Summary Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). 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 28·6 to 94·6. 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 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) 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 21·2 in 1990 to 20·1 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 73·8 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 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.

Introduction 1 United Nations 4 Nolte E

McKee M , 6 Rutstein DD

Berenberg W

Chalmers TC

et al. Measuring the Quality of Medical Care. , 7 Charlton JR

Velez R Some international comparisons of mortality amenable to medical intervention. , 8 Holland W Avoidable death as a measure of quality. 9 Nolte E

McKee M Measuring the health of nations: analysis of mortality amenable to health care. , 10 Treurniet HF

Boshuizen HC

Harteloh PPM Avoidable mortality in Europe (1980–1997): a comparison of trends. , 11 Nolte E

McKee M Variations in amenable mortality—trends in 16 high-income nations. , 12 Petrie D

Tang KK Relative health performance in BRICS over the past 20 years: the winners and losers. 13 McKeown T , 14 Illich I , 15 McKinlay JB

McKinlay SM The questionable contribution of medical measures to the decline of mortality in the United States in the twentieth century. , 16 Mackenbach JP The contribution of medical care to mortality decline: McKeown revisited. 17 Dye C

Fengzeng Z

Scheele S

Williams B Evaluating the impact of tuberculosis control: number of deaths prevented by short-course chemotherapy in China. , 18 Borgdorff MW

Floyd K

Broekmans JF Interventions to reduce tuberculosis mortality and transmission in low- and middle-income countries. , 19 Koenig MA

Khan MA

Wojtyniak B

et al. Impact of measles vaccination on childhood mortality in rural Bangladesh. 20 Campbell OM

Graham WJ Strategies for reducing maternal mortality: getting on with what works. , 21 Adam T

Lim SS

Mehta S

et al. Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. 22 Richards MA

Stockton D

Babb P

Coleman MP How many deaths have been avoided through improvements in cancer survival?. , 23 Stockton D

Davies T

Day N

McCann J Retrospective study of reasons for improved survival in patients with breast cancer in east Anglia: earlier diagnosis or better treatment. 24 Ebrahim S

Harwood R 25 Nolte E

Bain C

McKee M Diabetes as a tracer condition in international benchmarking of health systems. 26 Tonelli M

Wiebe N

Culleton B

et al. Chronic kidney disease and mortality risk: a systematic review. 4 Nolte E

McKee M , 6 Rutstein DD

Berenberg W

Chalmers TC

et al. Measuring the Quality of Medical Care. , 7 Charlton JR

Velez R Some international comparisons of mortality amenable to medical intervention. , 8 Holland W Avoidable death as a measure of quality. Panel Context and definitions With the present analysis, we use the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to approximate average levels of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Here we define key concepts frequently used in the literature focused on assessing health-care quality and how they relate to GBD terminology: Avertable burden refers to disease burden that could be avoided in the presence of high-quality personal health care in addition to disease burden that could be prevented through effective public health (ie, non-personal) interventions. Amenable burden entails disease burden that could be avoided in the presence of high-quality personal health care. 2 Tobias M

Yeh L-C How much does health care contribute to health gain and to health inequality? Trends in amenable mortality in New Zealand 1981–2004. , 3 Gay JG

Paris V

Devaux M

de Looper M 4 Nolte E

McKee M entails disease burden that could be avoided in the presence of high-quality personal health care.To be considered a cause amenable to personal health care, effective interventions must exist for the disease.The most widely used and cited list of causes amenable to health care is that of Nolte and McKee. Preventable burden involves disease burden that could be avoided through public health programmes or policies focused on wider determinants of health, such as behavioural and lifestyle influences, environmental factors, and socioeconomic status. 2 Tobias M

Yeh L-C How much does health care contribute to health gain and to health inequality? Trends in amenable mortality in New Zealand 1981–2004. , 3 Gay JG

Paris V

Devaux M

de Looper M involves disease burden that could be avoided through public health programmes or policies focused on wider determinants of health, such as behavioural and lifestyle influences, environmental factors, and socioeconomic status.For some causes, both personal health care and public health programmes and policies can reduce burden. 5 Murray CJ

Lopez AD On the comparable quantification of health risks: lessons from the Global Burden of Disease Study. Within the GBD framework, we have two related terms: attributable and avoidable burden. Attributable burden refers to the difference in disease burden observed at present and burden that would have been observed in a population if past exposure was at the lowest level of risk. Avoidable burden concerns the reduction in future disease burden if observed levels of risk factor exposure today were decreased to a counterfactual level. For this study, we use the definition of amenable burden and focus on amenable mortality to provide a signal on approximate average levels of national personal health-care access and quality. Future analyses facilitated through the GBD study aim to provide more comprehensive assessments of health systems using amenable burden and preventable burden. Garbage codes refer to causes certified by physicians on death certificates that cannot or should not be considered the actual underlying causes of death. Examples include risk factors like hypertension, non-fatal conditions like yellow nails, and causes that are on the final steps of a disease pathway (eg, certifying cardiopulmonary arrest as the cause when ischaemic heart disease is the true underlying cause of death). A vital strength of the GBD Study is its careful identification of garbage codes by cause, over time, and across locations, and subsequent redistribution to underlying causes based on the GBD cause list. Risk-standardisation involves removing the joint effects of environmental and behavioural risk exposure on cause-specific mortality rates at the country or territory level for each year of analysis, and then adding back the global average of environmental and behavioural risk exposure for every geography-year. The goal of risk-standardisation is to eliminate geographic or temporal differences in cause-specific mortality due to variations in risk factors that are not immediately targeted by personal health care—and thus provide comparable measures of outcomes amenable to personal health-care access and quality over place and time. Frontier analysis refers to the approach used for ascertaining the highest achieved values on the Healthcare Access and Quality Index (HAQ Index) on the basis of development status, as measured by the Socio-demographic Index (SDI). The HAQ Index frontier delineates the maximum HAQ Index reached by a location as it relates to SDI; if a country or territory falls well below the frontier value given its level SDI, this finding suggests that greater gains in personal health-care access and quality should be possible based on the country or territory's place on the development spectrum. Quantifying how much personal health care can improve population health and ultimately health-system performance is a crucial undertaking, particularly following the inclusion of universal health coverage (UHC) in the Sustainable Development Goals (SDGs).Mortality from causes considered amenable to personal health care serve as an important proxy of health-care access and quality ( panel ),and thus can be used to benchmark dimensions of health-system performance and to identify untapped potential for advancing personal health-care access and quality.Much debate exists concerning the relative contributions of personal health care, population-level health initiatives, and social determinants to population health.Studies show that access to high-quality health care substantially improves many health outcomes, including infectious diseases (eg, tuberculosis and measles);maternal and neonatal disorders;several cancers (eg, testicular, skin, and cervical cancers);and many non-communicable diseases (NCDs) such as cerebrovascular disease (stroke),diabetes,and chronic kidney disease.Consequently, assessing mortality rates from these conditions, which are considered amenable to personal health care,can provide vital insights into access to and quality of health care worldwide. Assessments of both mortality and disease burden attributable to risk factors modifiable through public health programmes and policy (eg, tobacco taxation), combined with access to high-quality personal health care, can provide a more complete picture of the potential avenues for health improvement. Research in context Evidence before this study In the last several decades, various studies have used measures of amenable mortality, or deaths that could be avoided in the presence of high-quality personal health care, to garner signals about health-system delivery, effectiveness, and performance. Rutstein and colleagues developed an initial list of conditions from which death was “unnecessary and untimely” during the late 1970s, while Charlton and colleagues were the first to apply this concept to population-level analyses in England and Wales. Although variations of amenable cause lists exist today, the most widely used cause list of 33 conditions was developed and further honed by Nolte and McKee during the early-to-mid 2000s. Such analyses of health-care access and quality, as approximated by amenable mortality, have been limited to Europe, Organisation for Economic Co-operation and Development (OECD) countries, and country-specific assessments, including the USA, Australia, and New Zealand. These studies acknowledge several methodological challenges that may impede the policy utility and applications of their results. Heterogeneity in cause of death certification and misclassification, even for countries with complete vital registration systems, can hinder comparability of results over time and place. Further, researchers commonly acknowledge that variations in measured amenable mortality rates may be more reflective of differences in underlying risk factor exposure rather than true differences in personal health-care access and quality. Added value of this study The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides an appropriate analytic framework through which these main challenges in approximating personal health-care access and quality can be addressed. First, the extensive cause of death data processing and standardisation that occur within GBD allow for the systematic identification and redress of cause of death certification errors or misclassification. These adjustments are conducted across all geographies and over time, accounting for known misclassification patterns and applying well established redistribution algorithms for causes designated to so-called garbage codes, or causes of death that could not or should not be classified as underlying causes of death. Second, we draw on GBD's comparative risk assessment analyses to risk-standardise national cause-specific mortality rates to global levels of risk exposure; this step helps to remove variations in death rates due to risk exposure rather than differences in personal health-care access and quality. Third, we construct the Healthcare Access and Quality (HAQ) Index based on risk-standardised cause-specific death rates to facilitate comparisons over time and by geography. Finally, we produced a HAQ Index frontier to enable a better understanding of the maximum observed levels of the HAQ Index across the development spectrum, and what untapped potential for improving personal health-care access and quality may exist given a country or territory's current resources. Implications of all the available evidence Our results point to substantive gains for advancing personal health-care access and quality throughout the world since 1990. However, the gap between places with the highest and lowest HAQ Index in 1990 increased by 2015, suggesting that geographic inequalities in personal health-care access and quality might be on the rise. In 2015, countries in western Europe generally had the highest HAQ Index values while geographies in sub-Saharan Africa and Oceania mainly saw the lowest, further emphasising these disparities. A number of countries achieved improvements in the HAQ Index that exceeded the average found for their development level, identifying possible success stories in markedly advancing personal health-care access and quality at the national level. Based on our frontier analysis, many countries and territories currently experience untapped potential for improving health-care access and quality, on the basis of their development, a finding that could be transformative for prioritising particular health-sector reforms, pinpointing cause-specific therapeutic areas that require more policy attention, and monitoring overall progress toward universal health coverage. 6 Rutstein DD

Berenberg W

Chalmers TC

et al. Measuring the Quality of Medical Care. 7 Charlton JR

Velez R Some international comparisons of mortality amenable to medical intervention. , 8 Holland W Avoidable death as a measure of quality. , 27 Rutstein DD

Berenberg W

Chalmers TC

Fishman AP

Perrin EB

Zuidema GD Measuring the quality of medical care: second revision of tables of indexes. , 28 Holland WW The ‘avoidable death’ guide to Europe. , 29 Mackenbach JP

