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Measuring Universal Health Coverage Based on an Index of Effective Coverage of Health Services in 204 Countries and Territories, 1990–2019: A Systematic Analysis for the Global Burden of Disease Study 2019 Publisher Pubmed



Lozano R1, 2 ; Fullman N1 ; Mumford JE1 ; Knight M1 ; Barthelemy CM1 ; Abbafati C10 ; Abbastabar H11 ; Abdallah F31 ; Abdollahi M12, 13 ; Abedi A36 ; Abolhassani H14, 37 ; Abosetugn AE38 ; Abreu LG40 ; Abrigo MRM42 Show All Authors
Authors
  1. Lozano R1, 2
  2. Fullman N1
  3. Mumford JE1
  4. Knight M1
  5. Barthelemy CM1
  6. Abbafati C10
  7. Abbastabar H11
  8. Abdallah F31
  9. Abdollahi M12, 13
  10. Abedi A36
  11. Abolhassani H14, 37
  12. Abosetugn AE38
  13. Abreu LG40
  14. Abrigo MRM42
  15. Abu Haimed AK43
  16. Abushouk AI48, 57
  17. Adabi M65
  18. Adebayo OM66
  19. Adekanmbi V69
  20. Adelson J1
  21. Adetokunboh OO70, 71
  22. Adham D73
  23. Advani SM77, 79
  24. Afshin A1, 2
  25. Agarwal G80
  26. Agasthi P84
  27. Aghamir SMK15
  28. Agrawal A85, 86
  29. Ahmad T87
  30. Akinyemi RO88, 93
  31. Alahdab F94
  32. Alaly Z95, 96
  33. Alam K97
  34. Albertson SB1
  35. Alemu YM98
  36. Alhassan RK101
  37. Ali M104
  38. Ali S105
  39. Alipour V106, 107
  40. Aljunid SM117, 118
  41. Alla F119
  42. Almadi MAH120, 123
  43. Almasi A124
  44. Almasihashiani A140
  45. Almasri NA143
  46. Almekhlafi HM144, 147
  47. Almulhim AM44
  48. Alonso J148, 149
  49. Alraddadi RM150
  50. Altirkawi KA121
  51. Alvisguzman N151, 152
  52. Alviszakzuk NJ153, 154
  53. Amini S141
  54. Aminirarani M156
  55. Amiri F125
  56. Amit AML159, 161
  57. Amugsi DA163
  58. Ancuceanu R164
  59. Anderlini D170, 172
  60. Andrei CL165
  61. Androudi S173
  62. Ansari F174, 183
  63. Ansarimoghaddam A184
  64. Antonio CAT160, 186
  65. Antony CM1
  66. Antriyandarti E188
  67. Anvari D189, 195
  68. Anwer R196
  69. Arabloo J106
  70. Arabzozani M197
  71. Aravkin AY1, 2, 3
  72. Aremu O200
  73. Arnlov J201, 205
  74. Asaad M206
  75. Asadialiabadi M108
  76. Asadipooya AA207, 212
  77. Athari SS213
  78. Atout MMW214
  79. Ausloos M215, 216
  80. Avilaburgos L217
  81. Ayala Quintanilla BP220
  82. Ayano G223
  83. Ayanore MA102
  84. Aynalem YA39
  85. Aynalem GL225
  86. Ayza MA229
  87. Azari S106
  88. Azzopardi PS235, 236
  89. B DB237
  90. Babaee E108
  91. Badiye AD246
  92. Bahrami MA208
  93. Baig AA247
  94. Bakhshaei MH60
  95. Bakhtiari A16
  96. Bakkannavar SM238
  97. Balachandran A248, 251
  98. Banach M252, 253
  99. Banerjee SK254
  100. Banik PC255
  101. Bante AB256
  102. Bante SA99
  103. Barkercollo SL259
  104. Barnighausen TW49, 260
  105. Barrero LH262
  106. Bassat Q263, 265
  107. Basu S50, 266
  108. Baune BT270, 271
  109. Bayati M209
  110. Baye BA272
  111. Bedi N146, 273
  112. Beghi E274
  113. Behzadifar M278
  114. Bekuma TTT279
