the score for the UK's healthcare access and quality was 90.5 (up from 78.0 in 1990), placing it 23rd out of 195 countries 2.
England saw local performance vary. In general, higher performance was primarily found in southern England, with South East England scoring highest on healthcare access and quality (92.8 in 2016) while North East England scored lowest (87.8 in 2016).
India - key findings
Overall in 2016, the score for India's healthcare access and quality was 41.2 (up from 24.7 in 1990), placing it 145th out of 195 countries.
India's gap between the highest and lowest scores on healthcare access and quality increased from 1990 to 2016 (from a 23.4 point difference to a 30.8 point difference). Goa and Kerala had the highest scores in 2016, each exceeding 60 points, whereas Assam and Uttar Pradesh had the lowest, each below 40.
Japan - key findings
Overall in 2016, the score for Japan's healthcare access and quality was 94.1 points, placing it 12th out of 195 countries. Since 1990, Japan saw its score increase 13.2 points (from 80.9 points in 1990).
Among countries with subnational assessments, Japan had the smallest differences between prefectures - with a gap of 4.8 points (from 95.1 in Tokyo and Nagano to 90.3 in Okinawa) - and all prefectures scoring more than 90 points in 2016. This gap between prefectures reduced from a 8.1-point difference in 1990.
Mexico - key findings
Overall in 2016, the score for Mexico's healthcare access and quality was 66.3 points, placing it 91st out of 195 countries. Since 1990, Mexico saw its score increase 20.8 points (from 45.5 points in 1990).
In 2016, there was a 17.0 point gap between the best- and worst-performing states (from 72.8 in Nuevo Leon to 55.8 in Chiapas). The lowest scores were generally concentrated along Mexico's southern border.
Mexico's pace of progress was faster from 1990-2000 as compared with 2000-2016. Nonetheless, state-level differences in Mexico narrowed slightly (from a 20.9 point difference in 1990, to 17.0 point difference in 2016).
USA - key findings
Overall in 2016, the score for the USA's healthcare access and quality was 88.7 points, placing it 29th out of 195 countries.
The USA had considerable disparities between states - with a gap of 11.0 points (from 92.5 in Massachusetts to 81.5 in Mississippi). Health care access and quality was highest in the north eastern states, Minnesota, and Washington state.
Between 1990-2016, the country's overall score improved by 8.0 points (from 80.7 in 1990) and inequalities between states shrunk (16.7 point difference in 1990, vs 11.0 point difference in 2016). However, most of this change occurred between 1990-2000 (the gap between best- and worst-performing states shrunk to 11.5 points in 2000), and comparatively little progress has occurred from 2000-2016.
The authors note some limitations, including that their estimates rely on accurate recording of deaths in each of the 195 countries analysed. The study does not take into account the differences between primary and secondary healthcare, and so cannot distinguish if changes in the healthcare access and quality index over time are due to improved primary, secondary or overall care. In addition, not all elements of healthcare access and quality are included in the index, and future work will analyse this more widely.
Writing in a linked Comment, Dr Svetlana V Doubova, Mexican Institute of Social Security, Mexico, says: "In the past, the priorities of public health and health-care services focused on infectious diseases and maternal and child health; today, the unbridled growth of non-communicable diseases is an additional priority. Also, health systems in different countries (eg, Brazil and Colombia) show a tendency to introduce the health-care networks that integrate primary, secondary, and tertiary care, in which investments should aim at strengthening the continuum of care across the different health-care providers. The study by Lozano and colleagues provides a comprehensive measure of the progress and the magnitude of the gaps among and within countries to provide accessible, high-quality health care."
NOTES TO EDITORS
This study was funded by the Bill & Melinda Gates Foundation. It was conducted by researchers from the GBD 2016 Healthcare Access and Quality Collaborators (see end of paper for full list).
Country-by-country data for all 195 countries is available in the Article within Figure 3 and Table 2. Subnational data for the 7 selected countries can be found via the link below.
Please note, differences reported for 2015 as compared with 2016 do not reflect changes in healthcare access and quality; instead, GBD 2016 findings reflect an improved assessment of national and, for selected locations, subnational levels of healthcare access and quality.
1 Quote direct from author and cannot be found in the text of the Article.
2 England was not ranked individually within the 195 countries, only as part of the UK.
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