Looman CW

Kunst AE

Habbema JD

van der Maas PJ Post-1950 mortality trends and medical care: gains in life expectancy due to declines in mortality from conditions amenable to medical intervention in The Netherlands. 2 Tobias M

Yeh L-C How much does health care contribute to health gain and to health inequality? Trends in amenable mortality in New Zealand 1981–2004. , 10 Treurniet HF

Boshuizen HC

Harteloh PPM Avoidable mortality in Europe (1980–1997): a comparison of trends. , 11 Nolte E

McKee M Variations in amenable mortality—trends in 16 high-income nations. , 30 Nolte E

McKee CM Measuring the health of nations: updating an earlier analysis. , 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. , 32 Manuel DG

Mao Y Avoidable Mortality in the United States and Canada, 1980–1996. , 33 Niti M

Ng TP Temporal trends and ethnic variations in amenable mortality in Singapore 1965-1994: the impact of health care in transition. 3 Gay JG

Paris V

Devaux M

de Looper M , 34 OECD 30 Nolte E

McKee CM Measuring the health of nations: updating an earlier analysis. , 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. 4 Nolte E

McKee M 9 Nolte E

McKee M Measuring the health of nations: analysis of mortality amenable to health care. , 11 Nolte E

McKee M Variations in amenable mortality—trends in 16 high-income nations. , 30 Nolte E

McKee CM Measuring the health of nations: updating an earlier analysis. , 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. , 35 Nolte E

Scholz R

Shkolnikov V

McKee M The contribution of medical care to changing life expectancy in Germany and Poland. In the late 1970s, Rutstein and colleagues first introduced the idea of “unnecessary, untimely deaths”, proposing a list of causes from which death should not occur with timely and effective medical care.Eventually termed “amenable mortality”, this approach has been modified and extended since, with researchers refining the list of included conditions by accounting for advances in medical care, the introduction of new interventions, and improved knowledge of cause-specific epidemiology.Numerous studies have subsequently assessed amenable mortality trends over time, by sex, and across ages in different populations;examples include analyses showing variations in amenable mortality within the European Union and Organisation for Economic Co-operation and Development (OECD),and how much the US health system has lagged behind other higher-income countries.Some studies also extended the set of amenable conditions to include those targeted by public health programmes.The most widely cited and utilised list of causes amenable to personal health care is that of Nolte and McKee,which has been extensively used in Europe, the USA, and other OECD countries. 4 Nolte E

McKee M , 36 Kelson M

Farebrother M The effect of inaccuracies in death certification and coding practices in the European Economic Community (EEC) on international cancer mortality statistics. 37 Mackenbach JP Health care expenditure and mortality from amenable conditions in the European Community. , 38 Poikolainen K

Eskola J Health services resources and their relation to mortality from causes amenable to health care intervention: a cross-national study. , 39 Pampalon R Avoidable mortality in Québec and its regions. , 40 Mackenbach JP

Kunst AE

Looman CW

Habbema JD

van der Maas PJ Regional differences in mortality from conditions amenable to medical intervention in The Netherlands: a comparison of four time periods. 4 Nolte E

McKee M , 41 Harris AR

Thomas SH

Fisher GA

Hirsch DJ Murder and medicine: the lethality of criminal assault 1960-1999. , 42 Lecky F

Woodford M

Yates D Trends in trauma care in England and Wales 1989–97. 43 Modig K

Andersson T

Drefahl S

Ahlbom A Age-specific trends in morbidity, mortality and case-fatality from cardiovascular disease, myocardial infarction and stroke in advanced age: evaluation in the Swedish population. , 44 Endreseth BH

Romundstad P

Myrvold HE

Bjerkeset T

Wibe A The Norwegian Rectal Cancer Group

Rectal cancer treatment of the elderly. Previously, several technical challenges have emerged concerning the quantification of mortality from conditions amenable to personal health care and its use for understanding overall health-care access and quality. First, discrepancies in cause of death certification practices and misclassification over time and across geographies affect comparisons of amenable mortality.Second, observed geographic and temporal variations in deaths from selected amenable causes (eg, stroke and heart disease) might be attributed partly differences in risk factor exposure (eg, diet, high BMI, and physical activity) rather than actual differences in access to quality personal health care. Public health programmes and policies might modify these risks in well-functioning health systems, but risk variation can still confound the measurement of personal health-care access and quality. Third, much of this work has occurred in higher-income settings, with few studies applying the concept of amenable mortality as a mechanism for assessing access and quality to personal health care in lower-resource settings. Other critiques involve weak correlations between observed trends and variations in amenable mortality and indicators of health-care provision and spending, although this result could occur if health-care quality is heterogeneous within countries.Additionally, existing lists might exclude causes for which health care can avert death, such as the effects of trauma care on various injuries,and the ages at which personal health care can reduce mortality, namely beyond the age of 75. 45 The Primary Health Care Performance Initiative (PHCPI)

Coverage Index. 46 International Labour Organization 47 Wang H

Naghavi M

Allen C

et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. 47 Wang H

Naghavi M

Allen C

et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The goal of this analysis is to use estimates of mortality amenable to personal health care from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) to approximate access to and quality of personal health care in 195 countries and territories from 1990 to 2015. Quantifying access to and quality of personal health care has many policy uses, and no consistent measures of personal health-care access and quality currently list across the development spectrum; for instance, the World Bank coverage index only includes three interventions,and the 2010–11 International Labour Organization's indicator of formal health coverage covered 93 countries, with substantial data missingness for sub-Saharan Africa.The highly standardised cause of death estimates generated through GBD,along with risk factor exposure,can address several limitations associated with previous studies of amenable mortality. GBD provides comprehensive, comparable estimates of cause-specific death rates by geography, year, age, and sex through its extensive data correction processes to account for variations in cause of death certification.The quantification of risk exposure and risk-attributable deaths due to 79 risk factors through GBD allows us to account for variations in risk exposure across geographies and time,and thus helps to isolate variations in death rates due to personal health-care access and quality. We also examine the relationship between our measure of health-care access and quality, as defined by risk-standardised mortality rates amenable to health care, across development levels, as reflected by the Socio-demographic Index (SDI). Finally, we produce a frontier of maximum levels of personal health-care access and quality observed on the basis of SDI, which allows us to quantify the potential for further improvement in relation to development status.

Methods Overview 4 Nolte E

McKee M , 9 Nolte E

McKee M Measuring the health of nations: analysis of mortality amenable to health care. , 11 Nolte E

McKee M Variations in amenable mortality—trends in 16 high-income nations. , 30 Nolte E

McKee CM Measuring the health of nations: updating an earlier analysis. , 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. , 35 Nolte E

Scholz R

Shkolnikov V

McKee M The contribution of medical care to changing life expectancy in Germany and Poland. Table 1 Causes for which mortality is amenable to health care mapped to GBD 2015 causes Amenable age range (years) Communicable, maternal, neonatal, and nutritional diseases Tuberculosis 0–74 Diarrhoea, lower respiratory, and other common infectious diseases Diarrhoeal diseases 0–14 Lower respiratory infections 0–74 Upper respiratory infections 0–74 Diphtheria 0–74 Whooping cough 0–14 Tetanus 0–74 Measles 1–14 Maternal disorders 0–74 Neonatal disorders 0–74 Non-communicable diseases Neoplasms Colon and rectum cancer 0–74 Non-melanoma skin cancer (squamous-cell carcinoma) 0–74 Breast cancer 0–74 Cervical cancer 0–74 Uterine cancer 0–44 Testicular cancer 0–74 Hodgkin's lymphoma 0–74 Leukaemia 0–44 Cardiovascular diseases Rheumatic heart disease 0–74 Ischaemic heart disease 0–74 Cerebrovascular disease 0–74 Hypertensive heart disease 0–74 Chronic respiratory diseases 1–14 Digestive diseases Peptic ulcer disease 0–74 Appendicitis 0–74 Inguinal, femoral, and abdominal hernia 0–74 Gallbladder and biliary diseases 0–74 Neurological disorders Epilepsy 0–74 Diabetes, urogenital, blood, and endocrine diseases Diabetes mellitus 0–49 Chronic kidney disease 0–74 Other non-communicable diseases Congenital heart anomalies 0–74 Injuries Unintentional injuries Adverse effects of medical treatment 0–74 The age groups for which mortality is regarded as amenable to health care are listed. Causes are ordered on the basis of the GBD cause list and corresponding cause group hierarchies. GBD=Global Burden of Disease. We employed the most widely cited and used framework for assessing mortality amenable to personal health care.The Nolte and McKee cause list does not include all possible causes for which health care can improve survival; however, it does provide a set of conditions for which there is a reasonable consensus that personal health care has a major effect ( table 1 ). Starting with this list, our analysis followed four steps: mapping the Nolte and McKee cause list to GBD causes; risk-standardising mortality rates to remove variations in death rates not easily addressed through personal health care; computing a summary measure of personal health-care access and quality using principal component analysis (PCA); and assessing the highest recorded levels of health-care access and quality across the development spectrum. 47 Wang H

Naghavi M

Allen C

et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. , 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. , 49 Vos T

Allen C

Arora M

et al. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. , 50 Kassebaum NJ

Arora M

Barber RM

et al. Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. 51 Naghavi M

Makela S

Foreman K

O'Brien J

Pourmalek F

Lozano R Algorithms for enhancing public health utility of national causes-of-death data. This study draws from GBD 2015 results; further detail on GBD 2015 data and methods are available elsewhere.For the present analysis, a vital strength of GBD is its careful evaluation and correction of cause of death certification problems and misclassification at the national level. In the GBD, we systematically identified causes of death that could not or should not be underlying causes of death (so-called garbage codes), and applied established statistical algorithms to correct for and redistribute these deaths. 52 Stevens GA

Alkema L

Black RE

et al. Guidelines for Accurate and Transparent Health Estimates Reporting: the GATHER statement. Our study complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER);additional information on the data and modelling strategies used can be found in the appendix Mapping the Nolte and McKee amenable cause list to the GBD cause list 4 Nolte E

McKee M , 9 Nolte E

McKee M Measuring the health of nations: analysis of mortality amenable to health care. , 11 Nolte E

McKee M Variations in amenable mortality—trends in 16 high-income nations. , 30 Nolte E

McKee CM Measuring the health of nations: updating an earlier analysis. , 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. , 35 Nolte E

Scholz R

Shkolnikov V

McKee M The contribution of medical care to changing life expectancy in Germany and Poland. 47 Wang H