  115. Bell ML280
  116. Bensenor IM281
  117. Berman AE286
  118. Bernabe E287
  119. Bernstein RS290
  120. Bhagavathula AS291, 292
  121. Bhandari D293, 296
  122. Bhardwaj P297
  123. Bhat AG302
  124. Bhattacharyya K303, 304
  125. Bhattarai S305
  126. Bhutta ZA306, 308
  127. Bijani A309
  128. Bikbov B277
  129. Bilano V312
  130. Biondi A313
  131. Birihane BM314, 315
  132. Bockarie MJ316, 317
  133. Bohlouli S319
  134. Bojia HA323
  135. Bolla SRR325
  136. Boloor A240
  137. Brady OJ326
  138. Braithwaite D331
  139. Briggs AM224
  140. Briko NI332
  141. Burugina Nagaraja S335
  142. Busse R336
  143. Butt ZA337, 338
  144. Caetano Dos Santos FL339
  145. Cahuanahurtado L340
  146. Camera LA341, 342
  147. Cardenas R344
  148. Carreras G345
  149. Carrero JJ202
  150. Carvalho F346
  151. Castaldellimaia JM282
  152. Castanedaorjuela CA154, 351
  153. Castelpietra G352, 353
  154. Castro F354
  155. Catalalopez F355, 356
  156. Cederroth CR203, 358
  157. Cerin E359, 360
  158. Chandan JS364
  159. Chang AY9
  160. Charan J298
  161. Chattu VK307
  162. Chaturvedi S366
  163. Chin KL367, 370
  164. Cho DY4
  165. Choi JYJ375
  166. Christensen H376
  167. Chu DT377
  168. Chung MT378
  169. Ciobanu LG294, 379
  170. Cirillo M380
  171. Compton K1
  172. Cortesi PA381
  173. Costa VM346
  174. Cousin E383
  175. Dahlawi SMA45
  176. Damiani G384, 386
  177. Dandona L1, 390, 392
  178. Dandona R1, 2, 390
  179. Darega Gela J272
  180. Darwesh AM393
  181. Daryani A190
  182. Dash AP395
  183. Davey G396, 398
  184. Davilacervantes CA399
  185. Davletov K400
  186. De Neve JW260
  187. Denovagutierrez E218
  188. Deribe K397, 398
  189. Dervenis N401, 402
  190. Desai R404
  191. Dharmaratne SD1, 2, 405
  192. Dhungana GP406
  193. Dianatinasab M210, 407
  194. Dias Da Silva D347
  195. Diaz D408, 409
  196. Dippenaar IN1
  197. Do HT410
  198. Dorostkar F109
  199. Doshmangir L175
  200. Duncan BB383
  201. Duraes AR411, 413
  202. Eagan AW51, 414
  203. Edvardsson D221, 415
  204. El Sayed I416
  205. El Tantawi M417
  206. Elgendy IY52, 418
  207. Elyazar IR419
  208. Eskandari K420, 421
  209. Eskandarieh S17
  210. Esmaeilnejad S320, 425
  211. Esteghamati A18
  212. Ezekannagha O428, 429
  213. Farag T1
  214. Farahmand M19
  215. Faraon EJA160
  216. Farinha CSES430, 431
  217. Farioli A432
  218. Faris PS433, 434
  219. Faro A436
  220. Fazlzadeh M20, 74
  221. Feigin VL1, 437, 439
  222. Fernandes E348
  223. Ferrara P382
  224. Feyissa GT440
  225. Filip I441, 442
  226. Fischer F443
  227. Fisher JL444
  228. Flor LS445, 446
  229. Foigt NA447
  230. Folayan MO448
  231. Fomenkov AA449
  232. Foroutan M450
  233. Francis JM451
  234. Fu W1
  235. Fukumoto T452
  236. Furtado JM283
  237. Gad MM453, 454
  238. Gaidhane AM455
  239. Gakidou E1, 2
  240. Galles NC1
  241. Gallus S275
  242. Gardner WM1