Naghavi M

Allen C

et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. , 53 Lozano R

Naghavi M

Foreman K

et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Drawing from Nolte and McKee's list of 33 causes amenable to personal health care,we mapped these conditions to the GBD cause list based on corresponding International Classification of Diseases (ICD) codes ( appendix p 18 ). In GBD, thyroid diseases and benign prostatic hyperplasia are part of a larger residual category and thus were excluded. Diphtheria and tetanus are separate causes in GBD so we reported them individually. Because of its extensive processes used to consistently map and properly classify ICD causes over time,GBD supported the assessment of 32 causes on the Nolte and McKee cause list from 1990 to 2015. Age-standardised risk-standardised death rates 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. , 54 Forouzanfar MH

Alexander L

Anderson HR

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. , 55 Lim SS

Vos T

Flaxman AD

et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Some variation in death rates for amenable causes are due to differences in behavioural and environmental risk exposure rather than differences in personal health-care access and quality.Using the wide range of risk factors assessed by GBD,we risk-standardised death rates to the global level of risk exposure.We did not risk-standardise for variations in metabolic risk factors directly targeted by personal health care: systolic blood pressure, total cholesterol, and fasting plasma glucose. For example, stroke deaths due to high systolic blood pressure are amenable to primary care management of hypertension. To risk-standardise death rates, we removed the joint effects of national behavioural and environmental risk levels calculated in GBD, and added back the global levels of risk exposure: mr jascy = m jascy ( 1 - J P A F j a s c y 1 - J P A F j a s g y )

where mjascy is the death rate from cause j in age a, sex s, location c, and year y; mrjascy is the risk-standardised death rate; JPAFjascy is the joint population attributable fraction (PAF) for cause j, in age a, sex s, country c, and year y for all behavioural and environmental risks included in GBD; and JPAFjasgy is the joint PAF for cause j, in age a, sex s, and year y at the global level. where mjascy is the death rate from cause j in age a, sex s, location c, and year y; mrjascy is the risk-standardised death rate; JPAFjascy is the joint population attributable fraction (PAF) for cause j, in age a, sex s, country c, and year y for all behavioural and environmental risks included in GBD; and JPAFjasgy is the joint PAF for cause j, in age a, sex s, and year y at the global level. GBD provides joint PAF estimation for multiple risks combined, which takes into account the mediation of different risks through each other. Further detail on joint PAF computation is available in the appendix (pp 5–8) 47 Wang H

Naghavi M

Allen C

et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. We used the GBD world population standard to calculate age-standardised risk-standardised death rates from each cause regarded as amenable to health care.We did not risk-standardise death rates from diarrhoeal diseases as mortality attributable to unsafe water and sanitation was not computed for high-SDI locations; such standardisation could lead to higher risk-standardised death rates in those countries compared with countries where mortality was attributed to unsafe water and sanitation.With all causes for which no PAFs are estimated in GBD, such as neonatal disorders and testicular cancer, risk-standardised death rates equalled observed death rates. The effects of risk-standardisation are highlighted by comparing the log of age-standardised mortality rates to the log of age-standardised risk-standardised mortality rates for amenable causes ( appendix p 14 ). For each SDI quintile, many countries had differing levels of age-standardised mortality rates but their risk-standardised mortality rates were similar, demonstrating how underlying local risk exposure can skew measures of mortality amenable to personal health care. Construction of the Healthcare Access and Quality Index based on age-standardised risk standardised death rates To construct the Healthcare Access and Quality (HAQ) Index, we first rescaled the log age-standardised risk-standardised death rate by cause to a scale of 0 to 100 such that the highest observed value from 1990 to 2015 was 0 and the lowest was 100. To avoid the effects of fluctuating death rates in small populations on rescaling, we excluded populations less than 1 million population from setting minimum and maximum values. Any location with a cause-specific death rate below the minimum or above the maximum from 1990 to 2015 was set to 100 or 0, respectively. s =0·98. We selected the PCA-derived HAQ Index because it provided the strongest correlations with six other currently available cross-country measures of access to care or health-system inputs ( 56 Lim SS

Allen K

Bhutta ZA

et al. Measuring the health-related Sustainable Development Goals in 188 countries: a baseline analysis from the Global Burden of Disease Study 2015. 57 WHO

Global Health Observatory. World Health Organization. 46 International Labour Organization 45 The Primary Health Care Performance Initiative (PHCPI)

Coverage Index. Table 2 Correlations between different constructions of the HAQ Index and existing indicators of health-care access or quality Source and year Geographies represented HAQ Index construction PCA weighted EFA weighted Geometric mean Mean Health expenditure per capita GBD 2015 195 0·884 0·880 0·854 0·864 Hospital beds (per 1000) GBD 2015 195 0·700 0·683 0·625 0·650 UHC tracer index of 11 interventions GBD 2015 188 0·826 0·820 0·812 0·818 Physicians, nurses, and midwives per 1000 WHO 2010 73 0·769 0·755 0·725 0·732 Proportion of population with formal health coverage ILO 2010–11 93 0·808 0·798 0·773 0·781 Coverage index of three primary health-care interventions World Bank 2015 123 0·601 0·589 0·557 0·570 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. Because each included cause provided some signal on average levels of personal health-care access and quality, we explored four approaches to construct the HAQ Index: PCA, exploratory factor analysis, arithmetic mean, and geometric mean. Details on these four approaches are in the appendix (pp 7, 8, 21, 22 ). All four measures were highly correlated, with Spearman's rank order correlations exceeding r=0·98. We selected the PCA-derived HAQ Index because it provided the strongest correlations with six other currently available cross-country measures of access to care or health-system inputs ( table 2 ). Three indicators came from the GBD Study 2015: health expenditure per capita, hospital beds per 1000, and the UHC tracer intervention index, a composite measure of 11 UHC tracer interventions (four childhood vaccinations; 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).Three indicators came from WHO (physicians, nurses, and midwives per 1000),the International Labour Organization,and the World Bank (coverage index based on diphtheria-pertussis-tetanus vaccine coverage, coverage of at least four antenatal care visits, and proportion of children with diarrhoea receiving appropriate treatment).All indicators had correlation coefficients greater than 0·60, and three exceeded 0·80 (health expenditure per capita, the UHC tracer index, and International Labour Organization formal health coverage). The appendix (pp 21, 22) provides final rescaled PCA weights derived from the first five components that collectively accounted for more than 80% of the variance in cause-specific measures. Colon and breast cancer had negative PCA weights, which implied higher death rates were associated with better access and quality of care; because this cannot be true we set these weights to zero in the final PCA-derived HAQ Index. The appendix (p 15) compares each geography's HAQ Index in 2015 with the log of its age-standardised risk-standardised mortality rates. Quantifying maximum levels of the HAQ Index across the development spectrum 58 Bogetoft P

Otto L 59 Hwang S-N

Lee H-S

Zhu J 58 Bogetoft P

Otto L To better understand maximum levels of personal health-care access and quality potentially achievable across the development spectrum, we produced a frontier based on the relationship between the HAQ Index and SDI. We tested both stochastic frontier analysis models and data envelopment analysis; however, the relationship between SDI and the HAQ Index did not fit standard stochastic frontier analysis models,and data envelopment analysis cannot account for measurement error and is sensitive to outliers.To generate a frontier fit that closely follows the observed HAQ Index and allowed for measurement error, we used free disposal hull analysis on 1000 bootstrapped samples of the data.Every bootstrap included a subset of locations produced by randomly sampling (with replacement) from all GBD geographies. The final HAQ Index value was drawn from the uncertainty distribution for each location-year, with outliers removed by excluding super-efficient units; additional methodological detail can be found in the appendix (pp 9–12) . Last, we used a Loess regression to produce a smooth frontier for each five-year interval from 1990 to 2015. For every geography, we report the maximum possible HAQ Index value on the basis of SDI in 1990 and 2015, while values for all years can be found in the appendix (pp 23–28) Uncertainty analysis 47 Wang H

Naghavi M

Allen C

et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. , 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. GBD aims to propagate all sources of uncertainty through its estimation process,which results in uncertainty intervals (UIs) accompanying each point estimate of death by cause, geography, year, age group, and sex. We computed the HAQ Index for each geography-year based on 1000 draws from the posterior distribution for each included cause of death. We report 95% UIs based on the ordinal 25th and 975th draws for each quantity of interest. Role of the funding source The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Discussion Drawing from GBD 2015, we constructed a novel measure of personal health-care access and quality—the HAQ Index—by using highly standardised estimates of 32 different causes that are amenable to personal health care. Compared with previous efforts, the HAQ Index provides a clearer signal on personal health-care access and quality over time and place because GBD provides enhanced comparability of cause of death data, helps to account for variation due to behavioural and environmental risk factors, and includes 195 countries and territories over time. Our analysis showed large differences in personal health-care access and quality, spanning from a low of 23·1 in Ethiopia in 1990 to higher than 90 in Andorra, Iceland, Switzerland, Norway, and Sweden in 2015. The global HAQ Index improved from 40·7 in 1990 to 53·7 in 2015, and 167 of 195 countries and territories significantly increased their HAQ Index during this time. Although the HAQ Index and SDI were highly correlated, we noted substantial heterogeneity for geographies at similar SDI. If every location reached the highest observed HAQ Index experienced by level of SDI, our global measure of health-care access and quality could have reached 73·8 in 2015—a clear indicator of untapped potential for health-care improvement worldwide. 60 Smith OK

Cortez RA

Tandon A

Nagpal S

Cotlear D 34 OECD , 46 International Labour Organization , 57 WHO

Global Health Observatory. World Health Organization. , 60 Smith OK

Cortez RA

Tandon A

Nagpal S

Cotlear D While most countries saw progress on the HAQ Index since 1990, the marked improvements recorded for countries including South Korea, Turkey, and China highlight that much more rapid advances are possible. A subset of countries narrowed the gap between observed personal health-care access and quality and what could be expected given their level of development—and then achieved gains beyond what might be anticipated on the basis of SDI. Peru, the Maldives, and Ethiopia are examples of such stand-out geographies for reaching higher-than-expected levels of personal health care and access since 1990. Case studies conducted by the World Bank highlight potential drivers of these countries' successes,and additional research on how certain health-system attributes, including financing arrangements, provider ownership, and stewardship functions, are related to personal health-care access and quality is warranted. Separating out measures of access from quality of care received would be ideal, especially because programmatic and policy options to address barriers in access and quality can differ across and within countries. Nonetheless, such information measured in a consistent manner is rarely available. Several geographies had minimal gains in reducing the difference between their observed HAQ Index and the highest levels achieved at a similar SDI—a warning sign that heightened health-care access and quality is not an inevitable product of increased development. Further, a subset of countries in southern sub-Saharan Africa, south Asia, and the Middle East saw widening gaps between HAQ Index values in 2015 and the frontier reached by countries of comparable SDI. These findings could reflect several challenges faced by these countries, including subnational inequalities in both wealth and health-care options; and recent or rapid epidemiological transitions wherein the health-care sector and cause-specific services offered trail behind the diseases afflicting populations. Along with examining the drivers of greater-than-expected gains, future studies should strive to understand why other countries are lagging behind—and how they can pursue advancing health-care access and quality for all individuals. 61 IAEG-SDGs Improving personal health-care access and quality is an important priority in the SDG era, emphasising the potential utility of the HAQ Index for SDG monitoring. At present, the UHC target—SDG 3.8—focuses mainly on so-called tracer interventions in the areas of maternal and child health, reproductive health, and a subset of infectious diseases,and thus fails to adequately capture the vital role of personal health care for NCDs and injuries. The HAQ Index provides a more comprehensive measure that reflects health-system capacity for effectively detecting risk for, managing, and preventing early death from a range of conditions. Combining the HAQ Index, coverage of health interventions, and prevalence of risk factors that are modifiable through public health initiatives could provide a more robust mechanism for tracking UHC progress across multiple dimensions of health-system action. 62 McKee M