  243. Geberemariyam BS457
  244. Gebrehiwot AM324
  245. Gebremeskel LG231, 459
  246. Gebremeskel GG230, 458
  247. Gesesew HA232, 460
  248. Ghadiri K126, 127
  249. Ghafourifard M176
  250. Ghashghaee A106, 110
  251. Ghith N461
  252. Gholamian A321, 322
  253. Gilani SA462, 464
  254. Gill PS465
  255. Gill TK294
  256. Ginindza TG467
  257. Gitimoghaddam M469
  258. Giussani G276
  259. Glagn M257
  260. Gnedovskaya EV438
  261. Godinho MA471
  262. Goharinezhad S108
  263. Gopalani SV474, 475
  264. Goudarzian AH191
  265. Goulart BNG383
  266. Gubari MIM476
  267. Guimaraes RA477
  268. Guled RA478
  269. Gultie T258
  270. Guo Y480
  271. Gupta R481, 482, 483, 484
  272. Hafezinejad N21, 162
  273. Hafiz A327, 485
  274. Haile TG458
  275. Hamadeh RR486
  276. Hameed S463
  277. Hamidi S487
  278. Han C1
  279. Han H1
  280. Handiso DW488
  281. Hanif A463
  282. Hankey GJ489, 490
  283. Haro JM264, 491
  284. Hasaballah AI492
  285. Hasan MM493, 494
  286. Hashi A479
  287. Hassan S496
  288. Hassan A31
  289. Hassanipour S499, 500
  290. Hassankhani H177, 502
  291. Havmoeller RJ503
  292. Hay SI1, 2
  293. Hayat K504, 505
  294. Heidari G506
  295. Heidarisoureshjani R22
  296. Hendrie D223
  297. Herteliu C216, 507
  298. Hird TR508
  299. Ho HC361
  300. Hole MK510
  301. Holla R241
  302. Hoogar P242
  303. Hopf KP511, 512
  304. Horita N513, 514
  305. Hossain N516
  306. Hosseini M23, 24
  307. Hosseinzadeh M394, 517
  308. Hostiuc M166
  309. Hostiuc S167, 520
  310. Househ M521
  311. Hsieh VCR522
  312. Hu G524
  313. Huda TM525, 530
  314. Humayun A531
  315. Hwang BF523
  316. Iavicoli I380
  317. Ibitoye SE89
  318. Ikeda N532
  319. Ilesanmi OS67, 90
  320. Ilic MD533, 535
  321. Inbaraj LR537
  322. Iqbal U538
  323. Irvani SSN539
  324. Irvine CMS1
  325. Islam MM222
  326. Islam SMS526, 545
  327. Islami F547
  328. Iso H548
  329. Iwu CJ71, 550, 552
  330. Jaafari J501
  331. Jadidiniaragh F178
  332. Jafarinia M157
  333. Jahagirdar D1
  334. Jahani MA309
  335. Jahanmehr N540, 541
  336. Jakovljevic M333, 536
  337. Janjani H20, 128, 129, 139
  338. Javaheri T553
  339. Jayatilleke AU555, 556
  340. Jenabi E61
  341. Jha RP557, 558
  342. Jha V245, 472
  343. Ji JS559, 560
  344. Jia P563
  345. Johnakinola YO89
  346. Jonas JB261, 564
  347. Joukar F499, 500
  348. Jozwiak JJ565
  349. Jurisson M566
  350. Kabir Z567
  351. Kalankesh LR179
  352. Kalhor R568, 569
  353. Kamath AM5
  354. Kanchan T299
  355. Kapoor N246
  356. Karami Matin B128, 129, 139
  357. Karanikolos M328, 329
  358. Karimi SM570, 571
  359. Kassebaum NJ1, 2, 6
  360. Katikireddi SV572
  361. Kayode GA573, 574
  362. Keiyoro PN575
  363. Khader YS579
  364. Khammarnia M185
  365. Khan M145
  366. Khan EA580
  367. Khang YH581, 582
  368. Khatab K583, 584
  369. Khater AM32
  370. Khater MM33
  371. Khatib MN456