Nolte E Measuring and evaluating performance. , 63 Risso-Gill I

Balabanova D

Majid F

et al. Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach. 64 Burki TK Radiotherapy challenges in Uganda. 65 Schoen C

Osborn R

Huynh PT

et al. Primary Care And Health-system performance: Adults' Experiences In Five Countries. Health systems can provide differential access and quality across therapeutic areas and levels of care. The HAQ Index reflects the average experience as captured by included conditions, and does not currently distinguish between diseases more strongly related to primary or secondary care. Our PCA weights suggest some conditions are less highly correlated with other causes, including colon cancer, breast cancer, testicular cancer, non-melanoma skin cancer, or diphtheria. The comparatively low weights on these outcomes could reflect measurement error, residual challenges in risk standardisation, or health-system heterogeneity by level of care. Subnational work that identifies variation in personal health-care access and quality within a particular health-system structure, and that uses multi-method approaches to view the health system from the perspective of patients and frontline providers,may help elucidate whether some health-system components function distinctly from its average. For example, access to and quality of oncology care might be relatively distinct from other health-system dimensions and, where appropriate treatment is contingent on specialists or particular equipment, such as radiotherapy for cancer, even a temporary loss of these resources may substantially affect outcomes.Conversely, access to high-quality primary care services, which enable early detection of conditions that are fatal if diagnosed at later stages, can be shaped by different factors, such as flexibility of clinic hours or types of insurance providers accepted. Mortality amenable to personal health care and mortality attributable to modifiable behavioural and environmental risk factors 4 Nolte E

McKee M , 9 Nolte E

McKee M Measuring the health of nations: analysis of mortality amenable to health care. , 11 Nolte E

McKee M Variations in amenable mortality—trends in 16 high-income nations. , 30 Nolte E

McKee CM Measuring the health of nations: updating an earlier analysis. , 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. , 35 Nolte E

Scholz R

Shkolnikov V

McKee M The contribution of medical care to changing life expectancy in Germany and Poland. 41 Harris AR

Thomas SH

Fisher GA

Hirsch DJ Murder and medicine: the lethality of criminal assault 1960-1999. , 42 Lecky F

Woodford M

Yates D Trends in trauma care in England and Wales 1989–97. , 66 Bartlett JA

DeMasi R

Quinn J

Moxham C

Rousseau F Overview of the effectiveness of triple combination therapy in antiretroviral-naive HIV-1 infected adults. , 67 Baird JK Effectiveness of antimalarial drugs. , 68 Group IAS Artesunate combinations for treatment of malaria: meta-analysis. , 69 Strader DB

Wright T

Thomas DL

Seeff LB Diagnosis, management, and treatment of hepatitis C. For the present study, we based the HAQ Index on the list of causes established by Nolte and McKee,and did not systematically re-examine scientific literature to update causes for which personal health care can significantly improve outcomes. Conducting this kind of systematic review is crucial to identifying additional causes for inclusion in the HAQ Index. Numerous causes should be considered, and would likely result in adding antiretroviral therapy for HIV, artemisinin-based combination therapies for malaria, treatment of hepatitis C, and improvements in emergency and trauma care, among others.Expanding the amenable cause list should be determined by clear criteria that define when health care sufficiently reduces cause-specific mortality and thus provides a strong enough signal about access and quality. Such additions will probably improve the HAQ Index, though the nature of PCA estimation and its measurement of common variance across 32 causes may not substantially change future results. This analysis stemmed from existing scientific literature on mortality amenable to health care, but personal health care also can have profound effects on non-fatal health outcomes (eg, hip replacement for oesteoarthritis or surgery for cataracts). Future updates of the HAQ Index should consider incorporating measures of non-fatal conditions amenable to personal health care, which would then capture health-system capacity to deliver health gains through improved functional health status. Understanding how much mortality or disease burden is avertable based on providing access to high-quality personal health care and modifying behavioural and environmental risks through public health initiatives is of high policy interest. GBD currently assesses mortality and burden attributable to a large set of risk factors, which supplies useful insights on the potential of risk modification to improve health. Quantification of the full potential of personal health care to reduce burden by cause would provide an important additional piece of policy-relevant information. Controlling for other factors through statistical modelling, such as income and educational attainment, we could examine how much cause-specific variation relates to the HAQ Index. Such work would help to pinpoint opportunities for national and subnational progress through health-system improvements, which would likely include public health programmes and policies as well as the organisation and delivery of personal health services across levels of care. Moving to performance measurement 58 Bogetoft P

Otto L 70 WHO 9 Nolte E

McKee M Measuring the health of nations: analysis of mortality amenable to health care. , 71 McKee M The World Health Report 2000: 10 years on. 71 McKee M The World Health Report 2000: 10 years on. In estimating the HAQ Index frontier by SDI,we quantified the gap between observed personal health-care access and quality and levels potentially achievable at a given level of SDI. With these analyses, we lay the foundation for a refined assessment of health-system performance. The World Health Report 2000, which sought to evaluate health-system performance by country,estimated the contribution of health systems for improving healthy life expectancy while statistically controlling for other factors. As suggested by Nolte and McKee,using a measure more directly related to health-system actions, such as mortality amenable to personal health care, could reduce the need to control for other factors in health-system performance assessment. The World Health Report 2000 framework used five broad dimensions—average levels of health, inequalities in health, average levels of health-system performance, inequalities in responsiveness, and fair financing—and then compared overall health system attainment based on a frontier for health expenditure per capita.Our current analysis only focused on the contribution of personal health care to mortality and the potential for improvement in this domain relative to development. In the future, GBD could support examining subnational health inequalities and expanding into health finance quantification of financial risk protection. A stronger empirical basis for assessing these three domains of health-system performance would also facilitate testing a range of efficiency and performance models. 72 Morris S

Hunter RM

Ramsay AIG

et al. Impact of centralising acute stroke services in English metropolitan areas on mortality and length of hospital stay: difference-in-differences analysis. 73 Merali HS

Lipsitz S

Hevelone N

et al. Audit-identified avoidable factors in maternal and perinatal deaths in low resource settings: a systematic review. 74 Jamison DT

Summers LH

Alleyne G

et al. Global health 2035: a world converging within a generation. Our frontier analysis showed that the highest observed HAQ Index levels, as achieved by geographies with an SDI of 0·8 or higher, steadily shifted higher over time. This expansion of health-care access and quality may reflect a rising share of GDP allocated to health among high-SDI countries. However, the frontier estimate for GDP per capita spent on health points to a similar shift upward at high expenditure. One explanation of this trend is new medical technologies and programmes, which could be driving an overall upward shift in health-care access and quality achievable in well financed systems. Another potential explanation is innovation in health-care organisation, such as the creation of centralised stroke care units in major cities.A more detailed examination of these changes may further elucidate how investing in medical innovations can affect health-system performance. In particular, this might shed light on the association between investment in health-care resources and outcomes, a relationship that is unlikely to be linear. For instance, audits have identified three main factors underlying maternal deaths: substandard care, delays in care, and problems with blood transfusions.Addressing the latter requires a different type of intervention, namely investments in infrastructure, than the former two factors. Such knowledge is of particular importance in the SDG era, as some studies point to advances in medical technology and innovation as the primary pathway for elevating health alongside increasing development. HAQ Index compared to other measures of access and quality of care 75 Mackenbach JP

McKee M A comparative analysis of health policy performance in 43 European countries. 25 Nolte E

Bain C

McKee M Diabetes as a tracer condition in international benchmarking of health systems. 76 Halstead S

Walsh J

Warren K Detailed results on HAQ Index components seem consistent with previous, albeit limited, studies on health-care performance. Within Europe, Nordic countries performed especially well, corresponding with past work on a composite measure of public health policies.Country performance on diabetes aligned with earlier work on diabetes mortality and incidence,wherein country-level differences were largely explained by known health-system changes, such as substantial improvements in several Baltic states during the late 1990s. In Latin America, Costa Rica's relatively high HAQ Index (72·9), as compared with nearby countries (eg, Nicaragua [64·3], Guatemala [55·7]), is consistent with its designation as an original “good health at low cost” country. 77 Campbell DT

Fiske DW Convergent and discriminant validation by the multitrait-multimethod matrix. , 78 Carmines EG

Zeller RA 37 Mackenbach JP Health care expenditure and mortality from amenable conditions in the European Community. , 38 Poikolainen K

Eskola J Health services resources and their relation to mortality from causes amenable to health care intervention: a cross-national study. , 39 Pampalon R Avoidable mortality in Québec and its regions. , 40 Mackenbach JP

Kunst AE

Looman CW

Habbema JD

van der Maas PJ Regional differences in mortality from conditions amenable to medical intervention in The Netherlands: a comparison of four time periods. 9 Nolte E

McKee M Measuring the health of nations: analysis of mortality amenable to health care. , 11 Nolte E

McKee M Variations in amenable mortality—trends in 16 high-income nations. , 31 Nolte E

McKee CM In amenable mortality—deaths avoidable through health care—progress in the US lags that of three European countries. 79 McCarthy D

Radley D

Hayes S In view of the paucity of standard health-care access and quality measures, assessing HAQ Index validity compared to other indicators was challenging. In this analysis, we identified three measures of health-system resources and three measures of intervention coverage that included at least 70 countries. These correlations, which all exceeded 0·60, offer some evidence of convergent validity but do not provide criterion validity.Nonetheless, these results are encouraging and stand in contrast to previous studies done in limited settings.In comparison with past work,the moderately high correlation with other health-care indicators might be due to our efforts to risk-standardise mortality amenable to health care; PCA weighting of different amenable conditions; and the inclusion of a substantively larger, more diverse set of health systems across the development spectrum. Additional validation analyses are needed to compare HAQ Index performance with other measures of health-care access and quality; such validation exercises might be more feasible at the subnational level with greater data density, such as states in the USA. Limitations 47 Wang H

Naghavi M

Allen C

et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. 48 Forouzanfar MH

Afshin A

Alexander LT

et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. This analysis has a number of limitations beyond those already described. First, many limitations experienced in GBD cause of death estimation are applicable to this study.Second, our risk-standardisation procedure might not represent all possible risk-outcome pairs as they pertain to included causes of amenable mortality (eg, determinants of testicular cancer or neonatal disorders).With its annual updates, GBD aims to improve upon its comparative risk assessment, and thus HAQ Index assessment is likely to be improved alongside advances in risk quantification. Third, two causes received negative weights in the PCA analysis and were subsequently excluded. One potential explanation for this is that joint PAFs for these causes may underestimate risk-attributable mortality in high-SDI countries (eg, the effects of diet, obesity, and physical inactivity for breast cancer). However, given the high Spearman's rank order correlation between the average of all 32 causes and the HAQ Index, excluding these causes from the PCA likely had minimal effect on our results. Fourth, we used PCA to construct the HAQ Index based on age-standardised risk-standardised death rates from the 32 causes. Alternative methods for index construction led to highly correlated results, but exact rankings somewhat varied. We subsequently view exact rank orders as less useful than comparing a given geography's HAQ Index values over time, to countries of similar SDI, and relative to the HAQ Index frontier. Fifth, while the HAQ Index offers a more robust indicator of overall health-care access and quality than currently available measures, it does not directly capture effects of personal health care on causes without substantial mortality (eg, depression, hip oesteoarthritis, and cataracts). The effects of health care on both fatal and non-fatal conditions may be highly correlated, but incorporating how access and quality of care explicitly affect non-fatal outcomes would improve measurement. Sixth, GBD corrections for cause of death misclassifications (so-called garbage codes) varies substantially by geography and thus can affect results. Even among high-SDI countries, GBD showed substantial variation for the proportion of amenable deaths assigned to garbage codes, ranging from 7·9% in Finland to 39·8% in Portugal ( appendix p 19 ). Seventh, for countries with complete or nearly complete vital registration (VR) data and few deaths misclassified based on ICD codes, the HAQ Index may be more robust and less prone to high levels of uncertainty than for countries with lower-quality or non-existent VR data. Mortality estimates that heavily draw from verbal autopsy data or other modelling approaches have larger UIs. Our results for most of sub-Saharan Africa, for example, include wide UIs and thus few countries recorded HAQ Index values that statistically differed from the regional mean. Eighth, we rescale the log age-standardised risk-standardised death rate for each cause from 0 to 100 using the observed range across countries from 1990 to 2015, but achieving 100 does not mean that additional improvement is not possible. Subsequently, the HAQ Index range reported here is relative to national achievements to date, and these thresholds may rise if or when improved personal health-care access and quality occurs for given causes. Ninth, the HAQ Index does not currently capture subnational inequalities in personal health-care access and quality, which might emerge on the basis of geographic location or socioeconomic status, among other factors. Future efforts to quantify these measures with greater geospatial resolution should be prioritised.

Conclusions Our analysis demonstrates that a policy-relevant summary measure of personal health-care access and quality can be derived from GBD. This novel measure supports the first-ever comparable assessment of personal health-care access and quality across 195 countries and territories, over time, and along the development spectrum. The HAQ Index considerably advances previous efforts to approximate personal health-care access and quality by systematically adjusting for cause of death certification biases and misclassification, risk-standardising death rates across geographies, and applying PCA to identify common dimensions of health-care access and quality associated with multiple conditions. Globally, most countries and territories recorded gains in personal health-care access and quality from 1990 to 2015, yet many still experienced levels that fell well below what has been achieved by geographies at a similar development status. Amid calls to improve monitoring of UHC and overall health-system performance, the HAQ Index provides a strong basis for benchmarking progress toward greater access and higher-quality personal health care alongside country-level gains in resources to achieve these aims.