  372. Khayamzadeh M544, 585
  373. Khubchandani J586
  374. Kianipour N131
  375. Kim YJ587, 588
  376. Kimokoti RW589
  377. Kinfu Y590, 591
  378. Kisa A592, 593
  379. Kissimovaskarbek K594
  380. Kivimaki M595, 597
  381. Kneib CJ4
  382. Kocarnik JM1, 599
  383. Kochhar S7, 600
  384. Kohler S260
  385. Kopec JA470, 601
  386. Korotkova AV602
  387. Korshunov VA334
  388. Kosen S603
  389. Kotlo A604
  390. Koul PA605
  391. Koyanagi A265, 606
  392. Krishan K607
  393. Krohn KJ1
  394. Kugbey N103
  395. Kulkarni V237
  396. Kumar GA390
  397. Kumar N237
  398. Kumar M576, 596
  399. Kurmi OP81, 365
  400. Kusuma D267, 608
  401. Kyu HH1, 2
  402. La Vecchia C385
  403. Lacey B609, 612
  404. Lal DK390
  405. Lalloo R495
  406. Landires I613, 616
  407. Lansingh VC617, 618
  408. Larsson AO619, 620
  409. Lasrado S621
  410. Lau KMM1
  411. Lauriola P622
  412. Lazarus JV623
  413. Ledesma JR1
  414. Lee PH187
  415. Lee SWH624, 625
  416. Leever AT1
  417. Legrand KE1
  418. Leigh J527
  419. Leonardi M626
  420. Li S368
  421. Lim SS1, 2
  422. Lim LL627, 628
  423. Liu X629
  424. Logroscino G630, 631
  425. Lopez AD1, 2, 371
  426. Lopukhov PD334
  427. Lotufo PA284
  428. Lu A1
  429. Ma J1
  430. Madadin M46
  431. Mahasha PW551
  432. Mahmoudi M632
  433. Majeed A268
  434. Malagonrojas JN155, 633
  435. Maleki S132
  436. Malta DC41
  437. Mansouri B133
  438. Mansournia MA23
  439. Martini S634, 635
  440. Martinsmelo FR636
  441. Martopullo I1
  442. Massenburg BB8
  443. Mastrogiacomo CI1
  444. Mathur MR388, 637
  445. Mcalinden C638
  446. Mckee M329
  447. Medinasolis CE639
  448. Meharie BG640
  449. Mehndiratta MM641, 642
  450. Mehrabi Nasab E25
  451. Mehri F111
  452. Mehrotra R391
  453. Mekonnen T643
  454. Melese A100
  455. Memiah PTN644
  456. Mendoza W645
  457. Menezes RG47
  458. Mensah GA317, 515
  459. Meretoja TJ647
  460. Meretoja A372, 598, 646
  461. Mestrovic T648, 649
  462. Miazgowski B650
  463. Michalek IM652
  464. Mirrakhimov EM653, 654
  465. Mirzaei M134
  466. Mirzaeialavijeh M135
  467. Mitchell PB473
  468. Moazen B260, 655
  469. Moghadaszadeh M180, 181
  470. Mohamadi E26
  471. Mohammad Y122
  472. Mohammad DK204, 435
  473. Mohammad Gholi Mezerji N62
  474. Mohammadianhafshejani A656
  475. Mohammed S260, 658
  476. Mohammed JA657
  477. Mokdad AH1, 2
  478. Monasta L660
  479. Mondello S661
  480. Moradi M128, 129, 139
  481. Moradilakeh M108
  482. Moradzadeh R140
  483. Moraga P509
  484. Morgadodacosta J349
  485. Morrison SD8
  486. Mosapour A310, 426
  487. Mosser JF1
  488. Mousavi Khaneghah A662
  489. Muriithi MK577
  490. Mustafa G663, 664
  491. Nabhan AF58, 665
  492. Naderi M132
  493. Nagarajan AJ666, 667
  494. Naghavi M1, 2
  495. Naghshtabrizi B63
  496. Naimzada MD668, 669
  497. Nangia V670
  498. Nansseu JR671, 672
  499. Nayak VC238
  500. Nazari J142