GBD 2015 Healthcare Access and Quality Collaborators

Ryan M Barber, Nancy Fullman, Reed J D Sorensen, Thomas Bollyky, Martin McKee, Ellen Nolte, Amanuel Alemu Abajobir, Kalkidan Hassen Abate, Cristiana Abbafati, Kaja M Abbas, Foad Abd-Allah, Abdishakur M Abdulle, Ahmed Abdulahi Abdurahman, Semaw Ferede Abera, Biju Abraham, Girmatsion Fisseha Abreha, Kelemework Adane, Ademola Lukman Adelekan, Ifedayo Morayo O Adetifa, Ashkan Afshin, Arnav Agarwal, Sanjay Kumar Agarwal, Sunilkumar Agarwal, Anurag Agrawal, Aliasghar Ahmad Kiadaliri, Alireza Ahmadi, Kedir Yimam Ahmed, Muktar Beshir Ahmed, Rufus Olusola Akinyemi, Tomi F Akinyemiju, Nadia Akseer, Ziyad Al-Aly, Khurshid Alam, Noore Alam, Sayed Saidul Alam, Zewdie Aderaw Alemu, Kefyalew Addis Alene, Lily Alexander, Raghib Ali, Syed Danish Ali, Reza Alizadeh-Navaei, Ala'a Alkerwi, François Alla, Peter Allebeck, Christine Allen, Rajaa Al-Raddadi, Ubai Alsharif, Khalid A Altirkawi, Elena Alvarez Martin, Nelson Alvis-Guzman, Azmeraw T Amare, Erfan Amini, Walid Ammar, Joshu Amo-Adjei, Yaw Ampem Amoako, Benjamin O Anderson, Sofia Androudi, Hossein Ansari, Mustafa Geleto Ansha, Carl Abelardo T Antonio, Johan Ärnlöv, Al Artaman, Hamid Asayesh, Reza Assadi, Ayalew Astatkie, Tesfay Mehari Atey, Suleman Atique, Niguse Tadele Atnafu, Sachin R Atre, Leticia Avila-Burgos, Euripide Frinel G Arthur Avokpaho, Beatriz Paulina Ayala Quintanilla, Ashish Awasthi, Nebiyu Negussu Ayele, Peter Azzopardi, Huda Omer Ba Saleem, Till Bärnighausen, Umar Bacha, Alaa Badawi, Amitava Banerjee, Aleksandra Barac, Miguel A Barboza, Suzanne L Barker-Collo, Lope H Barrero, Sanjay Basu, Bernhard T Baune, Kaleab Baye, Yibeltal Tebekaw Bayou, Shahrzad Bazargan-Hejazi, Neeraj Bedi, Ettore Beghi, Yannick Béjot, Aminu K Bello, Derrick A Bennett, Isabela M Bensenor, Adugnaw Berhane, Eduardo Bernabé, Oscar Alberto Bernal, Addisu Shunu Beyene, Tariku Jibat Beyene, Zulfiqar A Bhutta, Sibhatu Biadgilign, Boris Bikbov, Sait Mentes Birlik, Charles Birungi, Stan Biryukov, Donal Bisanzio, Habtamu Mellie Bizuayehu, Dipan Bose, Michael Brainin, Michael Brauer, Alexandra Brazinova, Nicholas J K Breitborde, Hermann Brenner, Zahid A Butt, Rosario Cárdenas, Lucero Cahuana-Hurtado, Ismael Ricardo Campos-Nonato, Josip Car, Juan Jesus Carrero, Daniel Casey, Valeria Caso, Carlos A Castañeda-Orjuela, Jacqueline Castillo Rivas, Ferrán Catalá-López, Pedro Cecilio, Kelly Cercy, Fiona J Charlson, Alan Z Chen, Adrienne Chew, Mirriam Chibalabala, Chioma Ezinne Chibueze, Vesper Hichilombwe Chisumpa, Abdulaal A Chitheer, Rajiv Chowdhury, Hanne Christensen, Devasahayam Jesudas Christopher, Liliana G Ciobanu, Massimo Cirillo, Megan S Coggeshall, Leslie Trumbull Cooper, Monica Cortinovis, John A Crump, Koustuv Dalal, Hadi Danawi, Lalit Dandona, Rakhi Dandona, Paul I Dargan, Jose das Neves, Gail Davey, Dragos V Davitoiu, Kairat Davletov, Diego De Leo, Liana C Del Gobbo, Borja del Pozo-Cruz, Robert P Dellavalle, Kebede Deribe, Amare Deribew, Don C Des Jarlais, Subhojit Dey, Samath D Dharmaratne, Daniel Dicker, Eric L Ding, Klara Dokova, E Ray Dorsey, Kerrie E Doyle, Manisha Dubey, Rebecca Ehrenkranz, Christian Lycke Ellingsen, Iqbal Elyazar, Ahmadali Enayati, Sergey Petrovich Ermakov, Babak Eshrati, Alireza Esteghamati, Kara Estep, Thomas Fürst, Imad D A Faghmous, Fanuel Belayneh Bekele Fanuel, Emerito Jose Aquino Faraon, Talha A Farid, Carla Sofia e Sa Farinha, Andre Faro, Maryam S Farvid, Farshad Farzadfar, Valery L Feigin, Andrea B Feigl, Seyed-Mohammad Fereshtehnejad, Jefferson G Fernandes, João C Fernandes, Tesfaye Regassa Feyissa, Florian Fischer, Christina Fitzmaurice, Thomas D Fleming, Nataliya Foigt, Kyle J Foreman, Mohammad H Forouzanfar, Richard C Franklin, Joseph Frostad, Tsegaye Tewelde G/hiwot, Emmanuela Gakidou, Ketevan Gambashidze, Amiran Gamkrelidze, Wayne Gao, Alberto L Garcia-Basteiro, Teshome Gebre, Amanuel Tesfay Gebremedhin, Mengistu Welday Gebremichael, Alemseged Aregay Gebru, Amha Admasie Gelaye, Johanna M Geleijnse, Ricard Genova-Maleras, Katherine B Gibney, Ababi Zergaw Giref, Melkamu Dedefo Gishu, Giorgia Giussani, William W Godwin, Audra Gold, Ellen M Goldberg, Philimon N Gona, Amador Goodridge, Sameer Vali Gopalani, Atsushi Goto, Nicholas Graetz, Felix Greaves, Max Griswold, Peter Imre Guban, Harish Chander Gugnani, Prakash C Gupta, Rahul Gupta, Rajeev Gupta, Tanush Gupta, Vipin Gupta, Tesfa Dejenie Habtewold, Nima Hafezi-Nejad, Demewoz Haile, Alemayehu Desalegne Hailu, Gessessew Bugssa Hailu, Alex Hakuzimana, Randah Ribhi Hamadeh, Mitiku Teshome Hambisa, Samer Hamidi, Mouhanad Hammami, Graeme J Hankey, Yuantao Hao, Hilda L Harb, Habtamu Abera Hareri, Josep Maria Haro, Mohammad Sadegh Hassanvand, Rasmus Havmoeller, Roderick J Hay, Simon I Hay, Delia Hendrie, Ileana Beatriz Heredia-Pi, Hans W Hoek, Masako Horino, Nobuyuki Horita, H Dean Hosgood, Aung Soe Htet, Guoqing Hu, Hsiang Huang, John J Huang, Bethany M Huntley, Chantal Huynh, Kim Moesgaard Iburg, Bogdan Vasile Ileanu, Kaire Innos, Asnake Ararsa Irenso, Nader Jahanmehr, Mihajlo B Jakovljevic, Peter James, Spencer Lewis James, Mehdi Javanbakht, Sudha P Jayaraman, Achala Upendra Jayatilleke, Panniyammakal Jeemon, Vivekanand Jha, Denny John, Catherine Johnson, Sarah C Johnson, Jost B Jonas, Knud Juel, Zubair Kabir, Yogeshwar Kalkonde, Ritul Kamal, Haidong Kan, Andre Karch, Corine Kakizi Karema, Seyed M Karimi, Amir Kasaeian, Nicholas J Kassebaum, Anshul Kastor, Srinivasa Vittal Katikireddi, Konstantin Kazanjan, Peter Njenga Keiyoro, Laura Kemmer, Andrew Haddon Kemp, Andre Pascal Kengne, Amene Abebe Kerbo, Maia Kereselidze, Chandrasekharan Nair Kesavachandran, Yousef Saleh Khader, Ibrahim Khalil, Abdur Rahman Khan, Ejaz Ahmad Khan, Gulfaraz Khan, Young-Ho Khang, Abdullah Tawfih Abdullah Khoja, Irma Khonelidze, Jagdish Khubchandani, Getiye Dejenu Kibret, Daniel Kim, Pauline Kim, Yun Jin Kim, Ruth W Kimokoti, Yohannes Kinfu, Niranjan Kissoon, Miia Kivipelto, Yoshihiro Kokubo, Anneli Kolk, Dhaval Kolte, Jacek A Kopec, Soewarta Kosen, Parvaiz A Koul, Ai Koyanagi, Michael Kravchenko, Sanjay Krishnaswami, Kristopher J Krohn, Barthelemy Kuate Defo, Burcu Kucuk Bicer, Ernst J Kuipers, Veena S Kulkarni, G Anil Kumar, Fekede Asefa Kumsa, Michael Kutz, Hmwe H Kyu, Anton Carl Jonas Lager, Aparna Lal, Dharmesh Kumar Lal, Ratilal Lalloo, Tea Lallukka, Qing Lan, Sinead M Langan, Van C Lansingh, Heidi J Larson, Anders Larsson, Dennis Odai Laryea, Asma Abdul Latif, Alicia Elena Beatriz Lawrynowicz, Janet L Leasher, James Leigh, Mall Leinsalu, Cheru Tesema Leshargie, Janni Leung, Ricky Leung, Miriam Levi, Xiaofeng Liang, Stephen S Lim, Margaret Lind, Shai Linn, Steven E Lipshultz, Patrick Liu, Yang Liu, Loon-Tzian Lo, Giancarlo Logroscino, Alan D Lopez, Scott A Lorch, Paulo A Lotufo, Rafael Lozano, Raimundas Lunevicius, Ronan A Lyons, Erlyn Rachelle King Macarayan, Mark T Mackay, Hassan Magdy Abd El Razek, Mohammed Magdy Abd El Razek, Mahdi Mahdavi, Azeem Majeed, Reza Malekzadeh, Deborah Carvalho Malta, Lorenzo G Mantovani, Tsegahun Manyazewal, Chabila C Mapoma, Wagner Marcenes, Guy B Marks, Neal Marquez, Jose Martinez-Raga, Melvin Barrientos Marzan, João Massano, Manu Raj Mathur, Pallab K Maulik, Mohsen Mazidi, Colm McAlinden, John J McGrath, Claire McNellan, Peter A Meaney, Alem Mehari, Man Mohan Mehndiratta, Toni Meier, Alemayehu B Mekonnen, Kidanu Gebremariam Meles, Ziad A Memish, Melkamu Merid Mengesha, Desalegn Tadese Mengiste, Mubarek Abera Mengistie, Bereket Gebremichael Menota, George A Mensah, Seid Tiku Mereta, Atte Meretoja, Tuomo J Meretoja, Haftay Berhane Mezgebe, Renata Micha, Anoushka Millear, Edward J Mills, Shawn Minnig, Mojde Mirarefin, Erkin M Mirrakhimov, Charles N Mock, Karzan Abdulmuhsin Mohammad, Shafiu Mohammed, Sanjay K Mohanty, Ali H Mokdad, Glen Liddell D Mola, Mariam Molokhia, Lorenzo Monasta, Marcella Montico, Maziar Moradi-Lakeh, Paula Moraga, Lidia Morawska, Rintaro Mori, Mark Moses, Ulrich O Mueller, Srinivas Murthy, Kamarul Imran Musa, Jean B Nachega, Chie Nagata, Gabriele Nagel, Mohsen Naghavi, Aliya Naheed, Luigi Naldi, Vinay Nangia, Bruno Ramos Nascimento, Ionut Negoi, Sudan Prasad Neupane, Charles R Newton, Marie Ng, Frida Namnyak Ngalesoni, Josephine Wanjiku Ngunjiri, Grant Nguyen, Dina Nur Anggraini Ningrum, Sandra Nolte, Marika Nomura, Ole F Norheim, Bo Norrving, Jean Jacques N Noubiap, Carla Makhlouf Obermeyer, Felix Akpojene Ogbo, In-Hwan Oh, Anselm Okoro, Olanrewaju Oladimeji, Andrew Toyin Olagunju, Pedro R Olivares, Helen E Olsen, Bolajoko Olubukunola Olusanya, Jacob Olusegun Olusanya, John Nelson Opio, Eyal Oren, Alberto Ortiz, Richard H Osborne, Majdi Osman, Mayowa O Owolabi, Mahesh PA, Amanda W Pain, Smita Pakhale, Elizabeth Palomares Castillo, Adrian Pana, Christina Papachristou, Mahboubeh Parsaeian, Tejas Patel, George C Patton, Deepak Paudel, Vinod K Paul, Neil Pearce, David M Pereira, Rogelio Perez-Padilla, Fernando Perez-Ruiz, Norberto Perico, Konrad Pesudovs, Max Petzold, Michael Robert Phillips, David M Pigott, Julian David Pillay, Christine Pinho, Suzanne Polinder, Constance D Pond, V Prakash, Manorama Purwar, Mostafa Qorbani, D Alex Quistberg, Amir Radfar, Anwar Rafay, Kazem Rahimi, Vafa Rahimi-Movaghar, Mahfuzar Rahman, Mohammad Hifz Ur Rahman, Rajesh Kumar Rai, Usha Ram, Saleem M Rana, Zane Rankin, Paturi Vishnupriya Rao, Puja C Rao, Salman Rawaf, Maria Albertina Santiago Rego, Marissa Reitsma, Giuseppe Remuzzi, Andre M N N Renzaho, Serge Resnikoff, Satar Rezaei, Mohammad Sadegh Rezai, Antonio L Ribeiro, Hirbo Shore Roba, Mohammad Bagher Rokni, Luca Ronfani, Gholamreza Roshandel, Gregory A Roth, Dietrich Rothenbacher, Nawal K Roy, Perminder S Sachdev, Ben Benasco Sackey, Mohammad Yahya Saeedi, Saeid Safiri, Rajesh Sagar, Mohammad Ali Sahraian, Muhammad Muhammad Saleh, Joshua A Salomon, Abdallah M Samy, Juan Ramon Sanabria, Maria Dolores Sanchez-Niño, Logan Sandar, Itamar S Santos, João Vasco Santos, Milena M Santric Milicevic, Rodrigo Sarmiento-Suarez, Benn Sartorius, Maheswar Satpathy, Miloje Savic, Monika Sawhney, Mete I Saylan, Ben Schöttker, Aletta E Schutte, David C Schwebel, Soraya Seedat, Abdulbasit Musa Seid, Canaan Negash Seifu, Sadaf G Sepanlou, Berrin Serdar, Edson E Servan-Mori, Tesfaye Setegn, Katya Anne Shackelford, Amira Shaheen, Saeid Shahraz, Masood Ali Shaikh, Marina Shakh-Nazarova, Mansour Shamsipour, Sheikh Mohammed Shariful Islam, Jayendra Sharma, Rajesh Sharma, Jun She, Sara Sheikhbahaei, Jiabin Shen, Peilin Shi, Mika Shigematsu, Min-Jeong Shin, Rahman Shiri, Haitham Shoman, Mark G Shrime, Ephrem Lejore Sibamo Sibamo, Inga Dora Sigfusdottir, Diego Augusto Santos Silva, Dayane Gabriele Alves Silveira, Shireen Sindi, Abhishek Singh, Jasvinder A Singh, Om Prakash Singh, Prashant Kumar Singh, Virendra Singh, Abiy Hiruye Sinke, Aklilu Endalamaw Sinshaw, Vegard Skirbekk, Karen Sliwa, Alison Smith, Eugene Sobngwi, Samir Soneji, Joan B Soriano, Tatiane Cristina Moraes Sousa, Luciano A Sposato, Chandrashekhar T Sreeramareddy, Vasiliki Stathopoulou, Nicholas Steel, Caitlyn Steiner, Sabine Steinke, Mark Andrew Stokes, Saverio Stranges, Mark Strong, Konstantinos Stroumpoulis, Lela Sturua, Muawiyyah Babale Sufiyan, Rizwan Abdulkader Suliankatchi, Jiandong Sun, Patrick Sur, Soumya Swaminathan, Bryan L Sykes, Rafael Tabarés-Seisdedos, Karen M Tabb, Getachew Redae Taffere, Roberto Tchio Talongwa, Musharaf Tarajia, Mohammad Tavakkoli, Nuno Taveira, Stephanie Teeple, Teketo Kassaw Tegegne, Arash Tehrani-Banihashemi, Tesfalidet Tekelab, Dejen Yemane Tekle, Girma Temam Shifa, Abdullah Sulieman Terkawi, Azeb Gebresilassie Tesema, JS Thakur, Alan J Thomson, Taavi Tillmann, Tenaw Yimer Tiruye, Ruoyan Tobe-Gai, Marcello Tonelli, Roman Topor-Madry, Miguel Tortajada, Christopher Troeger, Thomas Truelsen, Abera Kenay Tura, Uche S Uchendu, Kingsley N Ukwaja, Eduardo A Undurraga, Chigozie Jesse Uneke, Olalekan A Uthman, Job F M van Boven, Rita Van Dingenen, Santosh Varughese, Tommi Vasankari, Narayanaswamy Venketasubramanian, Francesco S Violante, Sergey K Vladimirov, Vasiliy Victorovich Vlassov, Stein Emil Vollset, Theo Vos, Joseph A Wagner, Tolassa Wakayo, Stephen G Waller, Judd L Walson, Haidong Wang, Yuan-Pang Wang, David A Watkins, Elisabete Weiderpass, Robert G Weintraub, Chi-Pang Wen, Andrea Werdecker, Joshua Wesana, Ronny Westerman, Harvey A Whiteford, James D Wilkinson, Charles Shey Wiysonge, Belete Getahun Woldeyes, Charles D A Wolfe, Sungho Won, Abdulhalik Workicho, Shimelash Bitew Workie, Mamo Wubshet, Denis Xavier, Gelin Xu, Ajit Kumar Yadav, Mohsen Yaghoubi, Bereket Yakob, Lijing L Yan, Yuichiro Yano, Mehdi Yaseri, Hassen Hamid Yimam, Paul Yip, Naohiro Yonemoto, Seok-Jun Yoon, Mustafa Z Younis, Chuanhua Yu, Zoubida Zaidi, Maysaa El Sayed Zaki, Carlos Zambrana-Torrelio, Tomas Zapata, Zerihun Menlkalew Zenebe, Sanjay Zodpey, Leo Zoeckler, Liesl Joanna Zuhlke, Christopher J L Murray.