  501. Ndejjo R674
  502. Negoi I168, 675
  503. Negoi RI169, 676
  504. Neupane S677
  505. Ngari KN678
  506. Nguefacktsague G673
  507. Ngunjiri JW679
  508. Nguyen CT518
  509. Nguyen DN518, 519
  510. Nguyen HLT518
  511. Nnaji CA318, 552
  512. Nomura S680, 681
  513. Norheim OF53, 497
  514. Noubiap JJ295
  515. Nowak C201
  516. Nunezsamudio V614, 615
  517. Otoiu A216
  518. Ogbo FA682
  519. Oghenetega OB91
  520. Oh IH684
  521. Okunga EW685
  522. Oladnabi M686
  523. Olagunju AT82, 688
  524. Olusanya JO689
  525. Olusanya BO689
  526. Oluwasanu MM89
  527. Omar Bali A690
  528. Omer MO479
  529. Ong KL1
  530. Onwujekwe OE691
  531. Ortegaaltamirano DVV219
  532. Ortiz A692, 694
  533. Ostojic SM695
  534. Otstavnov N668
  535. Otstavnov SS668, 696
  536. Overland S498, 698
  537. Owolabi MO68, 92
  538. Padubidri JR243
  539. Pakhale S357
  540. Palladino R268, 380
  541. Pana A216, 699
  542. Pandajonas S261
  543. Pangaribuan HU700
  544. Pathak M701
  545. Patton GC373, 702
  546. Paudel S705, 706
  547. Pazoki Toroudi H112, 113
  548. Pease SA1
  549. Peden AE471, 707
  550. Pennini A1
  551. Peprah EK708
  552. Pereira J709
  553. Pigott DM1, 2
  554. Pilgrim T710
  555. Pilz TM1
  556. Pinheiro M350
  557. Piradov MA439
  558. Pirsaheb M128, 129, 139
  559. Pokhrel KN711
  560. Postma MJ249, 250
  561. Pourjafar H712, 713
  562. Pourmalek F470
  563. Pourmirza Kalhori R136
  564. Pourshams A27
  565. Prada SI714, 715
  566. Pribadi DRA716
  567. Pupillo E274
  568. Quazi Syed Z455
  569. Radfar A717
  570. Rafiee A718
  571. Rafiei A192, 193
  572. Raggi A626
  573. Rahim F28, 719
  574. Rahman MA221, 720
  575. Rajabpoursanati A198
  576. Rana SM463, 721
  577. Ranabhat CL722, 723
  578. Rao SJ724
  579. Rasella D412
  580. Rashedi V114
  581. Rath GK300
  582. Rathi P244
  583. Rawaf S268, 726
  584. Rawaf DL269, 725
  585. Rawal L728
  586. Rawassizadeh R554
  587. Razo C1
  588. Renjith V729
  589. Renzaho AMN682, 683
  590. Reshmi B239
  591. Rezaei N14, 730
  592. Riahi SM199
  593. Ribeiro DC731
  594. Rickard J732, 733
  595. Roberts NLS1
  596. Roever L734
  597. Romoli M735, 736
  598. Ronfani L660
  599. Roshandel G687
  600. Rubagotti E737
  601. Rwegerera GM738
  602. Sabour S542
  603. Sachdev PS473, 739
  604. Saddik B740
  605. Sadeghi M158
  606. Sadeghi E128, 129, 139
  607. Safari Y128, 129, 139
  608. Sagar R301
  609. Sahebkar A741, 742
  610. Sahraian MA17
  611. Sajadi SM743, 744
  612. Salahshoor MR137
  613. Salem MRR35
  614. Salem H34
  615. Salomon J745
  616. Samadi Kafil H182
  617. Samy AM59
  618. Sanabria J387, 746
  619. Santricmilicevic MM533, 534
  620. Saraswathy SYI747, 748
  621. Sarmientosuarez R749, 750
  622. Sartorius B2, 330
  623. Sarveazad A115
  624. Sathian B751, 752
  625. Sathish T83
  626. Sattin D626
  627. Savic M753
  628. Sawyer SM373, 703
  629. Saxena D455, 754