Affiliations

Institute for Health Metrics and Evaluation (R M Barber BS, N Fullman MPH, R J D Sorensen MPH, A Afshin MD, L Alexander BA, C Allen BA, S Biryukov BS, Prof M Brauer ScD, D Casey BA, K Cercy BS, F J Charlson PhD, A Z Chen BS, A Chew ND, M S Coggeshall BA, Prof L Dandona MD, R Dandona PhD, D Dicker BS, R Ehrenkranz MPH, K Estep MPA, C Fitzmaurice MD, T D Fleming BS, K J Foreman PhD, J Frostad MPH, Prof E Gakidou PhD, W W Godwin BS, A Gold MSc, E M Goldberg BS, N Graetz MPH, M Griswold MS, Prof S I Hay DSc, B M Huntley BA, C Huynh BA, C Johnson PhD, S C Johnson MSc, N J Kassebaum MD, L Kemmer PhD, I Khalil MD, P Kim BA, K J Krohn BA, M Kutz BS, H H Kyu PhD, H J Larson PhD, Prof S Lim PhD, M Lind MPHc, P Liu BA, N Marquez BA, C McNellan BA, A Millear BA, S Minnig MSc, M Mirarefin MPH, Prof A H Mokdad PhD, M Moradi-Lakeh MD, M Moses MHS, Prof M Naghavi PhD, M Ng PhD, G Nguyen MPH, H E Olsen MA, A W Pain MPH, D M Pigott DPhil, C Pinho BA, Z Rankin BS, P C Rao MPH, M Reitsma BS, G A Roth MD, L Sandar BS, K A Shackelford BA, A Smith BA, C Steiner MPH, P Sur BA, S Teeple BA, C Troeger MPH, Prof S E Vollset DrPH, Prof T Vos PhD, J A Wagner BS, H Wang PhD, Prof H A Whiteford PhD, L Zoeckler BA, Prof C J L Murray DPhil), Division of Hematology, Department of Medicine (C Fitzmaurice MD), Harborview Injury Prevention and Research Center (C N Mock PhD, D A Quistberg PhD), Department of Anesthesiology & Pain Medicine, (D A Quistberg PhD), University of Washington, Seattle, WA, USA (Prof B O Anderson MD, J Leung PhD, J L Walson MD, D A Watkins MD); Council on Foreign Relations, Washington DC, Washington DC, USA (T Bollyky JD); European Observatory on Health Systems and Policies (E Nolte PhD), Department of Infectious Disease Epidemiology (H J Larson PhD), London School of Hygiene & Tropical Medicine, London, UK (Prof M McKee DSc, I M O Adetifa PhD, I D A Faghmous MPH, S M Langan PhD, Prof N Pearce PhD); School of Public Health (A A Abajobir MPH, F J Charlson PhD, J Leung PhD, Prof H A Whiteford PhD), School of Dentistry (Prof R Lalloo PhD), University of Queensland, Brisbane, QLD, Australia (Prof J J McGrath MD); College of Health Sciences, Department of Epidemiology, ICT and e-Learning Coordinator (M B Ahmed MPH), Jimma University, Jimma, Ethiopia (K H Abate MS, T T Ghiwot MPH, A T Gebremedhin MPH, M A Mengistie MS, S T Mereta PhD, T Wakayo MS, A Workicho MPH); La Sapienza, University of Rome, Rome, Italy (C Abbafati PhD); Virginia Tech, Blacksburg, VA, USA (Prof K M Abbas PhD); Department of Neurology, Cairo University, Cairo, Egypt (Prof F Abd-Allah MD); New York University Abu Dhabi, Abu Dhabi, United Arab Emirates (A M Abdulle PhD); Uro-Oncology Research Center (E Amini MD), Endocrinology and Metabolism Population Sciences Institute Research Institute (E Amini MD, Prof A Esteghamati MD, S Sheikhbahaei MD, N Hafezi-Nejad MD, A Kasaeian PhD), Non-Communicable Diseases Research Center (F Farzadfar MD, M Parsaeian PhD), Department of Epidemiology and Biostatistics, School of Public Health (M Parsaeian PhD), Center for Air Pollution Research (M S Hassanvand PhD), Institute for Environmental Research (M Shamsipour PhD), Hematology-Oncology and Stem Cell Transplantation Research Center (A Kasaeian PhD), Digestive Diseases Research Institute (Prof R Malekzadeh MD, G Roshandel PhD, S G Sepanlou PhD), Sina Trauma and Surgery Research Center (Prof V Rahimi-Movaghar MD), MS Research Center, Neuroscience Institute (M A Sahraian MD), Tehran University of Medical Sciences, Tehran, Iran (A A Abdurahman PhD, Prof M B Rokni PhD); School of Public Health (S F Abera MSc, G F Abreha MPH, K G Meles MPH, G R Taffere PhD), College of Health Sciences (D T Mengiste MS), Department of Medical Microbiology and Immunology (K Adane MS), Mekelle University, Mekelle, Ethiopia (T M Atey MS, M W Gebremichael MS, A A Gebru MPH, G B Hailu MSc, H B Mezgebe MS, D Y Tekle MS, A G Tesema MPH, Z M Zenebe MS); Food Security and Institute for Biological Chemistry and Nutrition, University of Hohenheim, Stuttgart, Germany (S F Abera MSc); NMSM Governement College Kalpetta, Kerala, India (Prof B Abraham MPhil); Public Health Promotion Alliance, Osogbo, Nigeria (A L Adelekan MPH); University of Ibadan, Ibadan, Nigeria (A L Adelekan MPH, R O Akinyemi PhD); KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya (I M O Adetifa PhD, A Deribew PhD); Dalla Lana School of Public Health (N Akseer MSc), Department of Nutritional Sciences, Faculty of Medicine (A Badawi PhD), University of Toronto, Toronto, ON, Canada (A Agarwal BHSc); McMaster University, Hamilton, ON, Canada (A Agarwal BHSc); All India Institute of Medical Sciences, New Delhi, India (Prof S K Agarwal, V K Paul MD, R Sagar MD, M Satpathy PhD); National Institute of Occupational Health (ICMR), Ahmedabad, India (S Agarwal PhD); CSIR - Institute of Genomics and Integrative Biology, Delhi, India (A Agrawal PhD); Department of Internal Medicine, Baylor College of Medicine, Houston, TX, USA (A Agrawal PhD); Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit (A Ahmad Kiadaliri PhD), Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden (Prof B Norrving PhD); School of Public Health (S Rezaei PhD), Kermanshah University of Medical Sciences, Kermanshah, Iran (A Ahmadi PhD); Debre Markos University, Debre Markos, Ethiopia (K Y Ahmed MPH, Z A Alemu MPH, G D Kibret MPH, C T Leshargie MPH, T K Tegegne MPH, T Y Tiruye MPH); Newcastle University, Newcastle upon Tyne, UK (R O Akinyemi PhD); Department of Epidemiology (T F Akinyemiju PhD), University of Alabama at Birmingham, Birmingham, AL, USA (D C Schwebel PhD); Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada (N Akseer, Z A Bhutta PhD); Washington University in Saint Louis, St. Louis, MO, USA (Z Al-Aly MD); Murdoch Childrens Research Institute (K Alam PhD), University of Melbourne, Melbourne, VIC, Australia (K Alam PhD); The University of Sydney, Sydney, NSW, Australia (K Alam PhD); Department of Health, Queensland, Brisbane, QLD, Australia (N Alam MAppEpid); International Centre for Diarrhoeal Disease Research (ICDDR), Bangladesh, Dhaka, Bangladesh (S S Alam MSc, A Naheed PhD, S M Shariful Islam PhD); Department of Epidemiology and Biostatistics, Institute of Public Health (K A Alene MPH), University of Gondar, Gondar, Ethiopia (A B Mekonnen MS); Nuffield Department of Medicine (D Bisanzio PhD, A Deribew PhD), Oxford Big Data Institute, Li Ka Shing Centre for Health Information and Discovery (Prof S I Hay DSc), University of Oxford, Oxford, UK (R Ali FRCP, D A Bennett PhD, Prof V Jha DM, K Rahimi DM); University of London, London, UK (S D Ali BA); SIR management consultants, Oxford, UK (S D Ali BA); Institute and Faculty of Actuaries, Oxford, UK (S D Ali BA); Gastrointestinal Cancer Research Center (R Alizadeh-Navaei PhD), Mazandaran University of Medical Sciences, Sari, Iran (M S Rezai MD); Luxembourg Institute of Health (LIH), Strassen, Luxembourg (A Alkerwi PhD, S Stranges PhD); School of Public Health, University of Lorraine, Nancy, France (Prof F Alla PhD); Department of Public Health Sciences (P Allebeck PhD), Division of Family Medicine and Primary Care, Department of Neurobiology, Care Science and Society (Prof J Ärnlöv PhD), Department of Clinical Science, Intervention and Technology (Prof J J Carrero PhD), Department of Neurobiology, Care Sciences and Society (NVS) (S Fereshtehnejad PhD), Aging Research Center (Prof M Kivipelto PhD), Department of Medical Epidemiology and Biostatistics (E Weiderpass PhD), Karolinska Institutet, Stockholm, Sweden (R Havmoeller PhD, S Sindi PhD); Ministry of Health, Jeddah, Saudi Arabia (R Al-Raddadi PhD); Department of Psychosomatic Medicine, Center for Internal Medicine and Dermatology (S Nolte PhD), Charité University Medicine Berlin, Berlin, Germany (U Alsharif MPH, C Papachristou PhD); King Saud University, Riyadh, Saudi Arabia (K A Altirkawi MD); Spanish Observatory on Drugs, Government Delegation for the National Plan on Drugs, Ministry of Health, Social Policy and Equality, Madrid, Spain (E Alvarez Martin PhD); Universidad de Cartagena, Cartagena de Indias, Colombia (Prof N Alvis-Guzman PhD); School of Medicine (A T Amare MPH, Prof B T Baune PhD), University of Adelaide, Adealaide, SA, Australia (A T Olagunju MS, L G Ciobanu MS); College of Medicine and Health Sciences (A T Amare MPH), Bahir Dar University, Bahir Dar, Ethiopia (T Setegn MPH); Ministry of Public Health, Beirut, Lebanon (W Ammar PhD, H L Harb MPH); African Population and Health Research Center, Nairobi, Kenya (J Amo-Adjei PhD); University of Cape Coast, Cape Coast, Ghana (J Amo-Adjei PhD); Department of Medicine (Y A Amoako FWACP), Komfo Anokye Teaching Hospital, Kumasi, Ghana (D O Laryea MD); University of Thessaly, Larissa, Greece (Prof S Androudi MD); Health Promotion Research Center, Department of Epidemiology and Biostatistics, Zahedan University of Medical Sciences, Zahedan, Iran (H Ansari PhD); West Hararghe Zonal Health Department, Chiro, Ethiopia (M G Ansha MPH); Department of Health Policy and Administration, College of Public Health (C A T Antonio MD), College of Public Health (E J A Faraon MD), University of the Philippines Manila, Manila, Philippines; School of Health and Social Studies, Dalarna University, Falun, Sweden (Prof J Ärnlöv PhD); University of Manitoba, Winnipeg, MB, Canada (A Artaman PhD); Department of Medical Emergency, School of Paramedic, Qom University of Medical Sciences, Qom, Iran (H Asayesh PhD); Mashhad University of Medical Sciences, Mashhad, Iran (R Assadi PhD); Hawassa University, Hawassa, Ethiopia (A Astatkie PhD, F B B Fanuel MPH); Graduate Institute of Biomedical Informatics (S Atique MS), College of Medical Science and Technology, Taipei Medical University, Taipei, Taiwan (D N A Ningrum MPH); Mizan Tepi University, Mizan Teferi, Ethiopia (N T Atnafu MS, H H Yimam MPH); PMA 2020, Mizan Teferi, Ethiopia (N T Atnafu MS); Clinical Trials Unit, BJ Medical College - Johns Hopkins University, Pune, India (S R Atre PhD); National Institute of Public Health, Cuernavaca, Mexico (L Avila-Burgos PhD); Institut de Recherche Clinique du Bénin (IRCB), Cotonou, Benin (E F G A Avokpaho MPH); Laboratoire d'Etudes et de Recherche-Action en Santé (LERAS Afrique), Parakou, Benin (E F G A Avokpaho MPH); The Judith Lumley Centre for Mother, Infant and Family Health Research, La Trobe University, Melbourne, VIC, Australia (B P Ayala Quintanilla PhD); Peruvian National Institute of Health, Lima, Peru (B P Ayala Quintanilla PhD); Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India (A Awasthi PhD); Ministry of Health, Addis Ababa, Ethiopia (N N Ayele MPH); Department of Paediatrics (P Azzopardi MEpi), Murdoch Childrens Research Institute (K Alam PhD, P Azzopardi MEpi, R G Weintraub MBBS, Prof G C Patton MD), Department of Paediatrics (P Azzopardi MEpi), Melbourne School of Population and Global Health (Prof A D Lopez PhD), Department of Medicine (A Meretoja PhD), University of Melbourne, Melbourne, VIC, Australia (K Alam PhD); Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, SA, Australia (P Azzopardi MEpi); Centre for International Health, Burnet Institute, Melbourne, VIC, Australia (P Azzopardi MEpi); Faculty of Medicine and Health Sciences, Aden University, Aden, Yemen (Prof H O Ba Saleem PhD); Department of Global Health and Population (Prof T Bärnighausen MD, A B Feigl ScD, J A Salomon PhD), Department of Epidemiology (P James ScD), Department of Nutrition (M S Farvid PhD), Harvard T.H. Chan School of Public Health, (I R Campos-Nonato PhD, E L Ding ScD), Harvard Medical School, Harvard University, Boston, MA, USA (M Osman MD, M G Shrime MD); Africa Health Research Institute, Mtubatuba, South Africa (Prof T Bärnighausen MD); Institute of Public Health, Heidelberg University, Heidelberg, Germany (Prof T Bärnighausen MD, S Mohammed PhD); School of Health Sciences, University of Management and Technology, Lahore, Pakistan (U Bacha PhD); Public Health Agency of Canada, Toronto, ON, Canada (A Badawi PhD); Farr Institute of Health Informatics Research (A Banerjee DPhil), Institute of Epidemiology & Health (T Tillmann MSc), University College London, London, UK (C Birungi MS); Faculty of Medicine (A Barac PhD), Institute of Social Medicine (M M Santric Milicevic PhD), Centre School of Public Health and Health Management, Faculty of Medicine (M M Santric Milicevic PhD), University of Belgrade, Belgrade, Serbia; Hospital Dr. Rafael A. Calderón Guardia, CCSS, San Jose, Costa Rica (M A Barboza MD); Universidad de Costa Rica, San Pedro, Costa Rica (M A Barboza MD); School of Psychology (S L Barker-Collo PhD), University of Auckland, Auckland, New Zealand (B del Pozo-Cruz PhD); Department of Industrial Engineering, School of Engineering, Pontificia Universidad Javeriana, Bogota, Colombia (L H Barrero ScD); Stanford University, Stanford, CA, USA (S Basu PhD, L C Del Gobbo PhD); School of Public Health (K Deribe MPH, A D Hailu MPH), Addis Ababa University, Addis Ababa, Ethiopia (K Baye PhD, T J Beyene MS, A Z Giref PhD, D Haile MPH, H A Hareri MS, B G Menota MS, G Temam Shifa MPH, B G Woldeyes MPH); Jhpiego-Ethiopia, Addis Ababa, Ethiopia (Y T Bayou PhD); College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA (Prof S Bazargan-Hejazi PhD); David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA (Prof S Bazargan-Hejazi PhD); College of Public Health and Tropical Medicine, Jazan, Saudi Arabia (N Bedi MD); IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy (E Beghi MD, G Giussani BiolD); University Hospital and Medical School of Dijon, University of Burgundy, Dijon, France (Prof Y Béjot PhD); University of Alberta, Edmonton, AB, Canada (A K Bello PhD); Internal Medicine Department (Prof I S Santos PhD), University of Sao Paulo, Sao Paulo, Brazil (I M Bensenor PhD, Prof P A Lotufo DrPH); College of Health Sciences (A Berhane PhD), Debre Berhan University, Debre Berhan, Ethiopia (T D Habtewold MS); Division of Health and Social Care Research (Prof C D Wolfe MD), King's College London, London, UK (E Bernabé PhD, Prof R J Hay DM, M Molokhia PhD); University Andes, Bogota, Colombia (O A Bernal PhD); College of Health and Medical Sciences (A S Beyene MPH, M T Hambisa MPH, M M Mengesha MPH, H S Roba MPH, A M Seid MS), Haramaya University, Dire Dawa, Ethiopia (M D Gishu MS, A A Irenso MPH, F A Kumsa MPH, A K Tura MPH); Division of Human Nutrition (J M Geleijnse PhD), Wageningen University, Wageningen, Netherlands (T J Beyene MS); Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan (Z A Bhutta PhD); Independent Public Health Consultants, Addis Ababa, Ethiopia (S Biadgilign MPH); IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy (B Bikbov MD, M Cortinovis Biotech D, Prof G Remuzzi MD); GBS-CIDP International Foundation, Menemen, Turkey (S M Birlik BS); Debre Markos University, Debre Markos town, Ethiopia (H M Bizuayehu MPH); World Bank, Washington DC, DC, USA (D Bose PhD); Danube-University Krems, Krems, Austria (Prof M Brainin PhD); University of British Columbia, Vancouver, BC, Canada (Prof M Brauer ScD, Prof N Kissoon MD, J A Kopec PhD, S Murthy MD); Faculty of Health Sciences and Social Work, Department of Public Health, Trnava University, Trnava, Slovakia (A Brazinova PhD); International Neurotrauma Research Organization, Vienna, Austria (A Brazinova PhD); College of Medicine (J Shen PhD), Ohio State University, Columbus, OH, USA (Prof N J K Breitborde PhD); Division of Clinical Epidemiology and Ageing Research (B Schöttker MPH), German Cancer Research Center, Heidelberg, Germany (Prof H Brenner MD); Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan (Z A Butt PhD); Metropolitan Autonomous University, Mexico City, Mexico (R Cárdenas ScD); National Institute of Public Health, Cuernavaca, Mexico (L Cahuana-Hurtado PhD, I R Campos-Nonato PhD, I B Heredia-Pi PhD, R Lozano MD, Prof E E Servan-Mori MSc); Nanyang Technological University, Singapore, Singapore (J Car PhD); Stroke Unit, University of Perugia, Perugia, Italy (V Caso MD); Colombian National Health Observatory, Instituto Nacional de Salud, Bogota, Colombia (C A Castañeda-Orjuela MSc); Epidemiology and Public Health Evaluation Group, Public Health Department, Universidad Nacional de Colombia, Bogota, Colombia (C A Castañeda-Orjuela MSc); Caja Costarricense de Seguro Social, San Jose, Costa Rica (Prof J Castillo Rivas MPH); Universidad de Costa Rica, San Pedro, Montes de Oca, Costa Rica (Prof J Castillo Rivas MPH); Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain (F Catalá-López PhD); Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada (F Catalá-López PhD); Independent Collaborator, Porto, Portugal (P Cecilio MS); Queensl