  630. Sbarra AN1
  631. Schaeffer LE1
  632. Schiavolin S626
  633. Schmidt MI383
  634. Schutte AE755, 756
  635. Schwebel DC757
  636. Schwendicke F759
  637. Seedat S72
  638. Sha F760
  639. Shahabi S211
  640. Shaheen AA761
  641. Shaikh MA762
  642. Shamsizadeh M763
  643. Shannawaz M764
  644. Sharafi K128, 129, 139
  645. Sharara F1
  646. Sharifi H422
  647. Shaw DH1
  648. Sheikh A54, 765
  649. Sheikhtaheri A116
  650. Shetty BSK238
  651. Shibuya K288
  652. Shiferaw WS39
  653. Shigematsu M766
  654. Shin JI767
  655. Shiri R768
  656. Shirkoohi R29, 30
  657. Shivakumar KM769
  658. Shrime MG56
  659. Shuval K770
  660. Siabani S138, 771
  661. Sierpinski R772, 773
  662. Sigfusdottir ID774, 775
  663. Sigurvinsdottir R774
  664. Silva DAS776
  665. Silva JP346
  666. Simonetti B777, 778
  667. Simpson KE1
  668. Singh JA758, 779
  669. Singh P780
  670. Sinha DN781, 782
  671. Skryabin VY783
  672. Smith EUR528, 529
  673. Soheili A785
  674. Soltani S128, 129, 139
  675. Soofi M135
  676. Sorensen RJD1, 7
  677. Soriano JB693, 786
  678. Sorrie MB257
  679. Soyiri IN787
  680. Spurlock EE1
  681. Sreeramareddy CT788
  682. Stanaway JD1, 2
  683. Steel N727, 789
  684. Stein C383
  685. Stokes MA546
  686. Sufiyan MB659
  687. Suleria HAR374
  688. Sultan I790, 791
  689. Szumowski L792
  690. Tabaresseisdedos R793
  691. Tabuchi T794
  692. Tadakamadla SK795
  693. Taddele BW796
  694. Tadesse DB458
  695. Taherkhani A64
  696. Tamiru AT226
  697. Tanser FC468, 797
  698. Tareque MI798
  699. Tarigan IU799
  700. Teagle WL78
  701. Tediosi F800
  702. Tefera YGG227
  703. Tela FG233
  704. Tessema ZT228
  705. Thakur B55, 801
  706. Titova MV668, 802
  707. Tonelli M803
  708. Topormadry R804, 805
  709. Topouzis F403
  710. Tovanipalone MRR285, 806
  711. Tran BX807
  712. Travillian R1
  713. Troeger CE1
  714. Tudor Car L808
  715. Uddin R171, 545
  716. Ullah I809, 810
  717. Umeokonkwo CD811
  718. Unnikrishnan B241
  719. Upadhyay E812
  720. Uthman OA466
  721. Vacante M313
  722. Valdez PR343, 813
  723. Varughese S814
  724. Vasankari TJ815
  725. Vasseghian Y130
  726. Venketasubramanian N816, 817
  727. Violante FS432, 818
  728. Vlassov V697
  729. Vollset SE1, 2
  730. Vongpradith A1
  731. Vos T1, 2
  732. Waheed Y819
  733. Walters MK1
  734. Wamai RG578, 820
  735. Wang H1, 2
  736. Wang YP282
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Source: The Lancet Published:2020


Abstract

Background: Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods: Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings: Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation: The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC. Funding: Bill & Melinda Gates Foundation. © 2020 Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license
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